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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 204-205

Bladder and uterine perforation after dilatation and curettage leading to high serum creatinine


Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Navi Mumbai, Maharashtra, India

Date of Submission02-Mar-2020
Date of Acceptance05-Mar-2020
Date of Web Publication29-Apr-2020

Correspondence Address:
Dr. Ajita Goli
Department of Obstetrics and Gynecology, MGM Medical College and Hospital, MGM Institute of Health Sciences (Deemed to be University), Sector-1, Kamothe, Navi Mumbai 410209, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_17_20

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  Abstract 

A case of iatrogenic bladder perforation as a complication of dilatation and curettage was reported. A 28-year-old patient with a history of medical termination of pregnancy by dilatation and evacuation performed 3 days back, presented with distension of abdomen and giddiness. The laboratory investigations pointed toward renal failure with raised serum creatinine, and ultrasound was suggestive of ruptured ectopic pregnancy with hemoperitoneum. An emergency laparotomy was performed. Intraoperative findings were hemoperitoneum, left ruptured ectopic pregnancy, uterine perforation, and urinary bladder perforation. Left salpingectomy was performed, and urinary bladder was repaired. The serum creatinine levels were normal within 24h. Urinary bladder perforation may be suspected in postoperative dilation and evacuation (D and E) patients with impaired renal function tests.

Keywords: Bladder perforation, complications of dilatation and curettage, ectopic pregnancy, raised serum creatinine in the bladder perforation, uterine perforation


How to cite this article:
Goli A, Dabholkar D, Kumar S. Bladder and uterine perforation after dilatation and curettage leading to high serum creatinine. MGM J Med Sci 2019;6:204-5

How to cite this URL:
Goli A, Dabholkar D, Kumar S. Bladder and uterine perforation after dilatation and curettage leading to high serum creatinine. MGM J Med Sci [serial online] 2019 [cited 2020 Oct 30];6:204-5. Available from: http://www.mgmjms.com/text.asp?2019/6/4/204/283456




  Case report Top


A 28-year-old lady came to the emergency department with chief complaints of abdominal distension and giddiness for 1 day. She gave the history of medical termination of pregnancy by dilatation and curettage 3 days back. She was gravida 3, para 2, both full-term vaginal deliveries 8 and 6 years back with no complications. On confirmation of pregnancy by urine pregnancy kit, ultrasound (USG) was carried out. The USG was reported as thick endometrium with the possibility of early pregnancy. Hence, dilation and curettage were conducted, and the patient was discharged after 8h of observation. The patient had uneventful recovery. On postoperative day 1, urine and stool were passed. On the 2nd postoperative day, she developed giddiness followed by distension of abdomen and was referred to the emergency department to MGM Hospital, Kalamboli, Navi Mumbai, Maharashtra, India.

On examination, the patient looked pale, pulse 120 per min, and blood pressure 90/50mm Hg. The urine pregnancy test was positive, and there was suspicion of ectopic pregnancy due to cervical motion tenderness and distension of abdomen possibly due to intra-abdominal hemorrhage. Intravenous fluid resuscitation was started as laboratory reports were awaited. USG of pelvis was suggestive of a left tubal mass of 4 × 5cm and hemoperitoneum of approximately 500mL. Hemoglobin level was 7.1g/dL, total leucocytes count was 18,000/mm3, platelet count was 2.2 lakh/mm3, bleeding time was 2min 40s, and clotting time was 4min. The renal function test showed creatinine level of 2.8mg/dL, indicative of impaired renal function. The possibility of acute tubular necrosis following hemorrhagic shock was kept in mind. The patient was taken for emergency laparotomy. Intraoperative findings were hemoperitoneum with left ruptured tubal ectopic pregnancy. Hemoperitoneum was drained and left salpingectomy was performed. There was 0.5cm uterine perforation Figure 1] but no bleeding. One prophylactic stitch with Vicryl no. 1 was taken. There was a serous fluid collection after peritoneal wash and suction. The inspection of the anterior compartment revealed a bladder perforation of approximately 1 × 1cm. Urine was gushing out from the urinary bladder through the perforation. The bladder was sutured with 3-0 catgut in a continuous manner in two layers, and the suprapubic catheter was introduced. Other adjacent structures were also checked, and no bowel perforation was noted. The patient was transfused two packed cell intraoperatively.
Figure 1: Perforation of uterus

