Uterine Perforation Following Manual Removal of the Placenta.

Abstract

We present here a case of uterine perforation following manual removal of the placenta during the third stage of normal labor. Total abdominal hysterectomy was performed, and the 4x3-cm perforation of the uterus and placenta accreta were confirmed. In this case, the round ligament covering the hematoma prevented bleeding into the peritoneal cavity and peritonitis. Manual removal of the placenta should be performed carefully following ultrasonographic assessment for placental abnormalities such as placenta accreta.

Uterine inversion and concomitant perforation following manual removal of placenta

“…Manual removal of the placenta is a standard practice for retained placenta, and uterine perforation following manual removal is very rare. In fact, there is only one reported case of such an event in the last 34 years, which required total abdominal hysterectomy to save the life of the woman [2]; and, to our knowledge, there is no report of uterine inversion and concomitant perforation occurring. Risk factors such as placenta previa, prior uterine surgery, and increased maternal age and parity did not apply to this patient.…”

“…

A life-threatening puerperal uterine perforation and an acute uterine inversion can both be caused by placenta accreta [1,2], but seldom together.A 22-year-old woman, gravida 2, presented in labor to the emergency unit of the Gynecology and Obstetrics Department at 30 weeks of pregnancy with preterm premature rupture of membranes, breech presentation, thick meconium-stained liqueur, and nonlocalization of fetal heart sounds confirmed by ultrasound. Placenta was fundal, approaching the right lateral wall.

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“…A life-threatening puerperal uterine perforation and an acute uterine inversion can both be caused by placenta accreta [1,2], but seldom together.…”

“…Risk factors such as placenta previa, prior uterine surgery, and increased maternal age and parity did not apply to this patient. Manual removal of the placenta was attempted because the surgeon felt a line of cleavage, but it is possible to mistake the uterine wall over the internal os for the placenta [2]. Although the placenta was extending to the right lateral wall, the perforation was fundal, which is possible only when the placenta is adherent at a few places, making it a focal placenta accreta [3].…”