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Appearance of uterine perforation by hysterosalpingography
IMAGES IN REPRODUCTIVE MEDICINE
FERTILITY AND STERILITY威 VOL. 82, NO. 5, NOVEMBER 2004 Copyright ©2004 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A.
Appearance of uterine perforation by hysterosalpingography Laurie Jane McKenzie, M.D., Ertug Kovanci, M.D., Paula Amato, M.D., John Buster, M.D., and Sandra Carson, M.D. Baylor College of Medicine, Houston, Texas
The appearance of a uterine perforation that occurred at the time of office hysteroscopy is shown via hysterosalpingogram and laparoscopy. (Fertil Steril威 2004;82:1428 –9. ©2004 by American Society for Reproductive Medicine.)
A 29-year-old woman underwent an office hysteroscopy 3 months after a repeat dilation and curettage for retained products of conception. The uterus was sounded to 7 cm and the fundus was visualized; however, the cornuae were obscured secondary to the presence of synechiae. A hysterosalpingogram demonstrated a fundal perforation, left of midline, that was believed to have occurred at time of hysteroscopy. Both fallopian tubes were patent and demonstrated free spillage of contrast. There was moderate intravasation of contrast material within the venous structures of the pelvis during fluoroscopic examination (Figs. 1 and 2), most pronounced on the patient’s left. Hysteroscopy and laparoscopy obtained 1 month after the hysterosalpingogram demonstrated an arcuate uterus and a region of healing at the prior perforation site (Fig. 3). Intrauterine synechiae were easily lysed.
Received July 14, 2004; revised and accepted July 14, 2004. Reprint requests: Laurie Jane McKenzie, M.D., Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, 6550 Fannin Street, Suite 801, Houston, Texas 77030 (FAX: 713798-6883; E-mail: [email protected]). 0015-0282/04/$30.00 doi:10.1016/j.fertnstert.2004. 07.926
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Management of Acute Uterine Perforation Uterine perforation is suspected if the depth of passage of the sound or dilator is
greater than the apparent uterine size. Very rapid flow of distention media or a low distention pressure with CO2 at the time of hysteroscope insertion should raise the suspicion of perforation. When uterine perforation occurs, the procedure must be abandoned. Marked intravasation of distention media may occur with normal infusion pressure through open uterine venous channels, or as in the case above, in the presence of uterine perforation (1). Hence, monitoring of intake and output of fluids during hysteroscopy is imperative to prevent fluid overload. When nonelectrolyte solutions are used as distention media, a discrepancy of 1,000 mL of fluids requires serum electrolyte assessment, and with a discrepancy of 1,500 mL, termination of the procedure should be considered (2). References 1. Vulgaropulos SP, Haley LC, Hulka JF. Intrauterine pressure and fluid absorption during continuous hysteroscopy. Am J Obstet Gynecol 1992;167:386 – 8. 2. Donnex J, Nisolle M. An atlas of operative laparoscopy and hysteroscopy. 2nd ed. New York: Parthenon Publishing, 2001.
FIGURE 1
FIGURE 2
Hysterosalpingogram of uterine perforation after office hysteroscopy. The perforation is in the fundal region, displaced left of midline (arrow). There is normal tubal patency bilaterally.
Note the marked venous intravasation of contrast, more pronounced in this later image. The patient’s left side, the site of perforation, demonstrates greater intravasation. Perforated site marked (arrow).
McKenzie. Uterine perforation. Fertil Steril 2004.
McKenzie. Uterine perforation. Fertil Steril 2004.
FIGURE 3 Laparoscopic view of the uterus 1 month after perforation. Note the region of healing at the prior perforation site (arrow).
McKenzie. Uterine perforation. Fertil Steril 2004.
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FERTILITY AND STERILITY威 VOL. 82, NO. 5, NOVEMBER 2004 Copyright ©2004 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A.
Appearance of uterine perforation by hysterosalpingography Laurie Jane McKenzie, M.D., Ertug Kovanci, M.D., Paula Amato, M.D., John Buster, M.D., and Sandra Carson, M.D. Baylor College of Medicine, Houston, Texas
The appearance of a uterine perforation that occurred at the time of office hysteroscopy is shown via hysterosalpingogram and laparoscopy. (Fertil Steril威 2004;82:1428 –9. ©2004 by American Society for Reproductive Medicine.)
A 29-year-old woman underwent an office hysteroscopy 3 months after a repeat dilation and curettage for retained products of conception. The uterus was sounded to 7 cm and the fundus was visualized; however, the cornuae were obscured secondary to the presence of synechiae. A hysterosalpingogram demonstrated a fundal perforation, left of midline, that was believed to have occurred at time of hysteroscopy. Both fallopian tubes were patent and demonstrated free spillage of contrast. There was moderate intravasation of contrast material within the venous structures of the pelvis during fluoroscopic examination (Figs. 1 and 2), most pronounced on the patient’s left. Hysteroscopy and laparoscopy obtained 1 month after the hysterosalpingogram demonstrated an arcuate uterus and a region of healing at the prior perforation site (Fig. 3). Intrauterine synechiae were easily lysed.
Received July 14, 2004; revised and accepted July 14, 2004. Reprint requests: Laurie Jane McKenzie, M.D., Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, 6550 Fannin Street, Suite 801, Houston, Texas 77030 (FAX: 713798-6883; E-mail: [email protected]). 0015-0282/04/$30.00 doi:10.1016/j.fertnstert.2004. 07.926
1428
Management of Acute Uterine Perforation Uterine perforation is suspected if the depth of passage of the sound or dilator is
greater than the apparent uterine size. Very rapid flow of distention media or a low distention pressure with CO2 at the time of hysteroscope insertion should raise the suspicion of perforation. When uterine perforation occurs, the procedure must be abandoned. Marked intravasation of distention media may occur with normal infusion pressure through open uterine venous channels, or as in the case above, in the presence of uterine perforation (1). Hence, monitoring of intake and output of fluids during hysteroscopy is imperative to prevent fluid overload. When nonelectrolyte solutions are used as distention media, a discrepancy of 1,000 mL of fluids requires serum electrolyte assessment, and with a discrepancy of 1,500 mL, termination of the procedure should be considered (2). References 1. Vulgaropulos SP, Haley LC, Hulka JF. Intrauterine pressure and fluid absorption during continuous hysteroscopy. Am J Obstet Gynecol 1992;167:386 – 8. 2. Donnex J, Nisolle M. An atlas of operative laparoscopy and hysteroscopy. 2nd ed. New York: Parthenon Publishing, 2001.
FIGURE 1
FIGURE 2
Hysterosalpingogram of uterine perforation after office hysteroscopy. The perforation is in the fundal region, displaced left of midline (arrow). There is normal tubal patency bilaterally.
Note the marked venous intravasation of contrast, more pronounced in this later image. The patient’s left side, the site of perforation, demonstrates greater intravasation. Perforated site marked (arrow).
McKenzie. Uterine perforation. Fertil Steril 2004.
McKenzie. Uterine perforation. Fertil Steril 2004.
FIGURE 3 Laparoscopic view of the uterus 1 month after perforation. Note the region of healing at the prior perforation site (arrow).
McKenzie. Uterine perforation. Fertil Steril 2004.
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