Case Report
Twenty eight years old G3P2L1MTP1 woman was referred with complaints of pain in abdomen since 5-6 years from private hospital in-view of ultrasonography and CT scan showing echogenic lesion in the endometrial cavity suggestive of foreign body for diagnostic and operative hysteroscopy. Ultrasonography was repeated at our institute which confirmed the previous sonography findings.

Her last menstrual period was on 18.8.2004, past cycles being regular of 30 days menstrual flow for 2-3 days.

She underwent MTP at 2 months gestation 5 years ago in private and her symptoms dated back to this surgical procedure.

Her general and systemic examination revealed no abnormality. Abdomen was soft. On vaginal examination, uterus was anteverted, normal size, fornices were clear and there was no fornicial or cervical tenderness on movement of cervix.

On admission haemoglobin was 12 gm%, WBC 11,000/mm3 N60 L40. X-ray chest was within normal limit. Platelet count was 2.6 lacs. Blood sugar, liver function and renal function tests were within the normal range. Pap smear was inflammatory.

Patient was posted for dilatation and curettage, Diagnostic Laparoscopy followed by exploratory laparotomy if required. Diagnostic hysteroscopy could not be performed as the endoscope sheath was under repair. Uterine sounding was done and a foreign body was felt. Shirodker IUCD hook was used to retrieve the foreign body, which failed. Subsequently sharp curettage was performed which also failed to remove the foreign body. Decision of diagnostic laparoscopy was taken. During laparoscopy two perforations were noted in the upper segment of uterus at anterior wall and fundus through which the omentum was seen to be entering the uterine wall upto the cavity. Decision of exploratory laparotomy was taken. Omentum was withdrawn from both perforations 3 centimeter of omentum which was trapped inside the endometrium was ligated and excised. Bleeding was noted from both perforation sites, suturing of both perforations was done with no 1 polyglactic 910 with figure of 8 sutures. Haemostasis checked. Postoperative period was uneventful. Patient was advised contraception. She was advised elective LSCS at 37 weeks for future pregnancy.

Discussion
What makes this case unusual is the fact that unrecognised uterine perforation presented years after MTP with omental entrapment in the uterus resulting in chronic pelvic pain.

Literature search shows that most of the cases of undiagnosed uterine perforation presented on day 3 or day 4 of uterine perforation with acute abdomen. Our patient presented with chronic pain in abdomen over 5 years. She had no recall of any acute abdominal symptoms following the MTP procedure.

On laparotomy, 23 cm of the trapped omentum was withdrawn from the uterine cavity and excised. Echo and images of this omental foreign body was seen on both ultrasound and CT scan.

Jeffcoats states expulsive uterine contractions can cause low backache especially over the area of the sacrum. He states this can occur during labour, abortion and attempts to expel polypoid growth, pus and blood from the uterine cavity.¹

Jeffcoats states that in patients with uterine perforation, indication for laparotomy is if abdominal contents prolapse through the hole or if there is any likelihood of having been injured before the accident was discovered.²

In this case, the accident which involved only the omentum and not the bowel was not suspected and recognised at the time of MTP 5 years back. It can be inferred that the perforation must have occurred towards the end of the MTP as the patient had post MTP regular menstruation. She also did not have significant post MTP bleeding as the perforation site was compressed by the retracting uterus and also by the trapped omentum. Hence no laparoscopy or laparotomy was performed.

The patient kept on having pain for which she took off and on some medications from local general practitioner with no relief.
The entrapped omentum behaved like a foreign body producing expulsive uterine contractions and chronic pelvic pain. Luckily there was no menstrual disturbances or signs of infection.

A similar case has been reported by Bhide A, Ganla K.³

References

1. Jeffcoate’s Principles of Gynaecology Sixth Edition. Arnold publication, 2001; 35 : 611-3.
2. Jeffcoate’s Principles of Gynaecology Sixth Edition. Arnold publication, 2001, chapter 13-injuries, Page 238-62.
3. Bhide A, Ganla K. Manual of medical termination of pregnancy “an update” third edition Jaypee Publication 1999 chapter 31-MTP : interesting cases page 159-64.