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Publicly Available Published by De Gruyter July 27, 2017

Sonohysterography in a suspected case of uterine perforation after dilatation and curettage for retained placenta

Norihito Yoshioka, Junichi Hasegawa, Akiko Tozawa, Kentaro Nakamura, Tai Kawahara, Ichiro Maeda and Nao Suzuki

Abstract

A 35-year-old woman, gravida 3, para 2, spontaneously delivered an infant without any major complications. On the 38th day after delivery, she returned to the hospital due to irregular bleeding. Transvaginal ultrasound showed a mass in the cervix; therefore, dilatation and curettage was performed, using placental forceps, to remove the retained placenta. During the procedure, a uterine perforation was suspected. Sonohysterography was performed in order to confirm the uterine perforation. The sonohysterogram revealed that the high echogenic mass that was suspected to be retained placenta was adhered on the posterior uterine myometrium. Saline that had been injected into the uterine cavity escaped into the Douglas pouch via a small hole in the posterior uterine wall. An emergency laparotomy was performed. Pathological examination of the removed uterus revealed placenta increta in the posterior wall, as well as an adjacent perforated fistula. Sonohysterographic diagnosis of uterine perforation in the present case was not only validated with diagnosis, but also the residual placenta was clearly visible. The use of sonohysterography for detection of a suspected case of uterine perforation after dilatation and curettage was accurate and provided a safe procedure for fast evaluation.

Case

A 35-year-old Japanese woman, gravida 3, para 2, spontaneously delivered an infant in the hospital. Any major complications including abdominal pain and abnormal bleeding were not seen after delivery. On the 38th day after delivery, she returned to the hospital due to irregular bleeding. Transvaginal ultrasound showed a mass in the cervix, leading to suspicion of a retained placenta. The bleeding did not decrease during observation; therefore, dilatation and curettage, using placental forceps, was performed to remove the retained placenta 2 days later.

During the procedure, the attending doctor suspected that a uterine perforation had been induced by the forceps and the patient was transferred to our perinatal center hospital. Upon examination, her vital signs were unremarkable, but she was experiencing severe abdominal pain, tenderness, nausea and vomiting, along with muscle guarding. The abdomen was flat and the uterus was soft and of normal size, though tender upon palpation.

An ultrasound examination could not clearly show uterine perforation or retained placenta and fluid collection in the Douglas pouch, though it seemed that there was minimal high echogenic focus in the thin uterine endometrium (Figure 1A). Sonohysterography was performed in order to confirm the uterine perforation. The sonohysterogram revealed an echogenic mass that was suspected to be retained placenta, adhered onto the posterior uterine myometrium. Saline that had been injected into the uterine cavity escaped into the Douglas pouch via a small hole in the posterior uterine wall, (Figure 1B). These images were confirmed by three-dimensional (3D) ultrasound imaging (Figure 2). Therefore, a diagnosis of placenta increta with uterine perforation subsequent to dilatation and curettage was made. The patient’s results for blood counts, biochemical tests and coagulation studies, were normal, with the exception of an elevated white blood cell count of 11,800/μL.

Figure 1: 
Two-dimensional (2D) ultrasound pictures.
(A) B-mode: Ultrasound examination could not clearly show the uterine perforation, retained placenta or fluid collection in the Douglas pouch. There was minimal high echogenic focus in the thin uterine endometrium. (B) Sonohysterography: A high echogenic mass was suspected to be retained placenta that was adhered on the posterior uterine myometrium. Injected saline flowing into the uterine cavity via a small fistula (arrow) in the posterior uterine wall was identified during sonohysterography. EM, endometrium; Cx, uterine cervix.

Figure 1:

Two-dimensional (2D) ultrasound pictures.

(A) B-mode: Ultrasound examination could not clearly show the uterine perforation, retained placenta or fluid collection in the Douglas pouch. There was minimal high echogenic focus in the thin uterine endometrium. (B) Sonohysterography: A high echogenic mass was suspected to be retained placenta that was adhered on the posterior uterine myometrium. Injected saline flowing into the uterine cavity via a small fistula (arrow) in the posterior uterine wall was identified during sonohysterography. EM, endometrium; Cx, uterine cervix.

