Uterine perforation during gynecologic procedures

INTRODUCTION — 

Uterine perforation is a potential complication of all intrauterine procedures and may be associated with injury to surrounding blood vessels or viscera (bladder, bowel), which can result in hemorrhage or sepsis. The risk of uterine perforation is increased by factors that make access to the endometrial cavity difficult (eg, cervical stenosis, severe anteflexion or retroflexion) or alter the strength of the myometrial wall (eg, pregnancy, lactation, menopause, previous uterine surgery).

Patients planning a procedure involving intrauterine instrumentation should be counseled about the risk of uterine perforation and, if perforation should occur, the possibility of additional procedures (eg, laparoscopy or laparotomy).

The prevention, diagnosis, and management of uterine perforation during gynecologic procedures will be reviewed here. Other complications of uterine surgery are discussed separately. (See "Complications of gynecologic surgery".)

INCIDENCE — 

The true incidence of uterine perforation is unknown, as many perforations are not recognized or confirmed. Thus, any reported incidence is likely an underestimate.

Data from studies reporting on uterine perforation vary based on the type of intrauterine procedure and patient population; examples are as follows [1-3]:

●Endometrial ablation – Uterine perforation occurs in approximately 1 percent of all endometrial ablation procedures; the rate appears to be higher for those undergoing resectoscopic compared with non-resectoscopic techniques. (See "Overview of endometrial ablation", section on 'Complications'.)

●Endometrial sampling – Uterine perforation occurs with endometrial sampling (with endometrial biopsy or dilation and curettage) in approximately 0.3 percent of premenopausal patients and 2.6 percent of postmenopausal patients. (See "Office-based endometrial sampling procedures", section on 'Side effects and complications' and "Dilation and curettage", section on 'Uterine perforation'.)

●Hysteroscopy – Uterine perforation occurs in approximately 1 percent of all hysteroscopic procedures. Rates are lower for those undergoing a diagnostic compared with an operative procedure. This is discussed in detail separately. (See "Hysteroscopy: Instruments and procedure", section on 'Uterine perforation'.)

●Intrauterine device (IUD) – Uterine perforation can also occur with an IUD; rates vary based on timing (during placement versus delayed migration; placement postpartum versus interval insertion). (See "Intrauterine contraception: Management of side effects and complications", section on 'Perforation'.)

●Uterine aspiration – Uterine perforation occurs in up to 5 percent of pregnant patients undergoing an intrauterine procedure to control postpartum hemorrhage. The risk is lower (eg, 0.5 to 1 percent) for first- and second-trimester procedures (eg, uterine aspiration for pregnancy loss or pregnancy termination). (See "Secondary (late) postpartum hemorrhage", section on 'Retained products of conception (RPOC)' and "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Complications' and "Overview of pregnancy termination", section on 'Uterine perforation' and "Pregnancy loss (miscarriage): Description of management techniques", section on 'Complications'.)

Up to 17 percent of uterine perforations are associated with other complications (eg, hemorrhage, visceral injury) [1-3].

RISK FACTORS — 

Risk factors for uterine perforation include those that make access to the endometrial cavity difficult or alter the strength of the myometrial wall and include [1,4]:

●Distortion of the uterus or cervix (eg, due to fibroids, intrauterine adhesions, previous surgery [including cervical excisional procedures], congenital anomalies [eg, unicornuate uterus], diethylstilbestrol [DES] exposure resulting in reduced uterine size).

●Menopausal changes (eg, endometrial atrophy, myometrial thinning, vaginal atrophy, cervical stenosis).

●Pregnancy or lactation.

●Uterine malposition (eg, extreme anteversion, anteflexion, retroversion, or retroflexion).

In addition, a lack of surgical experience, underestimation of gestational age (for pregnancy-related procedures), and severe levator ani muscle tension may be associated with an increased risk [2,3,5-7].

PREVENTION

Role of preprocedure preparation — For selected patients, preprocedure cervical and/or vaginal preparation may facilitate dilation and/or insertion of instruments into the uterine cavity.

●Cervical preparation – Patients with risk factors for uterine perforation (see 'Risk factors' above) may benefit from cervical preparation with a prostaglandin (eg, misoprostol, dinoprostone) or osmotic dilators (eg, laminaria). This is discussed in detail separately. (See "Hysteroscopy: Instruments and procedure", section on 'Cervical preparation and dilation' and "Intrauterine contraception: Insertion and removal", section on 'Misoprostol' and "Dilation and curettage", section on 'Cervical preparation' and "Pregnancy termination: Cervical preparation for procedural abortion".)

