ABSTRACT

Background

Dilation and curettage and vacuum aspiration are frequently performed gynaecological procedure used to treat uterine pathology. This procedure carries a risk of uterine perforation, which can lead to injury of abdominal organs and, rarely, to fallopian tubes.

Objectives

To evaluate symptoms and diagnostic signs and to propose the most appropriate management for the intussusception and incarceration of fallopian tubes following uterine aspiration and curettage.

Methods

We screened three major databases (Medline, Scopus, Google Scholar) from 2000 to May 2024. Our review examined tubal incarceration, causes, management, symptoms, parity, diagnosis timelines, visceral injury, and surgical complications. The methodological quality of the included studies was assessed using the JBI Critical Appraisal Checklist for case reports.

Main Outcome Measures

Diagnostic methods, complications and management of tubal incarceration following uterine perforation.

Results

We identified 24 papers, all of which were case reports or case series. In our analysis, tubal incarceration was observed in 25 of 26 cases (96.2%) and in 2 of which (7.7%) it was associated with the entrapment of the infundibulopelvic ligament. In 1 of 26 cases (3.8%) intussusception of fallopian tube was observed. The most frequently manifested symptoms were abdominopelvic pain, vaginal bleeding, vaginal discharge and amenorrhoea. The mean time to diagnosis was 15.4 months, with transvaginal ultrasound being the primary diagnostic tool, followed by hysteroscopy and diagnostic laparoscopy.

Conclusions

Diagnosing this condition should involve a detailed medical history, a comprehensive clinical examination, and imaging evaluations. If instrumental investigations are negative but suspicion remains, hysteroscopy and/or laparoscopy may be necessary.

What is New?

Tubal incarceration complicating uterine perforation can be  managed using hysteroscopy and laparoscopy.

Introduction

The risk of perforation during gynaecological procedures ranges from 0.1% to 4%. The highest risk is associated with postpartum procedures (4%), followed by operative hysteroscopies (1%), and the lowest risk is seen in diagnostic hysteroscopies or procedures involving premenopausal patients (0.1%-0.5%).¹ Hysteroscopic procedures generally present a lower risk of perforation and accidental organ damage compared to dilation and curettage (D&C) procedures, due to the greater control provided by direct vision.¹

D&C is one of the most common gynaecological procedures for the investigation of abnormal uterine bleeding, which nowadays has been replaced with procedures that are more accurate. Nevertheless, vacuum evacuation and curettage remains the standard to remove pregnancy tissue during a first-trimester abortion or miscarriage or post-partum retention of material, despite its highly invasive nature.² In contrast, for heavy menstrual bleeding or abnormal uterine bleeding, a hysteroscopic approach, whether “office” or operative, is currently recommended to identify the underlying cause, as it offers superior diagnostic and therapeutic accuracy compared to “blind” procedures like D&C.³

It is well-known that any intrauterine procedure, from a simple aspiration to a more complex curettage, carries a risk of uterine perforation.¹ While most perforations can be managed without additional interventions and typically do not result in significant morbidity, serious complications can occur. These include sepsis, haemorrhage, poor reproductive and obstetric outcomes, or injuries to the small intestines, bladder, rectum, appendix, and, rarely, the fallopian tubes, potentially leading to death.^{1, 4}

In this literature review, we have collected all cases published since inception concerning fallopian tube incarceration following intrauterine procedures. Our goal is to highlight suspicious symptoms and diagnostic signs and to propose the most appropriate management strategies. We have defined tubal incarcerations as cases in which the tube, or a portion of it, become trapped inside the uterus through a breach created by D&C or suction with a cannula during vacuum aspiration. Additionally, we have included cases of tubal intussusception, where one segment of the tube slips inside another, leading to its entrapment.

Methods

This research was approved by the Institutional Review Board of the Institute for Maternal and Child Health IRCCS Burlo Garofolo (RC 08/2022). A literature search was conducted in May 2024 using various combinations of the following terms: “Tubal incarceration,” “Tubal incarceration and uterine perforation,” and “Tubal incarceration after vacuum aspiration dilatation and curettage.” All cases published in the literature in any language until May 2024 were sourced from Google Scholar, PUBMED, and Scopus.

