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Uteroperitoneal fistula – a rare cause of failure of sterilization

P. L. Bhanap^1*, R. G. Narwade²

¹Professor, ²Assistant Professor, Department of OBGY IIMSR, Warudi, Badnapur, Jalna, Maharashtra, INDIA.

 

Abstract               Failed sterilization is uncommon event . Recanalization leading to failure is commonly understood reason for this. Here we present to you a rare case of uteroperitoneal fistula leading to so called sterilization failure.

Keywords: Uteroperitoneal fistula, failure of sterilization.

 

INTRODUCTION

Failure of sterilization is an uncommon event raising suspicion about surgical techniques and /or skill of the operating surgeon. Uteroperitoneal fistula contributing to failure of sterilization is known to occur if Fallopian tubes are ligated more proximally. Spontaneous rupture of uterus in labour, injury during dilatation and curettage, suction evacuation and other surgical procedures may also cause uteroperitoneal fistula. We present here a case of spontaneous rupture of uterus in labour causing uteroperitoneal fistula.

 

CASE REPORT

A 27 year old lady, presented to outpatient department of OBGY at IIMSR, Warudi, Badnapur with amenorrhoea of 47 days and complaining of nausea and vomiting. Her urine pregnancy test was positive and she opted for termination of pregnancy. She was married 8 years back. Her first pregnancy resulted in a full term normal delivery of a baby girl 7 years back and the child was well. She gave history of two consecutive terminations of pregnancies, each of about three and half months following the first delivery. In her forth pregnancy, she had undergone cerclage and the pregnancy resulted in delivery of a baby boy at term; the baby was now almost 2 years old and well. Twelve days after delivery, the woman had undergone diagnostic laparoscopy for some swelling of the womb, according to history, details were not known to her and she didn’t have reports of that operation either. She opted for minilap sterilization one year after the last delivery and it was uneventful. After six months, she became pregnant again and underwent medical termination with minilap sterilization. Again after eight months, she became pregnant, it was this time that we are reporting this case. Previous laparoscopy records were asked for, reviewed, which revealed evidence of broad ligament swelling on left side as a result of spontaneous rupture after last delivery. The condition was managed conservatively as operative notes didn’t mention hemorrhage or suturing of the rupture site. The second minilap sterilization operation clearly mentioned that there was evidence of tubal ligation seen on both the sides. This clearly reveals the fact that uterine injury and rent is the cause of so called repeated sterilization failure. The woman opted for medical termination of pregnancy which was done with manual vaccum aspiration. An IUCD was inserted and the husband was asked to get a vasectomy done for permanent method.

 

 

 

DISCUSSION

Uteroperitoneal fistula is a rare occurrence. Exact occurrence cant be known. Reported cases are few. Even when the sterilization is done, active spermatozoa, upon entering the uterine cavity, enter peritoneal cavity through this rent. Ovulation and subsequent fertilization ensues and biologically active embryos, through chemotaxis, are attracted towards endometrium and they find suitable site for implantation. Thus, failure of sterilization is not necessarily always a technical fault.  This fistula, many a times, is difficult to demonstrate by hysterosalpingography or chromopertubation because it is more likely to be functional than anatomical. A small opening in millimeters may not be visualized by aforementioned techniques but functionally, an active sperm and embryo, by virtue of its biological properties, can traverse the fistula either way. In the book, uterine fibroids: embolization and other treatments, Togas Tulandi mentions uteroperitoneal fistula as one of the complications of treating fibroids. Abhang Prabhu et al have published a case report Uteroperitoneal fistula secondary to puerperal sepsis following home delivery. They reported- it is also possible that the uterus may have been previously perforated during difficult home delivery conducted by non trained personal. The cause of this rupture is uncertain and the other reason one can only postulate is that the cervix was so tightly stenosed secondary to infection that it provided greater resistance to the outflow of pus than did the myometrium itself. With perforation of the pyometra, the infected contents of the uterus are released into the peritoneal cavity. Some reports of sonographic diagnosis, sometimes with use of color Doppler, have been published. But it has to be a major defect. Sterilization, done laparoscopically or by minilap, if carried out near proximal end of Fallopian tube, may lead to uteroperitoneal fistula and failure of sterilization. This has been documented widely but spontaneous rupture of uterus durng delivery, leading to uteroperitoneal fistula is not found on the internet database. Hence, we present this interesting case for increasing awareness about probable causes of failure of sterilization.

 

REFRENCES

1. Parkinson DJ, Alderman B. Spontaneous rupture of the uterus associated with pyometra. Postgraduate Medical Journal 1985; 61: 73-4.
2. Two-dimensional power Doppler-three-dimensional ultrasound imaging of a cesarean section dehiscence with utero-peritoneal fistula: a case report Pedro Royo et al, Journal of medical case reports 2009. 3;42
3. Abhang Prabhu et al, Bombay hospital journal, Vol 54 no. 02, April 2012.
4. Togas Tulandi, Uterine fibroids: embolization and other techniques. Cambridge University Press.

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