Aust NZ J Obstet Gynaecol 1992; 3 2 4: 359
Uterine Perforation Associated with Endometrial Ablation David Itzkowicl, FRACOG, FRCOG and Mark Beale’, FRACOG, FRCOG Royal Hospital for Women, Paddington, New South Wales
Summary: Three cases of uterine perforation associated with endometrial ablation are presented. Possible predisposing factors in 2 cases were previous Caesarean section and difficulty in cervical dilatation. Adequate training for gynaecologists in hysteroscopy is essential before undertaking any type of operative hysteroscopy. Endometrial ablation has been recommended as an alternative to hysterectomy for some patients with menorrhagia and other menstrual abnormalities (1,2). The procedure, with its reduced morbidity and hospital stay has obvious advantages, and is rapidly becoming popular in Australia. However, complications have occurred in each of the series reported in this country (1-3). We wish to report 2 cases referred to us after uterine perforation associated with failed endometrial ablation, and 1 uterine perforation from amongst our own patients.
Case Reports
Case I A 39-year-old woman had had 3 normal deliveries. For the last 4 years she had heavy periods. Dilatation and curettage showed no abnormality, and although she had some relief from progestogen and then Danocrine therapy, her heavy periods returned after cessation of this treatment. Under general anaesthesia she had an endometrial resection using a wire loop and cutting diathermy, apparently without any obvious problem. Postoperatively she had severe right iliac fossa pain requiring pethidine. Six weeks later she had a very heavy period which lasted 10 days, and this recurred approximately monthly thereafter associated with clots and colicky pain. She developed an offensive malodorous discharge which she described as ‘dead meat’, and was treated with antibiotics without relief. Vaginal examination 10 months postoperatively revealed an offensive vaginal discharge, and a bulky, tender anteverted uterus, which was of limited mobility. The tenderness was maximal on the right lateral aspect in the region of the broad ligament. Investigation revealed an elevated white cell count (11,2OO/cc, neutrophilia). A cervical swab grew no pathogen!. Diagnostic hysteroscopy under general anaesthesia using normal saline for uterine distension revealed a necrotic area 4 cm long and 2 cm wide along the right ~
1. Visiting Medical Officer.
Address for correspondence: Dr. David Itzkowic, Suite 3, Ebley House, 106 Ebley Street, Bondi Junction, New South Wales, 2022.
~
~~~~
lateral wall extending upwards from the internal 0s. The remainder of the uterine cavity appeared normal. At laparotomy (MB), a uterine perforation 4 cm in length was found on the right lateral wall extending upwards from just above the level of the internal 0s. The perforation communicated with both the peritoneal cavity and the broad ligament. The right ureter was adherent to the cervix at the lower end of the perforation. Total abdominal hysterectomy was performed. The patient made a good recovery. Pathology confirmed the large uterine perforation (figures 1 and 2). Proliferative endometrium was found throughout the uterine cavity.
Case 2 The woman, aged 39 years, had had a miscarriage then 3 Caesarean sections. The first of these was followed by a prolonged wound infection. At the third Caesarean the lower segment scar was noted to be ‘paper thin’. She had had menorrhagia for 8 years. Diagnostic hysteroscopy and curettage showed no abnormality and oral progestogen therapy gave no relief. Endometrial resection was undertaken under general anaesthesia. The cervix was found to be difficult to dilate. After the anterior uterine wall had been resected, the resectoscope was removed and upon reinsertion the uterus and bladder were perforated at the point of Caesarean incision in the upper cervical canal. The perforation was recognized, and before laparotomy to repair the perforation, an attempt was made to resect the posterior wall. At laparotomy perforations were found in the bladder, midline above the ureteric orifices and in the uterus as previously described. The bladder perforation was oversewn. No attempt was made to repair the uterus. The patient made a good recovery. However she then had 2 very heavy periods and presented requesting a repeat endometrial ablation. She was advised that there was considerable risk of repeat perforation. It was recommended that if at diagnostic hysteroscopy conditions were favourable then repeat ablation would be attempted. However if this was not so, or if uterine perforation occurred then abdominal hysterectomy would be done. She agreed to this plan and was given Danocrine 200 mg tds for 1 month to prepare the endometrium. At diagnostic hysteroscopy, performed under
3 60
AUST.A N D N.Z. JOURNAL OF OBSTETRICS A N D GYNAECOLOCY
Figure 1. Perforation of lateral wall of uterus above the level of the cervix.