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Postoperatively, the patient was given inotropes until blood pressure was 110/70mm Hg (6h). After 24h, all the investigations were repeated, hemoglobin level was 8.6g/dL, total leucocytes count 16,000/mm3, platelets 1.84 lakhs/mm3, and creatinine 0.8mg/dL. The suprapubic catheter was removed after 14 days, and the transurethral catheter was removed after 21 days, and the patient was discharged after 26 days, with no urinary complaint.


  Discussion Top


Uterine perforation can occur due to uterine anomalies,[1] infection, cervical stenosis, and forceful cervical dilatation for therapeutic and diagnostic procedures in pregnant or nonpregnant patients. Other injuries such as bowel perforation,[2] urinary bladder perforation,[3] and ureteric injury may be associated with the uterine injury. Uterine perforation can occur during other procedures such as hysteroscopy[4] and insertion of intrauterine contraceptives.[5],[6] Uterine perforation can be suspected with USG but final confirmation is made on laparoscopy or laparotomy. Bladder perforation may be suspected in postoperative dilation and curettage (D and C) patients having distension of abdomen and raised creatinine levels. Raised serum creatinine level is due to urine in the peritoneal cavity. Increased absorption of creatinine from urine by the peritoneum in cases of bladder rupture can give an impression of renal failure.[7] In the case of bladder rupture or perforation, the serum creatinine levels normalize within 24h of surgical repair.[8]


  Conclusion Top


This case signifies the importance of confirmation of intrauterine pregnancy before medical or surgical medical termination of pregnancy and more so to rule out an ectopic pregnancy. Bladder injury during dilatation and evacuation is a rare occurrence. Raised creatinine level without previous history of renal disorder should also raise suspicion of bladder injury in cases where intrauterine or pelvic surgeries are performed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shakir F, Diab Y. The perforated uterus. Obstet Gynaecol 2013;15:256-61.  Back to cited text no. 1
    
2.
Samita Bhat K, Ahuja VK, Somashekhar SP, Rakshit SH. Unusual bowel perforation following dilatation and curettage in a case of endometrial cancer. Indian J Gynecol Oncolog 2018;16:Article 24:1-3.  Back to cited text no. 2
    
3.
Madrid García FJ, Madroñero Cuevas C, Rivas Escudero JA, Parra Muntaner L, Monsalve Rodríguez M, García Alonso J. [Bladder perforation as a complication of uterine curettage after spontaneous abortion]. Arch Esp Urol 2004;57:552-4.  Back to cited text no. 3
    
4.
Pennsylvania Patient Safety Authority. Safety in the MR environment: Ferromagnetic projectile objects in the MRI scanner room. Pa Patient Saf Advis 2009;6:56-62.  Back to cited text no. 4
    
5.
Caliskan E, Oztürk N, Dilbaz BO, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care 2003;8:150-5.  Back to cited text no. 5
    
6.
Rowlands S, Oloto E, Horwell DH. Intrauterine devices and risk of uterine perforation: Current perspectives. Open Access J Contracept 2016;7:19-32.  Back to cited text no. 6
    
7.
Jang J, Lim KH. Pseudo-renal failure caused by urinary bladder rupture in multiple trauma patient. J Korean Soc Traumatol 2016;29:191-4.  Back to cited text no. 7
    
8.
Arun KG, Salahauddin, Leela V, Noel J, Venkatesh K, Ramakrishnan S, et al. Intraperitoneal bladder rupture mimicking acute renal failure. Indian J Nephrol 2008;18:26-7.  Back to cited text no. 8
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