Presentation
Recent surgical TOP at 21/40. Acute abdominal pain. Tender and distended abdomen.
Patient Data
Multiple fetal parts, including vertebrae, pelvis and femora, lie posterior to the uterus within the peritoneal cavity with closely associated free fluid and gas.
No intrauterine fetal parts identified.
Enlarged postpartum uterus with a large defect of the posterior aspect of its lower segment.
Inflated Foley catheter balloon in an empty bladder.
Other intra-abdominal viscera are unremarkable (mild bilateral pelvicalyceal fullness c/w 2nd trimester pregnancy).
Conclusion:
Perforated uterus post TOP with extrauterine migration of fetal parts, and free gas and fluid.
Presence of free gas raises possibility of bowel perforation. For urgent obstetric opinion.
Case Discussion
This young female patient had had a recent surgical termination of pregnancy performed elsewhere and had presented to our institution in extremis.
Uterine perforation is fortunately rare and may be either iatrogenic or a spontaneous event. Iatrogenic causes include virtually any O&G procedure including dilatation and curettage (D&C), hysteroscopy, IUCD insertion, etc. Spontaneous perforation is rarer and etiologies include gestational trophoblastic disease, pyometra, placenta accreta or even degenerating fibroid.
Uterine perforation following surgical termination of pregnancy is a rare event, usually in women that have had previous gynecological surgery 1. More rarely still is the passage of fetal parts into the abdominal cavity, with little in the published literature 2,3. In some cases of iatrogenic uterine perforation the perforation goes unrecognised during the initial procedure. D&C is considered a well-tolerated procedure with a low incidence of complications. Uterine perforation has been reported to occur in 0.07 to 1.2% cases 3.
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