Figure 2. Transverse section through uterus showing perforation.
general anaesthesia using carbon dioxide insufflation for uterine distension, a tent shaped defect was seen in the anterior cervical wall near the internal 0s. The uterine cavity was easily entered and appeared perfectly normal. The cervix was dilated to 10 mm and a rollerball endometrial ablation (DI) performed. Seventy watts of coagulation diathermy was used, each area being treated twice. Uterine distension was achieved with 1.5% glycine infusion under gravity. Six litres were infused and recovered. The patient was discharged from hospital 5 hours postoperatively.
become an increasing problem. The uterus was anteverted, and the cavity was sounded to 6 cm. The cervix was dilated to 10 cm with some difficulty, and rollerball ablation (DI) commenced with 1.5% glycine distension under gravity. The uterine cavity appeared normal. After the anterior, lateral and half the posterior walls had been completed, the resectoscope was removed to clean the ball electrode. Upon reinsertion of the resectoscope some difficulty was encountered due to tightness of the cervix, which ‘gave’ suddenly resulting in perforation of the fundus. The perforation was recognized. There was no bleeding. Uterine distension was maintained sufficiently to allow the remainder of the posterior wall to be treated and the operation was completed within a few minutes. Approximately two litres of 1.5% glycine was lost into the peritoneal cavity. Postoperatively the electrolytes remained normal. The intraperitoneal fluid was resorbed within 48 hours and the patient was discharged; 27 months postoperatively she has regular menstruation consisting of staining only for 2 days.
Case 3
This woman was aged 26 years, nulliparous and had Friedrich ataxia resulting in confinement to a wheelchair due to gross motor impairment. She could not manage her menstruation and had been treated for some years with Depo-Provera resulting in amenorrhoea. In the 12 months before referral for endometrial ablation, irregular prolonged vaginal bleeding had
DAVIDITZKOWIC AND MARKBEALE
DISCUSSION Uterine perforation is a recognized complication of endometrial ablation. Once perforation has occurred damage to other structures such as bowel, bladder or large blood vessels may occur. In Case 2 above, bladder perforation probably occurred due to a very thin uterine wall and an adherent bladder resulting from Caesarean section. Previous Caesarean section is sometimes associated with a tent shaped defect in the anterior cervical wall near the internal 0s. This should be looked for, and carefully avoided if present. Petrucco and Gillespie (2) reported a case of uterine perforation at the fundus associated with bowel damage during endometrial resection. Resection and anastomosis of a section of small bowel was required. Table 1. Complications Reported in 206 Patients Following Hysteroscopie Surgery (1-3) ~
Complication Haemorrhage Infection Haematometra Perforation of uterus Pregnancy
No. of patients 5 5
361
paras, those on Provera for prolonged periods, postmenopausal patients and patients delivered by Caesarean section. Easy insertion of the resectoscope will help prevent perforation of the uterus from this cause. In the 3 Australian series quoted, most of the patients had an endometrial ablation, either by laser, rollerball or resection. The patients reported were amongst the first patients treated by the authors with these new techniques. The incidence of uterine perforation was approximately 1 in 50 (4 of 206 patients). This risk is likely to decline with increasing experience and expertise. The complications reported in these 3 series are listed in table 1. These 3 cases of uterine perforation illustrate one of the possible complications that may be associated with endometrial ablation, and serve to remind us that adequate training in diagnostic and operative hysteroscopy is essential for gynaecologists planning to perform endometrial ablation or other operative hysteroscopic procedures.
2 4 1
In Case 3, perforation was associated with a tight cervix and difficulty with insertion of the resectoscope into the uterus. Consideration should be given to dilatation of the cervix preoperatively in cases where difficulty in dilating the cervix may be anticipated, such as nulli-
References 1. Maher PJ, Hill DJ. Transcervical endornetrial resection for abnormal uterine bleeding -report of 100 cases and review of the literature. Aust NZ J Obstet Gynaecol 1990; 30: 357-360. 2. Pettrucco OM, Gillespie A. The Neodymium: YAG laser and the resectoscope for the treatment of menorrhagia. Med J Aust 1991; 154: 518-520. 3. Lower AM, Richardson PA, Jequier AM. Letter, Aust NZ J Obstet Gynaecol 1991; 31: 192-193.
