Perforation. Hemorrhage. Hematometra

Perforation

The risk of perforation is less than 1 in every 1,000 first-trimester abortions. It increases with gestational age and is
greater for parous women than for nulliparous women. The use of laminaria reduces the risk. Perforation is best
evaluated by laparoscopy to determine the extent of the injury. Often, the abortion can be completed during the
laparoscopic procedure if the puncture is in the uterine fundus and there is no active bleeding.
The clinical picture produced by uterine perforation depends on the anatomic location of the injury. Perforations at
the junction of the cervix and lower uterine segment can lacerate the ascending branch of the uterine artery within the
broad ligament, giving rise to severe pain, a broad ligament hematoma, and intraabdominal bleeding. Management
requires laparotomy, ligation of the severed vessels, and repair of the uterine injury. Hysterectomy should not be
required to manage such an injury.
Low cervical perforations may injure the descending branch of the uterine artery within the dense collagenous
substance of the cardinal ligaments. In this case, there is no intraabdominal bleeding. The bleeding is external, through
the cervical canal, and may subside temporarily as the artery goes into spasm. Deaths have occurred as a result of this
bleeding several hours or even days after an unrecognized low cervical perforation. Usually, this complication can be
managed with hysterectomy, but consideration should be given to arteriography and selective embolization of the
hypogastric arteries if recurring postabortal hemorrhage suggests this diagnosis.

Hemorrhage

Excessive bleeding may indicate uterine atony, a low-lying implantation, a pregnancy of more advanced gestational age
than the first trimester, or perforation. Management requires rapid reassessment of gestational age by examination of
the fetal parts already extracted and gentle exploration of the uterine cavity with a curette and forceps. Intravenous
oxytocin should be administered, and the abortion should be completed. The uterus then should be massaged to ensure
contraction. When these measures fail, the patient should be transferred immediately to a hospital and should receive
intravenous fluids and have her blood crossmatched. Persistent postabortal bleeding strongly suggests retained tissue
or clot (hematometra) or trauma, and prompt surgical intervention with laparoscopy and repeat vacuum curettage is
indicated.

Hematometra

Esophageal Cancer
Lower abdominal pain of increasing intensity in the first 30 minutes after the procedure suggests either hematometra
or postabortal syndrome. If there is no fever or bleeding is brisk, and on examination the uterus is large, globular, and
tense, hematometra is the possible diagnosis. This condition could be mistaken for a broad ligament hematoma, except
that the mass is midline and arises from the cervix. The treatment is immediate reevacuation. Pretreatment with ergot
or the use of oxytocin reduces the incidence of this phenomenon.

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