Intraoperative uterine perforation: One approach to management

Uterine perforation may be diagnosed intraoperatively (eg, visualizing a hole in the uterine wall during hysteroscopy; omentum, bowel, or adipose tissue in the endometrial cavity or suction instrument) or suspected when there is a sudden loss of resistance, loss of visualization during hysteroscopy, or an instrument passes beyond the expected length of the uterus. Such patients can be managed expectantly or undergo surgical exploration. The choice of management depends on the likelihood of hemorrhage or visceral injury. In the absence of high-quality data, our approach is based on our clinical experience and expert opinion.

* Perforation occurred with a low-risk instrument (eg, blunt cervical dilator, manual vacuum aspiration) or when a high-risk instrument was not active.

¶ Perforations that occur anteriorly or posteriorly are also at high risk of visceral injury.

Δ Abdominal exploration can often be accomplished laparoscopically, even in the presence of hemoperitoneum and/or acute bleeding. However, laparotomy may be warranted in some patients.

◊ Postoperative monitoring of such patients and the recognition of delayed signs/symptoms of uterine perforation and vascular or visceral injury are discussed in related UpToDate content.

§ Prophylactic antibiotics are typically not administered; rather, antibiotics are reserved for patients with clinical signs of infection (eg, endometritis, peritonitis).

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Intraoperative uterine perforation: One approach to management