Uterine Perforation Associated with Endometrial Ablation David Itzkowicl, FRACOG, FRCOG and Mark Beale’, FRACOG, FRCOG Royal Hospital for Women, Paddington, New South Wales
Summary: Three cases of uterine perforation associated with endometrial ablation are presented. Possible predisposing factors in 2 cases were previous Caesarean section and difficulty in cervical dilatation. Adequate training for gynaecologists in hysteroscopy is essential before undertaking any type of operative hysteroscopy. Endometrial ablation has been recommended as an alternative to hysterectomy for some patients with menorrhagia and other menstrual abnormalities (1,2). The procedure, with its reduced morbidity and hospital stay has obvious advantages, and is rapidly becoming popular in Australia. However, complications have occurred in each of the series reported in this country (1-3). We wish to report 2 cases referred to us after uterine perforation associated with failed endometrial ablation, and 1 uterine perforation from amongst our own patients.
Case Reports
Case I A 39-year-old woman had had 3 normal deliveries. For the last 4 years she had heavy periods. Dilatation and curettage showed no abnormality, and although she had some relief from progestogen and then Danocrine therapy, her heavy periods returned after cessation of this treatment. Under general anaesthesia she had an endometrial resection using a wire loop and cutting diathermy, apparently without any obvious problem. Postoperatively she had severe right iliac fossa pain requiring pethidine. Six weeks later she had a very heavy period which lasted 10 days, and this recurred approximately monthly thereafter associated with clots and colicky pain. She developed an offensive malodorous discharge which she described as ‘dead meat’, and was treated with antibiotics without relief. Vaginal examination 10 months postoperatively revealed an offensive vaginal discharge, and a bulky, tender anteverted uterus, which was of limited mobility. The tenderness was maximal on the right lateral aspect in the region of the broad ligament. Investigation revealed an elevated white cell count (11,2OO/cc, neutrophilia). A cervical swab grew no pathogen!. Diagnostic hysteroscopy under general anaesthesia using normal saline for uterine distension revealed a necrotic area 4 cm long and 2 cm wide along the right ~
1. Visiting Medical Officer.
Address for correspondence: Dr. David Itzkowic, Suite 3, Ebley House, 106 Ebley Street, Bondi Junction, New South Wales, 2022.
~
~~~~
lateral wall extending upwards from the internal 0s. The remainder of the uterine cavity appeared normal. At laparotomy (MB), a uterine perforation 4 cm in length was found on the right lateral wall extending upwards from just above the level of the internal 0s. The perforation communicated with both the peritoneal cavity and the broad ligament. The right ureter was adherent to the cervix at the lower end of the perforation. Total abdominal hysterectomy was performed. The patient made a good recovery. Pathology confirmed the large uterine perforation (figures 1 and 2). Proliferative endometrium was found throughout the uterine cavity.
Case 2 The woman, aged 39 years, had had a miscarriage then 3 Caesarean sections. The first of these was followed by a prolonged wound infection. At the third Caesarean the lower segment scar was noted to be ‘paper thin’. She had had menorrhagia for 8 years. Diagnostic hysteroscopy and curettage showed no abnormality and oral progestogen therapy gave no relief. Endometrial resection was undertaken under general anaesthesia. The cervix was found to be difficult to dilate. After the anterior uterine wall had been resected, the resectoscope was removed and upon reinsertion the uterus and bladder were perforated at the point of Caesarean incision in the upper cervical canal. The perforation was recognized, and before laparotomy to repair the perforation, an attempt was made to resect the posterior wall. At laparotomy perforations were found in the bladder, midline above the ureteric orifices and in the uterus as previously described. The bladder perforation was oversewn. No attempt was made to repair the uterus. The patient made a good recovery. However she then had 2 very heavy periods and presented requesting a repeat endometrial ablation. She was advised that there was considerable risk of repeat perforation. It was recommended that if at diagnostic hysteroscopy conditions were favourable then repeat ablation would be attempted. However if this was not so, or if uterine perforation occurred then abdominal hysterectomy would be done. She agreed to this plan and was given Danocrine 200 mg tds for 1 month to prepare the endometrium. At diagnostic hysteroscopy, performed under
3 60
AUST.A N D N.Z. JOURNAL OF OBSTETRICS A N D GYNAECOLOCY
Figure 1. Perforation of lateral wall of uterus above the level of the cervix.
