Uterine perforation during surgical abortion: a review of diagnosis, management and prevention.
We analysed results of 13,907 women who underwent termination of pregnancy over a 6-year period in a public day-surgery clinic in South Australia to determine possible risk factors and preventive measures for known perforation of the uterus in surgical abortion. The perforation rate in the first trimester was 6 in 12,040 (0.05%) and in the second trimester (13-20 weeks), 6 in 1,867 (0.32%). Previous gynaecological surgery had been performed in 11 of 12 (92%) women sustaining perforation and was the main risk factor identified. No second trimester perforations occurred in the 2 years following identification of the risk factor and the introduction of precautionary protocols, and there was only 1 first trimester perforation. The overall reduction in perforation rate was from 0.13% to 0.02% (p=0.022). We conclude that previous gynaecological surgery including termination of pregnancy, lower segment Caesarean section and the large loop excision of transformation zone of the cervix (LLETZ) procedure, which may have resulted in scarring of the internal cervical os is a previously unreported risk factor for tearing of the internal os leading to perforation of the uterus during subsequent surgical abortion procedures. Dilatation of the cervix particularly for these 'at risk' procedures should be predominantly passive by the use of oral prostaglandins such as misoprostol and osmotic dilators.