Suspected Uterine Perforation

Uterine perforation is passage of the device or an instrument through the uterine wall, partial when part of the device lies in the myometrium and complete when it lies in the peritoneal cavity. It is uncommon, usually occurs at insertion, and is often silent. It can injure bowel, bladder, omentum and vessels. It is suspected when the sound or inserter passes deeper than expected, when the patient has sudden severe pain or collapse at insertion, or when the threads go missing afterwards.

Risk factors. Postpartum and postabortion insertion, breastfeeding, fixed or retroverted uterus, uterine anomaly, previous caesarean section, and an inexperienced inserter.

Immediate signs. Sudden loss of resistance, sound depth over the expected uterine length, severe pain, bleeding, vasovagal collapse, abdominal guarding or rigidity.

Delayed presentation. Missing threads, lower abdominal pain, fever, bowel or bladder symptoms, pregnancy, or discovery of a device on imaging.

Examination. Vital signs and oxygen saturation, abdominal tenderness, guarding and rigidity, and speculum examination for threads.

Differential diagnosis. Perforation, vasovagal reaction, severe cramping, cervical laceration, partial or complete expulsion, pelvic infection, ectopic pregnancy, and uterine rupture in a postpartum insertion.

Investigations.

• Pregnancy test and haemoglobin.
• Pelvic ultrasound to locate the device, and abdominal film if it is not in the uterus.
• Laparoscopy or hysteroscopy when imaging is inconclusive or removal is needed.
• Blood group and crossmatch when bleeding or instability is present.

Criteria for emergency referral. Severe abdominal pain, any change in vital signs, or peritoneal signs.

At the time of insertion. Stop the procedure immediately and remove the device and instruments. Keep the patient at rest, start an intravenous line, and monitor vital signs and abdominal tenderness, guarding and rigidity. Give prophylactic antibiotics.

Prophylactic antibiotic regimen. Ceftriaxone 1 g intravenously as a single dose with metronidazole 500 mg intravenously as a single dose. Reduce metronidazole in severe liver disease. Compatible with breastfeeding. In severe penicillin allergy use clindamycin 600 mg intravenously as a single dose.

Observation. Vital signs every 15 minutes for the first hour, then hourly for at least 4 to 6 hours. Discharge only if stable, comfortable, with no peritoneal signs and with a responsible adult, with instructions to return for increasing pain, fever, vomiting or bleeding.

Emergency surgery. Severe pain, unstable vital signs or peritoneal signs: refer for emergency laparoscopy or laparotomy to inspect and repair bowel, bladder and vessel injury.

Device found outside the uterus. Remove it by laparoscopy or laparotomy even if the patient is asymptomatic. A copper device provokes adhesions and bowel injury. A levonorgestrel device also needs removal.

Pain control. Paracetamol 1 g orally every 6 hours, maximum 4 g daily (3 g in liver disease or weight under 50 kg). Avoid NSAIDs until bleeding and visceral injury are excluded.

Backup contraception. Condoms or another method until a new method is established. If unprotected sex has occurred, give levonorgestrel 1.5 mg orally as a single dose within 120 hours.

Follow up. Review within 1 week and at 4 to 6 weeks. Check wound or port site and symptoms. Confirm removal of any extrauterine device.

Method decisions. Delay a new intrauterine device for at least 6 weeks after perforation, and place it with ultrasound control by an experienced provider. Offer an implant, injectable or another method meanwhile.

Referral and escalation. Refer for emergency surgery with peritoneal signs or instability, for every device found outside the uterus, and for any patient discharged home who returns with pain, fever or vomiting.