Management of Lateral Uterine Perforation at the Time of Hysteroscopy
Lateral uterine perforation at the time hysteroscopy is a rare, but potentially dangerous complication. The overall rate of hysteroscopic complications is low and diagnostic procedures have a lower rate than operative. Most perforations occur during insertion of the hysteroscope, tend to be located in the fundus, and are usually self-limited and less serious. Procedure type affects risk, and adhesiolysis has higher complication rate than polypectomy.
The uterine artery is the main source of blood to the uterus, along with anastomoses from the vaginal artery. Severe bleeding from lateral uterine perforations, albeit rare, can have catastrophic consequences. These perforations can be managed by laparoscopy or laparotomy, and may require emergent hysterectomy. The risks are related to the underlying cause of the damage to the lateral wall. If there is any concern for damage to surrounding organs, the threshold for directly visualizing the pelvis and bowel should be low. Lateral wall uterine perforations can lead to the development of a retroperitoneal hematoma, and cervical perforations can result in significant immediate or delayed bleeding. Laparoscopy or laparotomy may be needed to determine the extent of damage, including bowel or bladder injury.
Laparoscopic suturing of a perforation, placement of sutures during laparotomy, hysterectomy, or uterine artery embolization may be necessary. Keeping an open line of communication with the anesthesia team is also critical, especially as fluid overload or embolism may accompany the perforation. Any damage to the uterine vasculature may increase the chance of fluid overload as there is now an easier portal of entry for the distention media.
There is no evidence that the addition of antibiotics in these cases improves outcomes.
American College of Obstetricians and Gynecologists, ACOG Technology Assessment in Obstetrics and Gynecology. 2018 Obstet Gynecol 2018;131:e140-e150.
Jansen FW, Vredevoogd CB, Van Ulzen K, et al, Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000 Aug;96(2):266-70.
Probst AM, Lieberman RF, Harlow BL, Ginsburg ES. Complications of hysteroscopic surgery: predicting patients at risk. Obstet Gynecol. 2000 Oct;96(4):517-20.
Initial Approval July 2012, Revised July 2015, Reaffirmed January 2017; Reaffirmed July 2018; Reaffirmed January 2020.
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