Uterine perforation is a rare but serious complication involving a puncture or tear in the muscular wall of the uterus. This injury occurs almost exclusively during an invasive medical procedure involving the uterine cavity. While most perforations are small and resolve without long-term issues, the possibility of damage to surrounding organs or blood vessels makes it a significant concern. Understanding the causes, recognizing the symptoms, and knowing the necessary medical interventions are important for patient safety.
Understanding the Causes of Uterine Perforation
The vast majority of uterine perforations occur as a complication of procedures requiring instruments to be passed through the cervix into the uterus. These common procedures include Dilation and Curettage (D&C), performed to diagnose or treat conditions like heavy bleeding or to clear the uterine lining. Hysteroscopy, which uses a thin, lighted telescope to view the inside of the uterus, also carries a risk of perforation.
Another common procedure associated with this risk is the insertion or removal of an Intrauterine Device (IUD). The risk of perforation during IUD insertion is low, but it increases significantly if performed while a patient is breastfeeding or shortly after delivery. The risk of these procedures is heightened by factors that weaken the uterine wall or make instrumentation difficult.
A weakened myometrial wall, such as during pregnancy, the immediate postpartum period, or in postmenopausal women due to atrophy, increases susceptibility to injury. Difficult access to the uterine cavity is another factor, often caused by cervical stenosis (narrowing of the cervix) or a severely tilted uterus (retroverted). Less commonly, perforation can result from severe pelvic infections, such as pyometra, or from trauma.
Symptoms and Urgent Warning Signs
While some small perforations may be asymptomatic, patients should be alert for specific signs following an intrauterine procedure. The most common symptom is severe, persistent, or worsening abdominal or pelvic pain that is distinctly different from expected post-procedure cramping. This pain may be localized or spread throughout the abdomen, indicating irritation from internal bleeding or injury to other structures.
Another urgent sign is heavy vaginal bleeding or frank hemorrhage, which indicates a major blood vessel may have been injured. Even without external bleeding, signs of internal bleeding—such as dizziness, a rapid heart rate (tachycardia), or low blood pressure—require immediate medical attention.
Delayed symptoms can indicate a serious complication, especially if a surrounding organ was injured. Fever and signs of peritonitis, including a rigid or distended abdomen, nausea, and vomiting, may suggest an infection or bowel injury. Any change in bowel or bladder function after the procedure should prompt an immediate call to a healthcare provider.
Medical Intervention and Recovery
The diagnosis of uterine perforation is often suspected by the clinician during the procedure when an instrument advances further than expected due to a sudden loss of resistance. If the injury is not immediately recognized, diagnosis is confirmed using imaging techniques, most commonly an ultrasound or Computed Tomography (CT) scan. These studies help determine the size of the tear and assess whether surrounding structures like the bladder or bowel have been injured.
Treatment depends on the extent of the injury and the patient’s clinical status. Many small, uncomplicated perforations, particularly those high up in the fundus, are managed conservatively with observation, rest, and intravenous antibiotics to prevent infection. These minor tears often heal spontaneously without the need for surgical repair.
If the perforation is large, or if there is evidence of active bleeding or damage to abdominal organs, immediate surgical intervention is necessary. Repair is usually performed laparoscopically, but a full surgical opening of the abdomen (laparotomy) may be required for complex injuries. Most individuals recover fully, and future fertility is typically not affected, though close follow-up is necessary to monitor for delayed complications.