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Uterine rupture following perforation during curettage
Letters to the Editor 285
K.K. Mar’ P. Deyb A. Sauc
BGynaecology Department, bCytology and Gynaecologic Pathology cGynaecology Department, P.G.I.M.E.R., Chandigarh (India)
References 1
2
3
4
Shanbag AM, Baxi LV, Punde AS. Obstructed labour due to a pelvic hydatid cyst. J Obstet Gynaecol Br Commonw 81: 825, 1974. Lewall BD, McCorkell SJ. Hepatic echinococcal cysts, sonographic appearance and classification. Radiology 1.55: 773, 1985.
Corrqondence
Shrotri A, Sutaria UD, Bhosle RA: Hydatid disease in gynaecological practice. J Obstet Gynaecol Ind 35: 749, 1985. Jasper P, Peedicayil A, Nair S, George RK: Hydatid cyst obstructing labour: a case report. J Trop Med Hyg 92: 393, 1989.
to:
P. Dey Cytology and Gynaecologlc PatIIolrJgy Dept. Ream& Black ‘A’ 4th Floor, PGIMKR ChandIgarh - 160 012 Ilullr
Uterine rupture following perforation during curettage To the Editor
March 5th, 1993
Uterine rupture is a rare but catastrophic complication of perforation during curettage. A 30year-old Caucasian patient presented at 38 weeks’ gestation complaining of intermittent abdominal pain. Her past obstetric history included 3 vaginal deliveries and a termination of pregnancy. Most recently, in 1988, she had a blunt and sharp curettage for a missed abortion, but the procedure was discontinued when a uterine perforation was indicated by the recovery of omental fat. On admission, the patient was hemodynamically stable, with a slightly tender abdomen and an unfavorable cervix. A severe exacerbation of abdominal pain was associated with vomiting and a fetal heart rate deceleration to 80 beat&in. At emergency laparotomy, a female weighing 3850 g was delivered from an intact amniotic sac that had been expelled into the abdominal cavity. The contracted uterus had a rupture across the fundus, with omentum adherent to its margins. As active bleeding was minimal the uterus was closed and preserved. The total blood loss measured 1500 ml. The Apgar scores of the female infant were 1 at 1 min and 4 at 5 min. Intermittent positive pres-
Keywork
Uterine rupture; Curettage perforation.
sure ventilation for 4 days was required, and anticonvulsant therapy was administered for atypical seizures during the first 24 h. Discharge home without medication occurred on day 27. No abnormalities were detectable during examinations at discharge and at 6 months of age. Catastrophic uterine rupture is defined as ‘a complete separation of the wall of the pregnant uterus, with or without expulsion of the fetus, which endangers the life of the mother and/or fetus’ [l]. This rare obstetric emergency is associated with a high fetal mortality, particularly before the onset of labor and in the absence of a large uterine scar (55.9-58.3%) [2,3]. Four previous similar cases each resulted in fetal loss [4]. Uterine perforation is recognized during 1:273 to 1:472 curettage procedures and probably unrecognized much more frequently [4]. The omental tissue recovered during curettage and found adherent to the rupture margins may have obstructed healing of the perforation defect. This possibility supports the routine use of laparoscopy when extrauterine tissue is recovered at curettage. Uterine rupture is a rare late complication of curettage perforation and should be considered when any patient with a history of curettage presents with major placental abruption. Prompt laparotomy is required to minimize the substantial risk of maternal and fetal loss. Int J Gynecol Obstet 41
286
Letters to the Editor
A.J. Nordin J.A. Richardson
Dept. Obstetrics and Gynaecology Musgrove Park Hospital Taunton Somerset UK
3 Schrinsky DC, Benson RC: Rupture of the pregnant uterus: a review. Obstet Gynecol Surv 33: 217, 1978. 4 Chew SI, Choo HT: Spontaneous uterine rupture through perforation scar of previous curettement. Singapore Med J 23: 283, 1982. Correspondeoceto:
References 1 Plauche W, Von Almen W, Muller R: Catastrophic uterine rupture. Obstet Gynecol 64: 792, 1984. 2 Felmus LB, Pedowitz P, Nassberg S: Spontaneous rupture of the apparently normal uterus during pregnancy: a review. Obstet Gynecol Surv 8: 155, 1953.
