Management of uterine perforation following elective abortion.

Experience is reported with 28 uterine perforations encountered from June 1, 1973, to June 1, 1976, among 20,000 first trimester abortion patients at Reproductive Health Services, St. Louis, Missouri. In order to prevent this complication, one must perform an exacting pelvic examination. The use of a sound is controversial. Dilators should be introduced only a short distance through the internal os, and as much of the products of conception as possible should be aspirated. A sharp curette should be diagnostically. Various questions should be asked before the operator constructs a scheme for managing perforation. The current policy for management used at this clinic is outlined.

PIP: 28 uterine perforations occurred from June 1, 1973, to June 1, 1976, among 20,000 first trimester abortion patients at Reproductive Health Services, St. Louis, Missouri. The management of such perforations should depend on the site of the perforation and the completeness of the abortion. These questions should also be answered: 1) How many weeks pregnant is the patient? 2) Is there extragenital injury? 3) Is there hematoma formation or evidence of continuing intraperitoneal blood loss? The laparascope is valuable in evaluation of the perforation damage and in determining if laparatomy is necessary. If bleeding is extensive, laparotomy is indicated for uterine and vessel repair which may even involve hysterectomy. If the perforation is discovered before removal of all products of conception, the plan depends on the site of the perforation. If vital signs are steady either 1) the patient may be returned to the procedure room and a 2nd evacuation performed, avoiding the area of perforation; or 2) the patient may be admitted to hospital for laparascopic study and evaluation for a 2nd vaginal evacuation. If perforation seems to be lateral, with intraabdominal bleeding, the patient should be hospitalized at once for close observation.

Elective abortion. Complications seen in a free-standing clinic.

Experience is reported with the elective first trimester abortion of 16,410 pregnancies during a 31-month period by Reproductive Health Services of St. Louis, a free-standing clinic. Incidence of complications was 1.54%. The most common of these were incomplete evacuation, excessive postabortal bleeding, and uterine perforation. In patients with unquestioned perforation, the use of laparoscopy has been very valuable in ascertaining the exact nature of the perforation, in avoiding unnecessary laparotomy, and in giving intraabdominal visual guidance to concomitant suction evacuation in cases of an incomplete procedure. Aspects of the other complications are also discussed. In general, the findings support the view that even in the first trimester, the earlier in pregnancy that suction abortion is performed, the less likely it is to result in major complications. It is possible to perform first trimester abortions in a free-standing clinic with a satisfactorily low complication rate.

PIP: In elective first trimester of 16,410 pregnancies between June 1973-January 1976 at Reproductive Health Services of St. Louis, incidence of complications was 1.54%. The most common complication (32% of total complications) was incomplete evacuation of the uterus. Perforations of the uterus occurred in 34 patients (.2%); 1/3 of the perforations occurred in primigravidas. Excessive postabortal bleeding occurred in 41 patients and cervical lacerations in 22. 11 patients developed postabortal syndrome (PAS). In patients with unquestioned perforation, the use of laparoscopy is valuable in ascertaining the exact nature of the perforation, in avoiding unnecessary laparotomy, and in giving intraabdominal visual guidance to concomitant suction evacuation in cases of an incomplete procedure. The earlier that suction abortion is performed, the less likely it is to result in major complications; 56% of the complications occurred after the 10th week of pregnancy which represented 36% of the total procedures.