In our review, we evaluated cases of tubal incarceration, including their causes, management, symptoms, parity, diagnosis timelines, visceral injuries, previous gynaecological surgeries, and complications. Articles that were not relevant to the topic were excluded. All identified studies were examined for year, citation, title, authors, abstract, and full text. Duplicates were identified through manual screening performed by two researchers (C.R. and G.S.) and subsequently removed. The review followed PRISMA guidelines.⁵

The PRISMA flow diagram illustrating the selection process is provided in Figure 1. For the eligibility process, two authors (C.R. and G.S.) independently screened the titles and abstracts of all non-duplicated papers and excluded those not pertinent to the topic. The same two authors independently reviewed the full texts of papers that passed the initial screening and identified those to be included in the review. Discrepancies were resolved by consensus.

Due to the rarity of this condition, the included studies are all case reports. Consequently, we present the data in a descriptive manner. The methodological quality of the included studies was assessed using the JBI Critical Appraisal Checklist for case reports (Supplementary Table 1).

Results

After the literature search, we identified 24 articles comprising 26 cases (Table 1).^6-36 Most of the cases occurred after vacuum aspiration (11/26, 42.3%), 7 of 26 cases (27%) after D&C, 3 of 26 cases (11.5%) after curettage only, 3 of 26 (11.5%) cases after the combination of vacuum aspiration and curettage and, finally, 2 of 26 (7.7%) cases after combination of dilatation and curettage and vacuum aspiration. In 25 of 26 cases (96.2%), incarceration of the distal part of either the right or left fallopian tube was observed, of which in 2 cases (7.7%) tubal incarceration was associated with entrapment of the infundibulopelvic ligament, and in one of these two cases, the ipsilateral ovary was also involved. In 2 of 26 cases (7.7%) the avulsion of fimbrial part or distal part of the tube occurred and the rest remained entrapped. In 1 of 26 cases (3.8%) a tubal intussusception was observed. No concurrent injuries to other visceral organs, such as the bowel, sigmoid colon, or omentum, were reported in any of the screened cases.

The most common indication for the surgeries that led to tubal incarceration, avulsion or intussusception was surgical evacuation of the uterine cavity, either after a miscarriage (AS) or for voluntary termination of pregnancy (TOP) (73%). This was followed by removal of retained placenta after delivery or an incomplete afterbirth phase (23.2%). In one case (3.8%), the removal of an intrauterine device using Pean’s forceps led to tubal incarceration. The symptoms most frequently reported by patients included non-specific abdomino-pelvic pain (14/26, 54%), abnormal vaginal bleeding (8/26, 30.8%), vaginal discharge (5/26, 19.2%), secondary amenorrhoea (3/26 11.5%), secondary infertility (4/26, 15.4%) and postpartum haemorrhage (1/26, 3.8%). Two of 26 patients (7.7%) were completely asymptomatic (Table 2).

In our analysis, the mean time to diagnosis was 15.4 months, with a range from a few hours post-procedure to 5 years. In most cases, the suspected diagnosis was made using transvaginal ultrasound, followed by hysteroscopy and diagnostic laparoscopy. Magnetic resonance imaging (MRI) was used in 4 of 26 cases (15.3%) to complete the instrumental investigations, and computed tomography (CT) was used in 2 of 26 cases (7.7%).

Except for eight cases, laparoscopy was the approach of choice. In four cases (15.3%), the tube was extracted from the myometrium, which was subsequently sutured. In most cases (12 of 26, 46.1%), salpingectomy was necessary. In three cases, diagnostic hysteroscopy was performed concomitantly with laparoscopy. Except for one case of infection treated with antibiotics, there were no post-operative complications. Only one case presented with a life-threatening situation due to a postpartum haemorrhage of 2000 mL, which required the transfusion of 4 units of blood and fresh plasma, with no post-operative complications.

Two patients successfully delivered via caesarean section after laparoscopic correction of the tubal incarceration, and one patient was still pregnant without any related complications in the second trimester.