A.J. Nordin DeptObstetrics and Gynaecology MusgrovePark Hospital Taunton Somerset TA15DA UK
Conservative management of hemoperitoneum associated with injury after sexual intercourse To the Editor
November 10th. 1992
Hemoperitoneum as a result of coital injury without external genital trauma is very rare. Most cases reported in the English literature undergo laparotomy because of the presence of hemoperitoneum. We describe a patient with postcoital hemoperitoneum diagnosed by ultrasound, managed conservatively with culdocentesis and followed up with ultrasound. A 19-year-old female para O-O-O-Ocomplained of rectal pressure associated with dull right lower quadrant abdominal pain of 20 h duration. The symptoms started approximately 1 h after rough sexual intercourse with her new partner. She was afebrile and her vital signs were normal. Pelvic examination was remarkable for moderate cervical motion tenderness with feeling of fullness in the posterior fornix. Mild abdominal guarding was also noted. The urine pregnancy test was negative. Transabdominal ultrasound revealed a nongravid, anteriorly displaced uterus. The uterus was antepositioned by the fluid in the cul-de-sac. A moderate amount of fluid was present in the culde-sac. It measured approximately 56 x 50 x 60 mm in the greatest dimension. No adnexal mass
Keywords:Sexual injury; Hemoperitoneum. Int J Gynecol Obstet 41
was seen. Because of the patient’s history, a diagnosis of hemoperitoneum as a result of coital injury was considered. Culdocentesis was performed under sonographic guidance (Fig. 1) after which no further fluid was detected by sonogram and 105 ml nonclotted blood was obtained. No fluid reaccumulation was noted on further serial sonographic examination of the cul-de-sac after 2 h.
Fig. 1. Needle tip in the cul-de-sac with the uterus being displaced anteriorly by the fluid.
K.K. Mar’ P. Deyb A. Sauc
BGynaecology Department, bCytology and Gynaecologic Pathology cGynaecology Department, P.G.I.M.E.R., Chandigarh (India)
References 1
2
3
4
Shanbag AM, Baxi LV, Punde AS. Obstructed labour due to a pelvic hydatid cyst. J Obstet Gynaecol Br Commonw 81: 825, 1974. Lewall BD, McCorkell SJ. Hepatic echinococcal cysts, sonographic appearance and classification. Radiology 1.55: 773, 1985.
Corrqondence
Shrotri A, Sutaria UD, Bhosle RA: Hydatid disease in gynaecological practice. J Obstet Gynaecol Ind 35: 749, 1985. Jasper P, Peedicayil A, Nair S, George RK: Hydatid cyst obstructing labour: a case report. J Trop Med Hyg 92: 393, 1989.
to:
P. Dey Cytology and Gynaecologlc PatIIolrJgy Dept. Ream& Black ‘A’ 4th Floor, PGIMKR ChandIgarh - 160 012 Ilullr
Uterine rupture following perforation during curettage To the Editor
March 5th, 1993
Uterine rupture is a rare but catastrophic complication of perforation during curettage. A 30year-old Caucasian patient presented at 38 weeks’ gestation complaining of intermittent abdominal pain. Her past obstetric history included 3 vaginal deliveries and a termination of pregnancy. Most recently, in 1988, she had a blunt and sharp curettage for a missed abortion, but the procedure was discontinued when a uterine perforation was indicated by the recovery of omental fat. On admission, the patient was hemodynamically stable, with a slightly tender abdomen and an unfavorable cervix. A severe exacerbation of abdominal pain was associated with vomiting and a fetal heart rate deceleration to 80 beat&in. At emergency laparotomy, a female weighing 3850 g was delivered from an intact amniotic sac that had been expelled into the abdominal cavity. The contracted uterus had a rupture across the fundus, with omentum adherent to its margins. As active bleeding was minimal the uterus was closed and preserved. The total blood loss measured 1500 ml. The Apgar scores of the female infant were 1 at 1 min and 4 at 5 min. Intermittent positive pres-
Keywork
Uterine rupture; Curettage perforation.