●Treatment of vaginal atrophy – Patients with vaginal atrophy and/or stenosis may benefit from using a low-dose vaginal estrogen for one to two weeks before the procedure. Vaginal estrogen may help with speculum insertion, opening the speculum to a width that allows visualization of the entire cervix, and the ability to manipulate and angle instruments appropriately. Vaginal estrogens are discussed separately. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment".)

●Other – Topical anesthetic cream (eg, 2.5% lidocaine plus 2.5% prilocaine in a cream base) applied to the vaginal orifice and vulva by the patient at home or by the clinician prior to the procedure may be helpful in selected patients (eg, patients with anxiety to reduce levator spasm, patients with vaginal atrophy and a contraindication to estrogen therapy). (See "Vulvar lesions: Diagnostic evaluation", section on 'Procedure'.)

Intraoperative preventive measures

Assess uterine position — Perforation may result if cervical dilators are placed in the incorrect axis or with excessive force. To help facilitate accurate placement of instruments, a bimanual examination is performed at the beginning of the procedure to assess uterine position. In patients with obesity, a rectovaginal examination may be helpful to accurately determine if significant flexion of the uterus is present. (See "The gynecologic history and pelvic examination", section on 'Bimanual examination'.)

Straightening the uterine axis, by placing a tenaculum on the anterior lip of the cervix and applying gentile traction, also facilitates the placement of instruments through the endocervical canal into the uterus.

Techniques to facilitate cervical dilation — For patients in whom the cervix cannot be dilated easily, several techniques may help to safely dilate the cervix:

●Use smaller instruments (eg, os finder, lacrimal duct probe, urologic dilators). Care should be taken to avoid creating a false tract rather than passing the dilator into the cervical canal.

●Utilize ultrasound guidance [8]. In a randomized trial of 400 patients with a retroverted, retroflexed uterus (confirmed by ultrasound) undergoing IUD insertion, placement with versus without ultrasound guidance was associated with lower failure rates (0 versus 3 percent), shorter procedure time, and less bleeding [9]. Patients in the ultrasound group also reported lower pain scores. Intraoperative ultrasound guidance is discussed in more detail separately. (See "Dilation and curettage", section on 'Challenging cases'.)

●For patients undergoing hysteroscopic intrauterine procedures, vaginoscopy (without speculum insertion) can sometimes be performed to facilitate entry through the cervical canal. (See "Hysteroscopy: Instruments and procedure", section on 'Vaginoscopic technique'.)

●In the rare instance of external os stenosis, local anesthetic can be injected into the cervix and a stab incision made (eg, with a #11 scalpel blade) in the region of the external os; this generally facilitates access to the cervical canal and endocervix. Rarely, a shallow loop electrosurgical excision procedure (LEEP) can be performed to remove the stenosis and facilitate entry into the uterine cavity.

●Intracervical injection of dilute vasopressin (4 units per 80 mL normal saline) has also been reported [10]. Although generally well tolerated, vasopressin injection must be performed with caution since intravascular injection or absorption has been associated with profound hypertension, bradycardia, and intraoperative mortality [11]. Due to this rare but serious complication, vasopressin injection is not recommended in the office setting. (See "Hysteroscopy: Instruments and procedure", section on 'Cervical preparation and dilation'.)

Safe use of operative instruments — Safe use of transcervical instruments is imperative, as they are often passed blindly and depend upon knowledge of the uterine position and the use of appropriate pressure.

When uterine perforation occurs, it is typically during mechanical cervical dilation or insertion of a sharp uterine instrument [1-3,12,13]. Tapered (eg, Hanks or Pratt dilators) compared with blunt tip (eg, Hegars) dilators generally require less force and typically result in more gentle mechanical dilation.

The ability to visualize hysteroscopic instruments directly allows for additional safety measures during hysteroscopic procedures. For example, a resectoscope loop should always be moved toward the operator (and not pushed into the uterine wall) [14], and energy sources should not be activated unless there is a clear view of the instrument.

