Management of Lateral Uterine Perforation at the Time of Hysteroscopy
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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, are located at the fundus, and are self-limited and less serious. Procedure type affects risk, and procedures that include adhesiolysis have higher complication rates than simple polypectomies.
The main blood supply to the uterus comes through the uterine artery, along with anastomoses from the vaginal artery. Lateral uterine perforations, while rare, can lead to severe bleeding and catastrophic consequences. These perforations can be managed by laparoscopy or laparotomy, and may require emergent hysterectomy. 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.
Suturing of a perforation, either laparoscopically or via laparotomy, hysterectomy, or uterine artery embolization may be necessary. Clinicians must keep an open line of communication with the anesthesia team, especially as fluid overload or embolism may accompany the perforation. Damage to the uterine vasculature may increase the risk of fluid overload, as such damage can enable entry of distention media into the vasculature.
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; Revised September 2021; Revised May 2023.
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