sure ventilation for 4 days was required, and anticonvulsant therapy was administered for atypical seizures during the first 24 h. Discharge home without medication occurred on day 27. No abnormalities were detectable during examinations at discharge and at 6 months of age. Catastrophic uterine rupture is defined as ‘a complete separation of the wall of the pregnant uterus, with or without expulsion of the fetus, which endangers the life of the mother and/or fetus’ [l]. This rare obstetric emergency is associated with a high fetal mortality, particularly before the onset of labor and in the absence of a large uterine scar (55.9-58.3%) [2,3]. Four previous similar cases each resulted in fetal loss [4]. Uterine perforation is recognized during 1:273 to 1:472 curettage procedures and probably unrecognized much more frequently [4]. The omental tissue recovered during curettage and found adherent to the rupture margins may have obstructed healing of the perforation defect. This possibility supports the routine use of laparoscopy when extrauterine tissue is recovered at curettage. Uterine rupture is a rare late complication of curettage perforation and should be considered when any patient with a history of curettage presents with major placental abruption. Prompt laparotomy is required to minimize the substantial risk of maternal and fetal loss. Int J Gynecol Obstet 41
286
Letters to the Editor
A.J. Nordin J.A. Richardson
Dept. Obstetrics and Gynaecology Musgrove Park Hospital Taunton Somerset UK
3 Schrinsky DC, Benson RC: Rupture of the pregnant uterus: a review. Obstet Gynecol Surv 33: 217, 1978. 4 Chew SI, Choo HT: Spontaneous uterine rupture through perforation scar of previous curettement. Singapore Med J 23: 283, 1982. Correspondeoceto:
References 1 Plauche W, Von Almen W, Muller R: Catastrophic uterine rupture. Obstet Gynecol 64: 792, 1984. 2 Felmus LB, Pedowitz P, Nassberg S: Spontaneous rupture of the apparently normal uterus during pregnancy: a review. Obstet Gynecol Surv 8: 155, 1953.
A.J. Nordin DeptObstetrics and Gynaecology MusgrovePark Hospital Taunton Somerset TA15DA UK
Conservative management of hemoperitoneum associated with injury after sexual intercourse To the Editor
November 10th. 1992
Hemoperitoneum as a result of coital injury without external genital trauma is very rare. Most cases reported in the English literature undergo laparotomy because of the presence of hemoperitoneum. We describe a patient with postcoital hemoperitoneum diagnosed by ultrasound, managed conservatively with culdocentesis and followed up with ultrasound. A 19-year-old female para O-O-O-Ocomplained of rectal pressure associated with dull right lower quadrant abdominal pain of 20 h duration. The symptoms started approximately 1 h after rough sexual intercourse with her new partner. She was afebrile and her vital signs were normal. Pelvic examination was remarkable for moderate cervical motion tenderness with feeling of fullness in the posterior fornix. Mild abdominal guarding was also noted. The urine pregnancy test was negative. Transabdominal ultrasound revealed a nongravid, anteriorly displaced uterus. The uterus was antepositioned by the fluid in the cul-de-sac. A moderate amount of fluid was present in the culde-sac. It measured approximately 56 x 50 x 60 mm in the greatest dimension. No adnexal mass
Keywords:Sexual injury; Hemoperitoneum. Int J Gynecol Obstet 41
was seen. Because of the patient’s history, a diagnosis of hemoperitoneum as a result of coital injury was considered. Culdocentesis was performed under sonographic guidance (Fig. 1) after which no further fluid was detected by sonogram and 105 ml nonclotted blood was obtained. No fluid reaccumulation was noted on further serial sonographic examination of the cul-de-sac after 2 h.
Fig. 1. Needle tip in the cul-de-sac with the uterus being displaced anteriorly by the fluid.