Uterine perforation and small bowel incarceration 11 months after dilatation and curettage: sonographic and surgical findings

Abstract

In 2014, a 33-year-old primiparous woman was referred by her physician to the emergency department of the Catholic University of Rome for abnormal uterine findings at routine gynecological examination, performed 11 months after vaginal delivery. She was breastfeeding and her menstrual cycle had not yet recommenced. She had undergone dilatation and curettage (D & C) 4 weeks after delivery because of retained membrane. Gynecological examination revealed a tender uterus with a closed cervix and normal adnexa. Laboratory findings were not significant, with a normal white blood cell count and negative for β-human chorionic gonadotropin. On referral to our department, we performed a transvaginal ultrasound examination using a GE Voluson E8 (GE Medical Systems, Zipf, Austria) ultrasound system. A tubular structure, with distinct multilayered appearance of normal intestinal wall1, was seen penetrating into the uterine cavity through the anterior wall of the uterine body (Videoclip S1). The presence of typical normal echostructure of intestinal wall and peristaltic movement suggested perforation of the uterus with penetration of the bowel. Color Doppler ultrasound examination confirmed this hypothesis (Videoclip S2). A small amount of anechoic free fluid was seen in the cul-de-sac. Laparoscopy revealed about 10 cm of small intestine prolapsed through the uterine perforation, adherent to the myometrial wall. The uterine fundus had a hole of approximately 4 cm in size (Videoclip S3). The bowel had penetrated through this gap, occupying the entire endometrial cavity and reaching the upper part of the cervix. Adhesions between the bowel and the endometrial cavity and myometrium were removed and the uterine structure was reconstructed. A perforation of 1 cm was detected on the surface of the entrapped bowel that was resected laparoscopically. The patient was discharged after 5 days with no postsurgical complication. Delayed presentation of uterine perforation after D & C, as reported here, is rare2. Treatment usually consists of laparotomic surgery3; the laparoscopic approach described in this case is, we believe, one of few reported in the medical literature. A. De Cicco†, F. Mascilini‡, M. Ludovisi‡, F. De Cicco†, G. Scambia‡ and A. C. Testa*‡ †Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy; ‡Division of Gynecology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy *Correspondence. (e-mail: atesta@rm.unicatt.it) Videoclips S1 and S2 Grayscale (S1) and color Doppler (S2) ultrasound videoclips showing hyperechogenic tubular structure penetrating through anterior wall of uterine body. Videoclip S3 Intraoperative videoclip demonstrating defect in fundal myometrium of uterus, through which small bowel is incarcerated. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.