V.L. Deshmukh, K.A. Yellikar, A.R. Mahajan, I.K. Mullah. “Silent Uterine Perforation In Second Trimester: A Case Report”. Journal Of Evolution Of Medical And Dental Sciences 2013; Vol2, Issue 50, December 16; Page: 9765-9768.
ABSTRACT:Failure to detect uterine perforation during surgical abortion may result in adverse patient outcome besides having medicolegal implications.This rare case of uterine perforation was diagnosed 6 days after abortion & underscores the importance of remaining vigilant for this complication during & after the procedures. The patient underwent evacuation at 16 wks of gestation & was discharged after the procedure, assuming no complications. She presented with abdominal pain & bleeding PV after 4 days of the surgical event.Ultrasound & CT revolved the uterine perforation hence a patient complaining of abdominal pain following a recent abortion,related instrumentation should alter the clinician regarding the possibilities of perforation.
KEYWORDS: uterine rupture, perforation, maternal morbidity.
INTRODUCTION:Uterine rupture is uncommon, but a life threatening complication following second trimester abortion.The reported cases have been both in scarred & unscarred uterus.The occurrence is about 0.2% in unscarred uterus & 3.8-4.3% in scarred uterus1.
CASE REPORT: A 28 yrs old XYZ presented in emergency department of our hospital with complaints of pain in lower abdomen.She was P3L3A1. Previous deliveries were normal vaginal deliveries.6 days back she had undergone a evacuation in a private clinic at 16 wks of gestation. She gave history of oligohydraminos& probably congenitally malformed baby expelled at home.The details of which are not available.She went to the private clinic where a surgical evacuation was done to evacuate the remaining POCs. She was discharged next day from private clinic assuring that the procedure was uneventful & post procedure USG not necessary. She continued to have pain in abdomen 3 days postoperatively.She again presented to private clinic on the 4th day with complaints of pain in abdomen & bleeding PV. She gave history of removal of clots digitally from the vagina.Pain in abdomen worsened & was referred to tertiary care centre for further management.
At the time of admission in our hospital pulse was 120 BPM, BP was 120/80 mmHg, RR-20/min, she was pale. She had low grade fever with body temperature 37.60C. CVS, RS – WNL, Abdominal examination reveals tenderness in lower abdomen & left iliac fossa with no signs of peritoneal irritation. Abdominal tap was negative for hemoperitoneum. Guarding & rigidity present. Bowel sounds were heard. PS examination showed bleeding PV through OS, which was open. PV reveled on pelvic examination uterus was enlarged approximately 12 wks size, soft, tender, forniceal tenderness was present.Patient was admitted, relatives were explained about prognosis & investigations were sent. HB was 6gm%, TLC was 19700, DLC P86, L12, M1, E1, Platelet 2.5 lakhs, LFT, KFT, electrolytes, BT, CT – WNL. Urine microscopy showed pus cells 15-20 per HPF. Blood & urine culture sent.X-ray chest reveled evidence of bilateral pleural effusion. Clinically the diagnosis was endometritis / incomplete abortion / RPOCs with sepsis.Ultrasound pelvis was requested. Patient kept NBM, IV fluids started & Inj. Piperacillin&tazobactam 4.5gm IV BD, Inj. Metronidazole 500 mg IV TDS given & 3 units of whole blood transfused.
Transabdominal ultrasound revealed small Air Foci in endometrial cavity along with free fluid in pelvis. Left mid & lower abdomen were obscured, due to distended gas loops.However, abdominal signs & air foci made a suspect of uterine perforation although rent was not identified.
Contrast CT of the abdomen confirmed the fluid collections in PODs,additionally it showed a liner hypodense non enhancing fundal defect 3 x 3 cm, slightly left to the midline connection the uterine & abdominal cavity. This was consistent with uterine perforation.Multiple foci free intraperitoneal Air (pneumoperitoneum) was noted. Evidence of bilateral pleural effusion noted. Urinary bladder, liver, spleen & both kidneys werewithin normal limit.
