Teaching Case

A 27-year-old married female patient presented to the emergency department with active complaints of per-vaginal bleeding for two days and non-specific abdominal pain. Her symptoms started shortly after termination of an 18-week pregnancy via dilatation and curettage from a midwife outside the primary care hospital.

Abdominal X-ray showed dilated small bowel loops suggestive of intestinal obstruction. There were no definite signs of pneumoperitoneum. The large bowel was not dilated (Fig. 1). Contrast-enhanced computed tomography (CT) scan of abdomen and pelvis showed a large defect in the wall of uterine fundus measuring approximately 16 mm. The distal ileal loops and omental fat were seen herniating into the uterine cavity through this defect with extension into the cervix and upper vagina. These herniated loops appeared oedematous with grey attenuation and a speck of extra-mural air was also seen, suggestive of a strangulated hernia within the uterine cavity and bowel infarction (Fig. 2). The proximal small bowel loops were dilated and distal ileal loops were collapsed indicating mechanical obstruction.

Complications of dilatation and curettage (D&C) performed for abortion purposes include haemorrhage, infection and very rarely, uterine perforation. The incidence of uterine perforation, one of the most serious complications, is reported to be in between 0.07% to 1.2% [1]. Risk factors associated with uterine perforation include increased maternal age, greater parity, advanced gestational age, history of prior caesarean section and uterine attitude [2]. Cases with presence of acutely retroflexed uterus or uterine leiomyomas at the time of surgical termination are also more prone to uterine perforations. Increased experience of the surgeon and use of osmotic cervical dilation are protective factors. Uterine perforation is the reason for two thirds of hysterectomies performed for complications of D&C [3].

The most common location of myometrial perforation is along the fundus and at the relative avascular anterior or posterior midline surfaces [4]. Perforations are more likely to be troublesome if the rent is located laterally, the defect is more than 1.2 cm, they occur after the first trimester, or there is associated bowel injury. Perforations are generally recognised by the operator during the procedure in most of the cases, however, in many cases they may remain clinically undiagnosed and the patient is discharged.

Uterine perforation with suspected bowel entrapment diagnosed with ultrasound was first reported in 1983 by Dunner et al [5]. Rent in the wall of uterus can be seen with per-abdominal ultrasound. Cystic structures with echogenic foci giving dirty shadowing can be identified in the endometrial canal which can suggest herniated bowel with air. Free fluid with echogenic debris or echoes can be seen in cul-de-sac indicative of blood. Transvaginal ultrasound can be utilised to diagnose uterine perforation because it can identify free fluid within the pelvis, bowel loops herniating through the uterine wall, extrauterine fetal body parts or intraoperative presence of the curette within the myometrium [6]. Colour Doppler will not help and usually no colour flow will be identified in these structures due to aperistalsis in the intrauterine contents [7].

CT has a pivotal role in diagnosing in complex cases where ultrasound has limitations. In cases where bowel loops in the uterine cavity cannot be differentiated clearly, mesenteric fat can provide a clue to intrauterine bowel loops [8]. MRI of pelvis and abdomen has been used to evaluate the endometrial canal after a first trimester surgical abortion, but it is not a routine investigation in an emergency scenario [9]. Only one case is recorded in which there was incarceration of the greater omentum in the uterine cavity but without mechanical obstruction or strangulation [10].

Therefore, to conclude, uterine perforation with intrauterine bowel herniation/prolapse and strangulation should be in the differential diagnosis for patients who undergo instrumental abortion and come with signs of intestinal obstruction.

Written informed patient consent for publication has been obtained.