Intestinal Injury Associated With Uterine Perforation due to Surgical Abortion in Japan.

To the Editor

Unsafe abortion is one of the leading causes of maternal mortality. Uterine perforation has been observed to be one of main complications of surgical abortion. In 2012, for example, there were 19 uterine perforations in 100,851 induced abortions at less than 12 weeks of pregnancy (18.0 per 100,000) in Japan [1]. To date, some reviews and case reports had been reported concerning the presence of intestinal injuries associated with surgical abortion; however, the incidence of the complication has not been well documented [2-4].

We requested 2,544 obstetrical facilities that are members of Japan Association of Obstetricians and Gynecologists to provide information of uterine perforation associated with surgical abortion between 2011 and 2015. A total of 63 cases of uterine perforation were reported during the study period.

Table 1 shows the clinical description and outcomes of the 63 cases of uterine perforation due to surgical abortion. As shown in Table 1, the rate of perforation requiring surgical repair of uterus was at least 84%, while the incidence of intestinal injury requiring surgical repair was at least 56%. In addition, an ostomy was required in three cases of them (3/35; 9%).

Table 1

Clinical Description and Outcomes of 63 Cases of Uterine Perforation due to Surgical Abortion

	Number	Percentage
Total	63	100%
Indication for surgery
Artificial abortion	36	57%
Missed/incomplete abortion	25	40%
Unknown	2	3%
Gestational age at abortion
< 12 weeks	45	71%
≥ 12 weeks	5	8%
Unknown	13	21%
Additional surgery
Laparotomy	43	68%
Laparoscopic surgery	10	16%
No surgery	5	8%
Unknown	5	8%
Intestinal injury
Yes	35	56%
No	18	29%
Unknown	10	16%

In the current observation in Japan, the incidence of intestinal injury in the uterine perforations due to surgical abortion seemed to be high (about 60%). The incidence of total complications and uterine perforation associated with surgical abortion in Japan has seemed to be lower than that in the Western countries [1]. In Japan, the rate of sharp curettage still remains one of the most frequently used procedures for surgical abortion unlike the Western countries. The intraperitoneal manipulation with placental forceps and/or sharp curettage may be easy to damage the intestinal tract. If uterine perforation is suspected following surgical abortion in Japan, we should not prevent hesitating laparotomy.