34 yo female with significant complications following second trimester D&E
Date of Procedure: January 22, 2025
Procedure: Patient underwent a second-trimester Dilation and Evacuation (D&E). After Laminaria removal and cervical dilation, a 14mm suction curette and Sopher clamp were used to evacuate the uterine contents. On the final pass, a possible posterior uterine defect was visualized on ultrasound and palpated. Despite unclear confirmation of injury, multiple instrument passes had already occurred.
Due to concern for perforation, diagnostic laparoscopy was initiated and revealed a large expanding hematoma in the right retroperitoneum. Conversion to open laparotomy followed.
Injuries & Surgical Findings: Posterior uterine wall perforation (suspected by ultrasound and instrumentation)
Hemorrhage tracking into the right retroperitoneum, adjacent to the infundibulopelvic (IP) ligament
Ovarian vasculature disruption requiring: Right oophorectomy, Total abdominal hysterectomy, Bilateral salpingectomy, Persistent vaginal cuff bleeding Hematoma involving the right mesentery and cecum (trauma surgery consulted). Activation of massive transfusion protocol, arterial line placed, ICU transfer required
Outcomes
Loss of uterus and right ovary (permanent infertility, premature surgical menopause)
Massive intraoperative hemorrhage
Multidisciplinary intervention required (OB/GYN, Gyn Oncology, Trauma Surgery, Critical Care)
ICU admission post-op
Questions:
Uterine perforation during D&E — instrumentation extended beyond the uterine wall, likely due to Excessive force or depth? Blind use?
Ovarian vasculature injury: well outside normal surgical field?
Delayed recognition of injury — despite signs of perforation on ultrasound, earlier imaging or surgical halt was not performed?
Ultrasound guidance only used after suspected damage; not during curettage or forceps use?
Need for emergency laparotomy and organ removal directly traceable to procedural injury?
Overall concern for intraoperative misjudgment and failure to adhere to procedural safeguards.
Operative notes attached for reference.
Thank you in advance for your time and opinions.
Files:
No questions yet!
Do you believe there might have been medical error?
There was enough concern to have repeated the ultrasound and then denote specifically exam was done to evaluate / rule out a defect, If defect were identified/confirmed before additional instrumentation done, there likely would not have been as much injury. The need for hysterectomy wasn’t completely delineated in the operative report - exploration of right retroperitoneum, removal of right ovary of consideration was the right retroperitoneal bleed was secondary to right gonadal vein or arterial bleed makes sense. Mesenteric bleeding makes sense. Was there active bleeding in the uterus? Could it have been controlled with ligation rather than hysterectomy?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If uterine perforation were confirmed earlier, and no additional instrumentation done, likely no significant injury (other than uterine defect) or less significant injury (only localized bleed and not mesenteric) or sequence (sounds like there was DIC towards the end
What makes you a good expert for this case?
I am a gynecologic oncologist in practice x 10 years at alarge academic center, routinely on back up call for OBGYNs
How often do you encounter cases similar to this one in your practice?
I encounter variations of this scenario - possible perforation, retroperitoneal bleed, intraoperative hemorrhage - on intraoperative consult about once a month or so
Do you believe there might have been medical error?
It’s easy to grab a soft dilated uterus with Sopher forceps.. they seemed to be using ultrasound and it happened anyway. Must have been lateral in order to case hematoma (they got uterine artery)
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It’s a risk of the procedure. Very horrible consequence that the GYN couldn’t repair but a risk of the procedure
What makes you a good expert for this case?
I have been an obgyn 14 years and done these procedures. Under ultrasound guidance and even with ultrasound it’s challenging. Expanding hematoma would be so very hard to find origin. Also losing one over will not make her menopausal. So at least there is that.
How often do you encounter cases similar to this one in your practice?
I’ve never had one but have heard of a handful over the course of my career
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