Based on sonographic& CT findings diagnosis of uterine perforation with likelihood of bowel injury was suspected.Patient posted for emergency laparotomy. Written & informed consent taken from patient & relatives. On opening the abdomen the perforation was identified on the left side of the uterine cornua around 3 x 3 cm. This was surrounded by localized pus collection mainly on left side. POD was empty.Bilateral fallopian tubes were edematous, reddened & inflamed.
Fig. 3: Left sided perforation
Fig. 2: Left sided perforation
Intraperitoneal Pus drained out. Subtotal hysterectomy was done as edges were ragged, lacerated, edematous & widely infected. Bowel injury ruled out. Saline lavage given & abdomen closed after putting drain. Post-operative period was uneventful. On day 3 TLC was 12000, day 5 TLC became 70000 & patient discharged on day 14.
DISCUSSION:It is unusual to observe a uterine perforation after 2nd trimester abortion. The diagnosis of the perforation is difficult & has to be substantiated by ultrasound / CT. Abortion related morbidity & mortality increased significantly as pregnancy advanced with a sharp rise in rate of severe complications in induced abortions after 14 wks of pregnancy2. However the complication that endangers the life of patient is reported to be 6 – 30% in 2nd trimester abortions3. Scarred uterus is the most important factor in uterine rupture however high parity, prior h/o D&C, adherent placenta can also be the precipitating factor in unscarred uterus.The scar of LSCS takes time to heal, as the puerperal uterus remains contracting & retracting. This can interfere with healing process where as the scar of myomectomy heals properly because of the quiescent uterus4.
According to the WHO, in every 8 min. a women in developing nations will die of complications arising from unsafe abortions leading to a maternal mortality upto 13%5.
The commonest site of myometrial perforation is relatively avascular area of anterior & posterior Medline surfaces.Perforations more likely to troublesome if rent located laterally. If defect > 1.2 cm, they occur in 2nd trimester abortions or there is associated bowel injury6. In most case the perforation can be recognized by the operator during the procedures however in many cases the perforation may remain clinically undiagnosed & patient may get discharged.These patients, present subsequently with serious complications.Usual presenting compliant is abdominal pain & not excessive vaginal bleeding.Ultrasound is often the initial diagnostic modality. It can show the site of uterine perforation as a hypoechoic / anechoic transmural defect is myometrium extending to endometrium with presence of extrauterine fluid. Use of high resolution transvaginal probe enhances detection of perforation defect & mural hematoma. On CT the site perforation is seen as hypoattenuating defect with disruption of myometrial continuity6.
In our case there was history of D&C done.Instrumentation for evacuation itself,can be a positive factor for uterine rent during the procedure. A high index of suspicion should be kept while doing the procedure.The features of sepsis, unexplainable bulky soft uterus & tenderness in lower abdomen complied us to consider the possibility of uterine perforation. However in our case patients relatively stable condition, absence of hemoperitoneum, initially mislead us to be a case of septic abortion. But after the ultrasound & CT findings we concluded it to be a uterine perforation. Absence of other visceral injuries favored the condition in these women. Subtotal hysterectomy done in our case because of lower part of uterus was intact, healthy & not affected.Hence only the affected part was removed.Our case illustrates the importance of maintaining the high index of suspicion by the gynecologist as well as the radiologist in patient presenting with abdominal pain a few days after undergoing surgical abortion related instrumentation. Ultrasound & CT can help in the diagnosis. The role of MRI in this cases is not clearly defined as it doesn’t seems to offer any significant diagnostic advantage over the CT scan.
CONCLUSION:Uterine perforation in 2nd trimester MTP is rare especially in unscarred uterus.However if it occurs it endangers the life of patient with acute complications like sepsis, ARF, DIC, ARDS, Peripartum hysterectomy, visceral injury &post operative complications like thromboembolism & infection.It is important cause of maternal mortality. All these complications are avoidable if suspicion of uterine perforation is kept in mind with patient presenting with abdominal pain & recent history of abortion.
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