A Rare Case of Necrotic Uterine Cornua

INTRODUCTION: Uterine perforation during dilation and curettage (D&C) is rare, occurring at rates between 0.1% and 2%. Various factors, such as pregnancy, infection, adhesions, and surgical technique, affect the risk. Complications may include bleeding, infection, bowel perforation, and, in rare instances, uterine necrosis. OBJECTIVE: The objective of this video is to review management options and highlight an unusual presentation of necrotic uterine cornua after uterine perforation and prior instrumentation. METHODS: This video demonstrates the management of a 36-year-old G1P1001 who underwent a vaginal delivery complicated by postpartum hemorrhage with continued pain and bleeding. She underwent multiple procedures postpartum due to her continued pain, including D&C, uterine artery embolization, and diagnostic laparoscopy. Imaging revealed an arteriovenous malformation or retained products of conception. The patient was counseled on next surgical options, and in consideration of future fertility desires, the decision was made to proceed with wedge resection. On laparoscopy and hysteroscopy, necrotic tissue was visualized in the right cornua and a wedge resection and repair were performed without complication. RESULTS: Pathology results indicated the presence of vascular malformation and necrotic villi. The patient had resolution of symptoms following her surgery, and ultrasound and MRI imaging at 6 and 12 months, respectively, showed no lesions in the uterus. CONCLUSIONS: Pregnancy, infection, and surgical technique increase the risk of uterine perforation. While perforation alone can lead to necrosis, this is rare. Combining different procedures that lead to devascularization, such as uterine artery embolization and electrosurgery, increases the risk of necrosis. This patient underwent two blind D&Cs, use of electrosurgery on the perforation site, and uterine artery embolization, amplifying her risk of necrosis. This case highlights the risks associated with the combination of these managements, along with the need for meticulous hysteroscopic technique and limitation of electrosurgery.