Gupta AS
Gynecology has few surgical procedures that are done more by the tactile senses rather than under direct vision. These procedures are D&C, suction evacuation for termination of pregnancy, uterine manipulation during laparoscopic evaluation for infertility, insertion of the Veres’ needle or trocar cannula for primary port placement during a laparoscopy. Almost all intrauterine procedures can result in uterine injuries. Some of these injuries can have serious immediate complications, some have serious late sequlae and some of them may go unnoticed.
It is actually difficult to know the true incidence of uterine perforations as most of these are self reported and as mentioned earlier since some of the procedures are blind and only dependent on tactile sensation they can be missed unless there is a high degree of suspicion which is then followed through by diagnostic laparoscopy to confirm presence or absence of a uterine perforation.
Perforations that occur by a uterine sound, a curette with no suction connected, a dilator usually do not have immediate or acute presentations unless the lateral uterine wall involving the uterine vessels is injured. In such a case signs of acute blood loss would be the clinical presentation. Perforations that occur during a suction evacuation of a pregnant uterus or when instruments like ovum forceps are used that can avulse tissues they need to be evaluated carefully immediately as they can result in not only uterine injuries but also injury to hollow viscus like the bowel and bladder with disastrous life threatening morbidity and mortality.
Confirmation of a uterine perforation is done by laparoscopy and if perforation is present then it can be repaired by laparoscopy depending on the expertise of the surgeon or by laparotomy. Procedure like evacuation of a pregnancy is completed under laparoscopic guidance. When there is injury during suction evacuation or by an ovum forceps then the entire bowel and its mesentery should be minutely evaluated to detect and then repair the trauma.
Injuries that occur in a uterus heal by various degrees of fibrosis and the scar in a small non gravid uterus would be negligible or insignificant. However, when these women conceive, some unique problems can develop. First of all the placenta that forms may develop morbid adhesions focally on this scar tissue due to defect in the decidual basalis and its Nitabuch layer. This allows the trophoblast to penetrate beneath the decidua and attach to the myometrium or the serosa or also go beyond the serosa resulting in placenta accreta, increta or percreta respectively. Pregnancy with morbid adhered placenta is high risk with serious consequences to the mother and the child. Scar tissue does not have the elasticity and the distensibility of the normal myometrium. As the pregnancy grows the scar tissue stretches and thins out and can rupture. Old uterine injuries in the upper segment will be more likely to get disrupted then injuries and scars in the lower segment and these upper segment scars may give way in the antenatal rather than intrapartum period. Almost 40 % of the times the placenta will implant on the anterior wall of the upper segment and anterior perforations being the commonest can result in morbidly adhered placenta or rupture uterus or both.
In this issue of our esteemed journal we bring one such case who presented with uterine rupture and had a placenta percreta at the site of the rupture that we suspect occurred due to an occult remote uterine injury. Unfortunately her uterus had to be removed and her reproductive career got curtailed.
The august issue of our journal is now in your hand and I hope that you enjoy the collection of cases that we have presented in this issue.