Optimize pain management — Pain management is individualized based on the needs of the patient and the procedure type. Pain management ranges from no analgesia to an intracervical or paracervical block, oral or intravenous sedation, and regional or general anesthesia. This is discussed in detail separately. (See "Pudendal and paracervical block" and "Hysteroscopy: Instruments and procedure", section on 'Pain management' and "Intrauterine contraception: Insertion and removal", section on 'Analgesia' and "First-trimester pregnancy termination: Uterine aspiration", section on 'Pain management' and "Second-trimester pregnancy termination: Dilation and evacuation", section on 'Anesthesia'.)

CLINICAL PRESENTATION

Intraoperative — Uterine perforation is generally recognized intraoperatively rather than postoperatively.

●Uterine perforation is diagnosed intraoperatively when:

•A hole in the uterine wall is directly visualized on hysteroscopy, laparoscopy, or laparotomy. The most common site of uterine perforation is the fundus [4,15].

•Omentum, bowel, or adipose tissue is visible through an opening in the myometrium or is present in the endometrial cavity or in a suction instrument (figure 1).

•Adipose tissue is identified in a curettage specimen.

●Uterine perforation should be suspected when any of the following occurs:

•Sudden loss of resistance.

•A uterine sound, dilator, or operating instrument passes beyond the expected length of the uterus.

•During hysteroscopy, loss of visualization due to sudden loss of uterine distension, and an abrupt increase in the distending fluid deficit.

•Clinical signs of visceral or vascular injury (eg, excessive bleeding, hypotension, acute onset of hematuria). Occult retroperitoneal or intraabdominal hemorrhage can also occur, with perioperative hypotension the first sign of a complication.

Perforation at the fundus typically leads to minimal bleeding, whereas a lateral uterine perforation is more likely to lacerate uterine blood vessels. A low cervical perforation can lacerate the descending branch of the uterine artery, which can also present with delayed cervical bleeding if the artery initially goes into spasm.

Postoperative — Postoperatively, uterine perforation should be suspected with any of the following:

●Abdominal and/or pelvic pain – While mild to moderate cramping is expected for several hours after a uterine procedure, severe or persistent abdominal pain is unusual and requires prompt evaluation [16]. The pain may be focal or diffuse since its source may be a specific injury to the uterus, bowel, or bladder.

●Abdominal distension – Abdominal distention, especially when occurring in the presence of tachycardia, is concerning for occult retroperitoneal or intraabdominal bleeding (eg, a slowly expanding retroperitoneal hematoma) or bowel injury (perforation or incarceration in the uterine defect [17]).

●Heavy or persistent vaginal bleeding

●Hematuria

●Hypotension

●Rectal bleeding (rare) in patients with bowel injury

It is important to note that these symptoms/signs are nonspecific, and thus, other etiologies (not related to uterine perforation) must also be considered.

Delayed — Some injuries (eg, bowel, bladder) can go unrecognized, and consequently, the patient can present with symptoms days to weeks after the procedure [18]. Fallopian incarceration can present at even longer intervals [19-21].

Such patients may present with acute or indolent symptoms, with or without peritonitis. Nonspecific symptoms include fever, tachycardia, abdominal or pelvic pain, abdominal distention, and vaginal discharge. Other signs and symptoms, such as ileus, hypotension, and hypothermia, may indicate a more severe infection.

This is described in detail separately. (See "Complications of laparoscopic surgery".)

EVALUATION AND MANAGEMENT — 

Patients with suspected uterine perforation may be managed expectantly, undergo diagnostic testing, or undergo surgical exploration. The choice of management depends on the timing of presentation, likelihood of hemorrhage or visceral injury, and type of instruments (eg, electrosurgical, blunt dilator) (algorithm 1).

In the absence of high-quality data, our approach is based on our clinical experience and expert opinion.

Intraoperative suspicion of perforation — If uterine perforation is suspected intraoperatively, the procedure should be halted immediately. All instruments are typically removed. If immediate abdominal exploration is planned, an instrument may be left in situ for better localization of the injury site. The patient should be kept in a stable position to avoid moving bowel loops away from the area. Retaining the "at risk" loops of the bowel in the pelvis facilitates the identification of injuries.