Figure 2. Transverse section through uterus showing perforation.
general anaesthesia using carbon dioxide insufflation for uterine distension, a tent shaped defect was seen in the anterior cervical wall near the internal 0s. The uterine cavity was easily entered and appeared perfectly normal. The cervix was dilated to 10 mm and a rollerball endometrial ablation (DI) performed. Seventy watts of coagulation diathermy was used, each area being treated twice. Uterine distension was achieved with 1.5% glycine infusion under gravity. Six litres were infused and recovered. The patient was discharged from hospital 5 hours postoperatively.
become an increasing problem. The uterus was anteverted, and the cavity was sounded to 6 cm. The cervix was dilated to 10 cm with some difficulty, and rollerball ablation (DI) commenced with 1.5% glycine distension under gravity. The uterine cavity appeared normal. After the anterior, lateral and half the posterior walls had been completed, the resectoscope was removed to clean the ball electrode. Upon reinsertion of the resectoscope some difficulty was encountered due to tightness of the cervix, which ‘gave’ suddenly resulting in perforation of the fundus. The perforation was recognized. There was no bleeding. Uterine distension was maintained sufficiently to allow the remainder of the posterior wall to be treated and the operation was completed within a few minutes. Approximately two litres of 1.5% glycine was lost into the peritoneal cavity. Postoperatively the electrolytes remained normal. The intraperitoneal fluid was resorbed within 48 hours and the patient was discharged; 27 months postoperatively she has regular menstruation consisting of staining only for 2 days.
Case 3
This woman was aged 26 years, nulliparous and had Friedrich ataxia resulting in confinement to a wheelchair due to gross motor impairment. She could not manage her menstruation and had been treated for some years with Depo-Provera resulting in amenorrhoea. In the 12 months before referral for endometrial ablation, irregular prolonged vaginal bleeding had
DAVIDITZKOWIC AND MARKBEALE
DISCUSSION Uterine perforation is a recognized complication of endometrial ablation. Once perforation has occurred damage to other structures such as bowel, bladder or large blood vessels may occur. In Case 2 above, bladder perforation probably occurred due to a very thin uterine wall and an adherent bladder resulting from Caesarean section. Previous Caesarean section is sometimes associated with a tent shaped defect in the anterior cervical wall near the internal 0s. This should be looked for, and carefully avoided if present. Petrucco and Gillespie (2) reported a case of uterine perforation at the fundus associated with bowel damage during endometrial resection. Resection and anastomosis of a section of small bowel was required. Table 1. Complications Reported in 206 Patients Following Hysteroscopie Surgery (1-3) ~
Complication Haemorrhage Infection Haematometra Perforation of uterus Pregnancy
No. of patients 5 5
361
paras, those on Provera for prolonged periods, postmenopausal patients and patients delivered by Caesarean section. Easy insertion of the resectoscope will help prevent perforation of the uterus from this cause. In the 3 Australian series quoted, most of the patients had an endometrial ablation, either by laser, rollerball or resection. The patients reported were amongst the first patients treated by the authors with these new techniques. The incidence of uterine perforation was approximately 1 in 50 (4 of 206 patients). This risk is likely to decline with increasing experience and expertise. The complications reported in these 3 series are listed in table 1. These 3 cases of uterine perforation illustrate one of the possible complications that may be associated with endometrial ablation, and serve to remind us that adequate training in diagnostic and operative hysteroscopy is essential for gynaecologists planning to perform endometrial ablation or other operative hysteroscopic procedures.
2 4 1
In Case 3, perforation was associated with a tight cervix and difficulty with insertion of the resectoscope into the uterus. Consideration should be given to dilatation of the cervix preoperatively in cases where difficulty in dilating the cervix may be anticipated, such as nulli-
References 1. Maher PJ, Hill DJ. Transcervical endornetrial resection for abnormal uterine bleeding -report of 100 cases and review of the literature. Aust NZ J Obstet Gynaecol 1990; 30: 357-360. 2. Pettrucco OM, Gillespie A. The Neodymium: YAG laser and the resectoscope for the treatment of menorrhagia. Med J Aust 1991; 154: 518-520. 3. Lower AM, Richardson PA, Jequier AM. Letter, Aust NZ J Obstet Gynaecol 1991; 31: 192-193.
