Perforation of the uterus

The scene

Having discussed the risks of the procedure and gained patient consent, the consultant gynaecologist performing the operation dilated her cervix and introduced a plastic suction catheter into the uterus. When a loop of the small bowel was unexpectedly pulled into the sucker, the procedure was immediately stopped.

The consultant, a member of the MDU, performed laparoscopy which showed a haemoperitoneum with a small perforation low on the posterior side of the uterus. The consultant proceeded straight to laparotomy to repair the perforation. During the operation, he examined the large and small bowel – both were found to be intact. He repaired the defect.

When, post-operatively, the patient's abdomen became distended and urine output diminished, the consultant took a clinical decision to perform a second laparotomy. This revealed oozing from the uterus at the base of the broad ligament. One ovary was ischaemic and was removed. Further attempts to stop the bleeding being unsuccessful, the uterus was also removed.
 
The patient was discharged after six days. Two years later, she brought a claim for clinical negligence against the consultant, alleging that he had failed to ascertain or appreciate the position of her uterus before starting the termination procedure, and then failed to locate the midline, resulting in perforation laterally near to the uterine artery and vein. If entry through the cervix had been made in the mid-line, it was alleged, the uterine perforation would not have occurred in a low posterior position.

It was further alleged that, peri-operatively, the consultant had failed to recognise that a perforation had occurred until a loop of small bowel appeared in the suction curette and that the perforation should have been recognised, and the procedure stopped, at an earlier stage. If the termination procedure had been performed correctly, the claimant alleged, no perforation would have occurred and she would not have had to undergo a total hysterectomy and a salpingo-oophorectomy.

The outcome

The MDU obtained an expert report from a consultant obstetrician and gynaecologist who considered the patient understood and consented to the risks of the procedure, including perforation which can require hysterectomy, although very rarely.

The expert did not believe the claimant's contention – that the instrument must have been passed in a lateral direction, thereby causing perforation – was consistent with evidence or logic. He remained supportive of the manner in which the procedure was performed. The expert also added that the member, who was very experienced in this procedure, correctly managed the perforation by performing laparoscopy and, subsequently, laparotomy when it became apparent that some internal surgical remedy would be required.

Despite the MDU's expert evidence, which remained supportive of the member throughout, the matter proceeded to trial, where the judge found in favour of the doctor.

In his judgment, the judge observed that perforation of the uterus during termination of pregnancy is a recognised surgical complication that can happen even when the procedure is carried out with all reasonable skill and care by a competent surgeon.

The risk is not surprising, he added, since introducing dilators and a suction curette into a gravid uterus carries the risk that implements may be pushed through the uterine wall, especially as the procedure is done blind and by feel alone.
 
He called the member a 'skilled and capable operator' who was very experienced in this technique, and did not accept that there had been any lack of care or attention on the part of the member. In fact, he said, the idea that our member had introduced several dilators and a curette at an angle to the mid-line of the cervix was not feasible. More likely, the instruments were introduced into the mid-line but were deflected off-centre either by folds in the arbor vitae or because the cervix was not lying in a perpendicular plane.

It was the judge's view that until the member saw small bowel in the curette, he was plainly unaware that a perforation had happened, meaning that he could not have recognised the complication any sooner. The judge found that there was no negligence and found for the defendant.

This page was correct at publication on 20/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.