Vital signs are monitored, and an examination is performed to identify any other injuries (eg, cervical laceration). If occult bleeding is suspected (eg, due to deterioration in vital signs or abdominal distension), laboratory testing is performed to obtain hematocrit and coagulation studies. While imaging cannot confirm or exclude uterine perforation, intraoperative transvaginal or abdominal ultrasound can be used to assess for a broad ligament or retroperitoneal hematoma.

Symptomatic patients and asymptomatic patients at high risk of injury

●Immediate abdominal exploration is performed in patients:

•With signs of intraperitoneal hemorrhage or visceral injury (eg, hypotension, dropping hematocrit, increasing abdominal distension)

•In whom a high-risk instrument (eg, electrosurgical energy, morcellation, electric suction aspiration) was active at the time of perforation. The potential for serious injury with such instruments is increased.

•In whom the perforation occurred laterally (given the proximity to the uterine vessels); the risk of broad ligament hematoma formation in such patients is high [22].

The surgical technique of abdominal exploration is described below and in detail separately. (See 'Surgical technique' below and "Complications of laparoscopic surgery".)

●For patients in whom the perforation occurred anteriorly or posteriorly, cystoscopy or proctoscopy can help determine if abdominal exploration is warranted [22].

Asymptomatic patients at low risk of injury — Asymptomatic patients in whom uterine perforation is thought to have occurred at the fundus with a low-risk instrument (eg, cervical dilation with a blunt instrument, manual vacuum aspiration) or a high-risk instrument that was not active at the time of perforation can often be managed expectantly [2,4]. In our experience, the potential for vascular or visceral injury in such patients is low.

●Completing the original procedure – The original procedure may be completed under ultrasound guidance (and without use of electrical suction or an energy source) or laparoscopic guidance. Laparoscopy allows for direct visualization of the perforation site and retraction of surrounding structures.

However, for patients undergoing a hysteroscopic procedure, completing the procedure may not be possible if the hysteroscopic distending media is leaking from the perforation site and visualization becomes difficult. In such cases, the procedure may need to be aborted and rescheduled for a later date.

●Limited role of prophylactic antibiotics – In our practice, we do not give prophylactic antibiotics to asymptomatic patients with suspected uterine perforation. We treat with antibiotics only if clinical signs of infection (eg, endometritis, peritonitis) are present. No studies have addressed this issue.

●Postoperative care and follow-up – The patient is carefully monitored in the recovery room for deterioration in vital signs or active bleeding. This may reasonably occur over several hours. Hemoglobin and hematocrit (if not already performed) may be obtained and then repeated in three to four hours. A stable patient may be discharged home with strict instructions to call their clinician if pain is severe or persistent, vaginal bleeding is heavy, or there are other symptoms of ongoing complications of uterine perforation (eg, hematuria, abdominal distension, fever, lightheadedness). Any patient who calls with concerns or increasing symptoms postoperatively should be seen and evaluated promptly.

Patients should be counseled that they will likely experience mild cramping or light bleeding. Acetaminophen or nonsteroidal anti-inflammatory drugs are usually adequate for postoperative pain control. Other standard postoperative instructions for gynecologic procedures can generally be followed. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

We see patients for a follow-up visit one week following the procedure to discuss the procedure details and to assess for any other complications.

Postoperative or delayed suspicion of perforation — The possibility of uterine perforation with subsequent vascular or visceral injury must always be considered when managing a patient who presents with concerns after an intrauterine procedure. A high level of suspicion is required, as unrecognized injuries (eg, bowel) can be rapidly fatal. (See "Overview of gastrointestinal tract perforation".)

In addition to obtaining vital signs and performing a pelvic and abdominal examination, laboratory evaluation is obtained, which may include hematocrit, white blood cell count, coagulation testing, urine culture, and/or blood cultures.

In patients with anemia, fever, and/or pelvic mass or tenderness, pelvic ultrasound is the initial imaging test of choice to identify a broad ligament or retroperitoneal hematoma or a tubo-ovarian abscess and can also exclude some other etiologies of pelvic pain (eg, adnexal torsion). Additional imaging (eg, plain radiograph, computed tomography [CT]) is performed in those with suspected bowel or bladder injury. This is discussed in detail separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Primary evaluation and management' and "Overview of gastrointestinal tract perforation".)

If fallopian tube incarceration is suspected, hysteroscopy and laparoscopy are performed for diagnosis and management [19-21]. (See 'Surgical technique' below and "Complications of laparoscopic surgery".)