Figure 2: 
3D ultrasound pictures: Similar to 2D ultrasound pictures, whereas ultrasound examination could not clearly show the intra-uterine cavity and perforation (arrow) (A), the fistula (arrow) in the posterior uterine wall was clearly evident after saline injection during sonohysterography (B). EM, endometrium; Cx, uterine cervix; D, Douglas pouch.

Figure 2:

3D ultrasound pictures: Similar to 2D ultrasound pictures, whereas ultrasound examination could not clearly show the intra-uterine cavity and perforation (arrow) (A), the fistula (arrow) in the posterior uterine wall was clearly evident after saline injection during sonohysterography (B). EM, endometrium; Cx, uterine cervix; D, Douglas pouch.

An emergency laparotomy was performed. A small amount of bloody ascites was found in the abdominal cavity. The perforation was approximately 2 cm in size and located in the posterior uterine wall accompanied by mild bleeding (Figure 3). As intestinal injury was suspected, the entire intestinal tract was surgically explored, but no intestinal perforation was found. Because of the macroscopic uterine perforation and placenta increta already identified, a hysterectomy was performed. The postoperative surgical specimen is shown in Figure 4. Pathological examination of the removed uterus revealed the placenta increta in the posterior wall, as well as an adjacent perforated fistula. The patient recovered uneventfully and was discharged 10 days after surgery.

Figure 3: 
Picture of the uterus during surgery: The perforation was approximately 2 cm in size in the posterior uterine wall, with mild bleeding (arrow).

Figure 3:

Picture of the uterus during surgery: The perforation was approximately 2 cm in size in the posterior uterine wall, with mild bleeding (arrow).

Figure 4: 
Pathological findings of the removed uterus: Placenta increta in the posterior wall and perforated fistula near the placenta increta.

Figure 4:

Pathological findings of the removed uterus: Placenta increta in the posterior wall and perforated fistula near the placenta increta.

Discussion

An intrauterine procedure, such as dilatation and curettage, requires that the surgeon operate essentially “blind” and if a perforation were to occur, it could be life-threatening [1]. A rapid and certain diagnosis is imperative.

Sonohysterography is an ultrasonographic procedure that uses an intrauterine saline infusion as an additional diagnostic tool for the identification of intrauterine lesions. The combination of ultrasound and infusion improves the ability to visualize the uterine cavity [2], [3], [4]. It has been previously reported that saline infusion sonohysterography provides higher accuracy than transvaginal ultrasonography for detecting retained placenta [1]. In fact, in the present case, the endometrium primarily appeared to be thin on simple B-mode ultrasonography. However, the irregular surface of the placenta in the uterine cavity was made visible after the saline infusion, whereas the presence of the adherent residual placenta could not be visualized even by using computed tomography imaging.

In addition, the flow of the infusing saline during sonohysterography enabled us to identify the perforation at the posterior uterine wall. We can prove the usefulness of sonohysterography for detecting uterine perforation. It is usually extremely difficult to make a diagnosis of placenta and uterine abnormalities, such as placenta increta, after infant delivery because of the normal thickening of the uterine myometrium with involution of the uterus [5].

Although sonohysterography can easily identify a perforation in the uterine wall, precise depiction of residual placenta in the uterine cavity at the same time is still somewhat limited, as the uterine cavity cannot be adequately inflated enough with saline. It is expected that the saline would be likely to flow out of the perforation.

In conclusion, to our knowledge, this is the first report demonstrating the use of sonohysterography for the identification of a perforated uterus using after dilatation and curettage due to placenta increta. Sonohysterographic diagnosis of uterine perforation in the present case was not only validated by diagnosis, but also by the identification of the residual placenta. We believe that sonohysterography is useful for rapid determination of uterine perforations in suspected cases after dilatation and curettage.

Author’s Statement

  1. Conflict of interest: Authors state no conflict of interest.

Material and Methods

  1. Informed consent: Informed consent has been obtained from all individuals included in this study.

  2. Ethical approval: The research related to human subject use has complied with all the relevant national regulations, and institutional policies, and is in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

References

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Received: 2017-03-15
Accepted: 2017-05-12
Published Online: 2017-07-27

©2017 Walter de Gruyter GmbH, Berlin/Boston

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