Conservative Management of Iatrogenic Uterine Perforation at 22 Weeks of Gestation Permitting for a Third-Trimester Delivery

Introduction: Acute cholecystitis is one of the most common causes of nonobstetric procedures in pregnancy (Jayalal 2015; Post 2019; Tolcher 2018; Nezhat 1997), with suggested need for cholecystectomy if the diagnosis is made in pregnancy, irrespective of the indicators for urgent or emergent surgery (Post 2019). This is because delaying surgical treatment has been suggested as increasing the risk of perinatal morbidity and mortality (Jayalal 2015). Laparoscopic cholecystectomy in pregnancy can be safely performed, while recognizing the changes in anatomy and physiology occurring due to the ongoing conception (Jayalal 2015; Post 2019). However, inadvertent uterine perforation of the gravid uterus has been reported in the literature, resulting in risk of premature delivery, miscarriage, chorioamnionitis, and rupture (Tolcher 2018). In this report, we present a case of incidental iatrogenic second trimester uterine perforation by a trocar during laparoscopic cholecystectomy that was addressed conservatively following identification and repair which permitted for delay of delivery until early in the third-trimester delivery. Case Presentation: 32-year-old lady, G4P3 presented to the Emergency Department at 22+2/7 weeks of gestation with a two day history of epigastric pain, radiating to the right upper quadrant and the right shoulder. Surgical history was pertinent for one prior cesarean section due to breech presentation, with the uterine incision repaired in two layers. Vital signs were overall reassuring. The physical exam was consistent with a gravid uterus and a positive Murphy sign. Laboratory test results were significant for hyperglycemia: 207 (74-106mg/dl); SGOT: 78.2 (<31 UI/L); phosphatase alkaline: 235.4 (35-104 UI/L); lipase: 1524 (13-60 UI/L); and amylase: 781 (20-100 UI/L). Abdominal ultrasound showed a distended, thin-walled gallbladder containing several biliary stones of differing size with the common bile duct dilated at 0.4 cm. The patient was admitted for persistent abdominal pain refractory to analgesics. The general surgeon was consulted, and the plan was made for laparoscopic cholecystectomy upon reaching 23 weeks of gestation. Intraoperatively, three trocars were inserted and extensive adhesions were noted to invest the gallbladder, omentum, liver, and abdominal wall. A laceration measuring 1 cm in diameter in the uterine wall occurred with the introduction of the umbilical trocar as the uterus was adherent to the abdominal wall. The blind entry technique had been used. The trocar was mobilized and the adheiolysis performed. The cholecystectomy was successfully completed and upon reducing intrabdominal gas pressure, the amniotic fluid leak was noted. The general surgeon thereafter repaired the uterine laceration with a polyglactin suture in a figure of 8 fashion. Hemostasis was ensured. Postoperative obstetrical ultrasound performed soon thereafter suggested the presence of a 1000g fetus; cephalic presentation; fundal placenta with notable anterior and posterior uterine investment without signs of retroperitoneal hematoma or abruptio placentae. The amniotic fluid was suggested to be ‘cloudy’. The patient received a course of antibiotics and antenatal corticosteroids for postoperative chorioamnionitis prophylaxis and fetal lung maturity. She was also started on an oral progesterone. The patient was closely monitored with serial ultrasounds and fetal heart monitoring. At 28 weeks of gestation, the patient presented to the hospital with preterm labor at which time she received a second course of steroids for fetal lung maturity and was subsequently discharged after complete resolution of uterine contractions. One week later, the patient again developed episodic abdominal pain. Contraction tomography showed regular uterine contractions that was nonresponsive to conservative measures. She was then transferred to the operating room for urgent cesarean section due to concern of uterine rupture at the site of the injury. Cesarean intraoperative findings included a healing site where the uterine injury had occurred, with a near-complete dehiscence along the transverse axis of the lower transverse uterine segment. Examination of the placenta indicated trauma to the anterior uterine wall that had been of full thickness. Discussion: The incidence of cholecystitis in pregnancy ranges from 0.05% to 0.8% (Date 2008). The higher rates of incidence in pregnancy are due to expected physiologic changes, namely supersaturation of cholesterol driven by increased estrogen levels along with the relaxation of the smooth muscle in the gallbladder caused by elevated progesterone. Given these physiologic changes, risk of occurrence requiring admission has been reported to be as high as 38-70% after initial conservative treatment (Date 2008). The guidelines of the Japanese Society of Gastroenterological Endoscopic Surgery (published only in Japanese) recommend laparoscopic surgery during the second trimester (14-27 weeks) in pregnant women. In this report, we presented an unusual case of direct trocar injury at 23 weeks which was managed conservatively on outpatient basis with the injury site remaining intact despite a full wall thickness injury. This patient delivered via cesarean section at 29 weeks, after which the neonate remained inpatient in the NICU for a period of 2 months. This case demonstrates the utility of a conservative approach in the setting of a stable patient and fetus in the setting of an intrapartum iatrogenic uterine perforation. This is one of a few cases in published literature with successful neonatal outcomes. This approach opens the door for conservative management in future cases after weighing the potential risks of chorioamnionitis and uterine rupture which could develop at any time. Conclusion: While iatrogenic trocar injury in pregnancy is rare, conservative management and stabilization of the mother and fetus may be possible to delay delivery for steroid administration and promotion of fetal maturation. This case highlights the potential benefits of such management route in the setting of a stable pregnancy.