Specific complications are treated as appropriate (eg, transfusion, antibiotic therapy, surgical repair of a perforated viscus).

SURGICAL TECHNIQUE

●Mode of surgery – Abdominal exploration can often be accomplished laparoscopically, even in the presence of hemoperitoneum and/or acute bleeding. However, as it can be difficult to evaluate the entire bowel during laparoscopy and laparoscopic repair of some injuries can be challenging, laparotomy may be warranted in some patients.

Laparoscopy, compared with laparotomy, is associated with less perioperative morbidity. In a meta-analysis of 27 randomized clinical trials comparing operative laparoscopy with laparotomy for benign gynecologic conditions, the overall risk of minor complications (eg, fever, wound, or urinary tract infection) was lower in patients undergoing laparoscopic procedures [23]. Recovery time is also shorter after laparoscopy. One limitation of this meta-analysis, however, is that it did not include patients with uterine perforation or acute bleeding. This study is discussed in more detail separately. (See "Overview of gynecologic laparoscopic surgery and nonumbilical entry sites", section on 'Laparoscopy versus laparotomy'.)

●Procedure – Once the abdomen is entered, areas of brisk bleeding from the uterus or vessels should be controlled immediately. Bleeding from the uterine site can be stemmed using topical hemostatic agents; injection of intramyometrial vasoconstrictors, tourniquets, and/or electrocoagulation can also be used (see "Management of hemorrhage in gynecologic surgery", section on 'Topical hemostatic agents' and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Vasopressin and other vasoconstrictors' and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Tourniquets'). Large perforations (>1 cm) are reapproximated with sutures to prevent future bowel (or fallopian tube) incarceration. Depending on the site and extent of injury, resection of the perforated uterine segment may be necessary for repair [2]. Failing these measures, uterine artery embolization or hysterectomy may be needed in cases of brisk bleeding that cannot be controlled with more conservative measures [2,12]. It is important to note that when abdominal exploration is performed postoperatively, the absence of a visible defect does not exclude a previous uterine perforation, as small defects may spontaneously close after the procedure.

Adjacent structures are assessed for injury. If there is concern for ureteral or bladder injury, the integrity of these structures can be assessed by the intravenous administration of one of several dyes or by direct visualization. Cystoscopy can be used to assess the integrity of the bladder and is used to visualize the ureteral orifices and assess for bilateral flow. Findings consistent with bowel injury may be more difficult to identify (eg, hemorrhage into the bowel wall, blanching of the bowel if energy sources were used). Retroperitoneal injury may be similarly difficult to recognize. The surgeon should look carefully for enlarging retroperitoneal hematoma formation.

If injury to the bowel, bladder, or major vessels has occurred, consultation with a general surgeon, vascular surgeon, urologist, and/or interventional radiologist is obtained to help determine the extent of the injury and aid in management.

EFFECTS ON FUTURE REPRODUCTION — 

A uterine perforation, like any uterine incision, is likely to heal well. Adhesion formation is possible; however, no adverse effects of uterine perforation on fertility have been reported.

Uterine perforation may weaken the uterine wall and increase the risk of uterine rupture during a subsequent pregnancy [24-26]. However, the risk of uterine rupture in a subsequent pregnancy is likely small in the absence of other risk factors (eg, extensive hysteroscopic surgery, transmural myomectomy, previous cesarean birth). In our practice, we advise cesarean birth only for patients with uterine perforation and another risk factor for uterine rupture. (See "Choosing the route of delivery after cesarean birth".)

In one literature review including 18 reports of uterine rupture in patients who had a prior operative hysteroscopy, over half (10 patients) had a uterine perforation during the hysteroscopy; however, these patients also had other risk factors for rupture (eg, extensive hysteroscopic resection of a septum or adhesions and/or electrosurgery) [24]. A subsequent systematic review found 14 additional case reports of uterine rupture in pregnancy after an intervention complicated by uterine perforation [27]. Further high-quality studies are needed.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

SUMMARY AND RECOMMENDATIONS

●General principles – Uterine perforation is a potential complication of all intrauterine procedures. Injury to surrounding blood vessels or viscera (bladder, bowel) may result in hemorrhage or sepsis. (See 'Introduction' above.)