Discussion

Our review compiles cases of tubal damage following uterine perforation due to dilatation & curettage or vacuum aspiration. The analysis of the various cases reveals that the procedure most frequently associated with tubal damage is vacuum aspiration and the surgical indication is termination of pregnancy. Moreover, in most cases, the tube itself, entrapped in the myometrium, acts as a hemostatic agent, contributing to a delayed diagnosis, as the most common symptom is non-specific pelvic pain. Furthermore, as reported in our results, the incarceration of the tube is not accompanied by the incarceration of other abdominal organs, further reducing the presence of other suspicious signs or symptoms. The three most frequent symptoms are abdomino-pelvic pain (54%), abnormal vaginal bleeding (30.8%), vaginal discharge (19.2%) and they are aspecific and not directly related to a tubal pathology, leading to a mean time for the diagnosis of 15.4 months and to the low incidence reported in the literature.²²

The data suggested the most significant risk factor for uterine perforation, accounting for approximately 95.6% of cases, was the surgeon’s inexperience especially when surgery (vacuum aspiration or dilatation and curettage) is performed after a miscarriage or for voluntary termination of pregnancy when the uterus is less resistant.^{4, 22-26}

Transvaginal ultrasound is the first-line instrumental exam, with findings of a hyperechoic tubular structure in the myometrium or endometrial cavity, possibly associated with intra-pelvic free fluid, which is often misdiagnosed as an endometrial polyp, submucous myoma, or intrauterine adhesion.²⁷ 3D transvaginal ultrasound and color Doppler can assist in differential diagnosis.²⁸

CT can be used in acute patients while, MRI can aid in challenging cases in stable patients where ultrasound and CT are not informative.^{29, 30} However, according to the data from our analysis, it may be quicker and less stressful for the patient to proceed directly with a diagnostic hysteroscopy, as suggested by Wang et al.³¹ in order to obtain a bioptic diagnosis. Moreover, Boughizane et al.³² and Camus et al.³³ recommended a combined approach with laparoscopy for the double diagnostic and therapeutic value of laparoscopy in these cases and for optimal tubal preservation.

In most of our review cases, salpingectomy was performed after extracting the tube from the myometrium, if a tubal preservation is affordable it could be useful to perform chromo-salpingoscopy in order to verify tubal function. Dysfunction of the fallopian tubes is a leading cause of tubal infertility, with proximal tubal blockage accounting for about 26% of all infertility cases.³⁴ In addiction, with a view to future pregnancies suturing the myometrial breach is advisable even if it represents an area of minor resistance and tissue alteration, which may be susceptible to placentation issues or complications during manual placenta removal (2.7%).⁴

There are no specific guidelines on how to complete childbirth in these cases, with decisions made by the gynaecologist in consultation with the patient. Elective C-sections were performed in the cases described in this review. Ceccaldi et al.³⁵ suggested that large fundal myometrial defects and thin fibrosis may favor elective caesarean delivery. However, there is no absolute contraindication to vaginal delivery, though labour and delivery should be closely monitored to prevent uterine rupture.

Preventive strategies for uterine perforation include careful preoperative evaluation, appropriate instrumentation and techniques, and adequate training and experience of the surgeon.²³ Ultrasound guidance during surgical termination is supported to reduce procedure-related morbidity.²² Damiani et al.³⁶ recommends using negative pressure not exceeding 500 mmHg (or 0.07 bar) during vacuum aspiration to reduce the risk of adjacent organ suction in case of uterine perforation.

The strength of this manuscript lies in the extensive literature review period with the largest number of cases considered. All studies selected during the eligibility phase were manually compared to avoid overlapping cases. The methodological quality of the included studies was assessed using the JBI Critical Appraisal Checklist for case reports. Conversely, the main limitation is the inclusion of only case reports due to the rarity of this complication. For this reason, we aimed to gather data in order to provide clinical suspicion signs based on the patient’s history, along with a diagnostic and management algorithm (Figure 2).

Conclusion

A thorough diagnosis of uterine perforation with secondary tubal damage requires a detailed medical history, a comprehensive clinical examination, and imaging evaluation. If instrumental investigations are negative but clinical suspicion remains, direct visualisation tools such as hysteroscopy and/or diagnostic laparoscopy may be necessary.

Given the rarity of this condition, there are no specific guidelines on how to manage this complication, considering that the majority of cases involve women of reproductive age, it is essential to preserve their reproductive function by assessing tubal integrity and function and preserving the myometrium as much as possible.

Supplementary Table 1. https://l24.im/z7O2PI