Prolapse of the Small Intestine from the Uterine Perforation at Dilatation and Curettage

Dilatation and curettage (D&C) sometimes causes uterine perforation, which usually does not cause a serious problem. Here, we report uterine perforation caused by D&C, in which the small intestine prolapsed from the uterus, requiring intestinal resection. D&C was performed for missed abortion at 9 weeks. After dilating the cervix, forceps grasped tissue that, upon being pulled, resulted in the intestine being prolapsed into the vagina. Laparotomy revealed a perforation at the low anterior uterine wall, through which the ileum had prolapsed. The mesentery of the prolapsed ileum was completely detached and the ileum was necrotic, which was resected. The uterus and the intestine were reconstructed. Although intestinal prolapse is considered to be caused by “unsafe” D&C performed by inexperienced persons or even by nonphysicians in developing countries, this occurred in a tertiary center of a developed country. We must be aware that adverse events such as uterine perforation with intestinal prolapse can occur even during routine D&C. 1. Introduction Conservative management is usually recommended for uterine perforation during dilatation and curettage (D&C); however, according to Williams Obstetrics Textbook [1] “considerable intra-abdominal damage can be caused by instrument passed through a uterine defect.” We here report a patient in whom the small intestine prolapsed through a uterine perforation to the vagina. Small intestinal mesentery was detached from the intestine, causing intestinal necrosis and requiring intestinal resection. 2. Case Presentation A D&C was performed on a 36-year-old 2 parous woman because of missed abortion at 9 weeks of gestation. She had undergone lower segment cesarean section twice. A gestational sac (GS) 34？mm in diameter with a 3？mm beatless embryo was observed within the uterine body, which was in slight anteversion and anteflexion. With a hygroscopic dilator placed for 12 hours, D&C was performed. Although abdominal ultrasound did not clearly show the sound, the procedure continued, expecting an “easy” D&C. The cervix was dilated with metal cervical dilator without difficulty. We usually use forceps and not a suction curette. We inserted the forceps into the uterine cavity, held the expected gestational sac, but felt slight difficulty in removing it, and immediately loosened the forceps. The intestine then prolapsed through the cervical ostium into the vagina (Figure 1(a)). Figure 1: Prolapsed small intestine and operative findings. (a) The small intestine is observed in the vagina. (b) The ileum is prolapsed through the