●Risk factors – Risk factors for uterine perforation include those that make access to the endometrial cavity difficult (eg, cervical stenosis, severe anteflexion, or retroflexion) or alter the strength of the myometrial wall (eg, pregnancy, lactation, menopause, previous uterine surgery). (See 'Risk factors' above.)

●Prevention

•Preprocedure preparation – For some patients, preprocedural cervical (eg, misoprostol, laminaria) or vaginal (eg, low-dose vaginal estrogen) preparation may be used to facilitate dilation and/or insertion of instruments into the uterine cavity and to decrease the risk of uterine perforation. This is discussed in detail separately. (See 'Role of preprocedure preparation' above and "Hysteroscopy: Instruments and procedure", section on 'Cervical preparation and dilation' and "Dilation and curettage", section on 'Cervical preparation' and "Intrauterine contraception: Insertion and removal", section on 'Misoprostol' and "Pregnancy termination: Cervical preparation for procedural abortion".)

•Intraoperative measures – Intraoperative measures that may help dilate the cervix and/or reduce uterine perforation include straightening the uterine axis by placing a tenaculum on the anterior lip of the cervix and applying gentile traction, using smaller instruments (eg, os finder, lacrimal duct probe, urologic dilators), utilizing intraoperative ultrasound, and performing vaginoscopy (without speculum insertion) to facilitate entry through the cervical canal. (See 'Intraoperative preventive measures' above.)

●Clinical presentation

•Intraoperatively, uterine perforation may present when a hole is identified in the uterine wall or when omentum, bowel, or adipose tissue is visualized in the endometrial cavity, suction instrument, or curettage specimen. Uterine perforation may also present intraoperatively as a sudden loss of resistance, an instrument passing beyond the expected length of the uterus, loss of visualization or distention during hysteroscopy, or clinical signs of visceral or vascular injury (eg, excessive bleeding, hypotension, acute onset of hematuria). (See 'Intraoperative' above.)

•In the immediate postoperative period or in the days/weeks after the procedure, symptoms and signs of uterine perforation are often nonspecific (eg, abdominal pain, vaginal bleeding, vaginal discharge, fever), and a high level of suspicion is required to identify such patients. (See 'Postoperative' above and 'Delayed' above and 'Postoperative or delayed suspicion of perforation' above.)

●Patients requiring surgical management (algorithm 1)

•Immediate abdominal exploration is required in patients with signs of intraperitoneal hemorrhage or visceral injury (eg, hypotension, dropping hematocrit, increasing abdominal distension), in whom a high-risk instrument (eg, electrosurgical energy, morcellation, electric suction aspiration) was active at the time of perforation, or if the perforation occurred laterally (given the proximity to the uterine vessels). The potential for serious injury with such instruments is high. (See 'Symptomatic patients and asymptomatic patients at high risk of injury' above.)

•For patients in whom the perforation occurred anteriorly or posteriorly, cystoscopy or proctoscopy can help determine if abdominal exploration is warranted. (See 'Symptomatic patients and asymptomatic patients at high risk of injury' above.)

•For patients with uterine perforation who require abdominal exploration, we suggest laparoscopy rather than laparotomy (Grade 2B). Laparoscopy can often be performed even in the presence of hemoperitoneum and/or acute bleeding. However, as it can be difficult to evaluate the entire bowel during laparoscopy and laparoscopic repair of some injuries can be challenging, laparotomy may be warranted in some patients. (See 'Surgical technique' above.)

●Candidates for observation – For asymptomatic patients in whom uterine perforation is thought to have occurred with a low-risk instrument (eg, cervical dilation with a blunt instrument, manual vacuum aspiration) or a high-risk instrument that was not active at the time of perforation, we suggest observation rather than immediate abdominal exploration (Grade 2C). In our experience, the potential for vascular or visceral injury in such patients is low. (See 'Asymptomatic patients at low risk of injury' above.)

●Effects on future reproduction – A uterine perforation, like any uterine incision, is likely to heal well. However, uterine perforation may weaken the uterine wall and increase the risk of uterine rupture during subsequent pregnancy. In the absence of other risk factors (eg, extensive hysteroscopic surgery, transmural myomectomy, previous cesarean birth), this risk is likely minimal. In our practice, we advise cesarean birth only for patients with uterine perforation and another risk factor for uterine rupture. (See 'Effects on future reproduction' above.)