Manual intrauterine aspiration (MIUA) is an instrumental procedure used to evacuate uterine contents through suction. It is an effective and cost-efficient technique for uterine evacuation. Its simplicity and portability make it a reproductive health tool of choice. More than 25 years of clinical research conducted in over 100 countries have demonstrated that MIUA is safer and as effective as curettage [1][2]. Accordingly, this technique represents a first-line therapeutic option for the management of abortion conditions with misoprostol, in the presence of hemorrhage, and notably in cases of gestational trophoblastic disease. However, adequate mastery of the technique is required, as severe complications such as uterine perforation may occur. Based on these considerations, we report two cases of severe complications following MIUA in our institution.

These observations illustrate that although MIUA is a widely used and technically simple method of uterine evacuation, it may lead to life-threatening complications. Proper training, strict adherence to procedural technique, and early recognition of complications are essential for all practitioners involved in postabortion care.

Indeed, in our country where access to healthcare is difficult in remote areas, midwives are trained within the framework of delegated competence in order to handle certain situations such as abortion, the application of vacuum extraction, and certain obstetric maneuvers.

Uterine perforation remains one of the most frequent immediate complications, most commonly reported after clandestine induced abortion [1][2]. In the present cases, digestive symptoms were the primary alerts leading to diagnosis, consistent with reports by Cissé et al. [3], who described gastrointestinal findings in all four of their cases complicated by peritonitis. Other studies have similarly reported uterine perforation discovered during laparotomy for acute abdominal emergencies [4][5].

In our observations, the mean delay before diagnosis was approximately forty-eight hours, although published delays vary widely. Amarin and Badria [6] reported delays up to five days, while Cissé et al. [3] noted an average of seven days. Such delays may reflect the reluctance of patients who undergo clandestine abortion to seek timely medical care due to fear of legal consequences.

The indication for MIUA in our patients hemorrhagic abortion is consistent with published practice [7]. Clinical presentations included intestinal obstruction in the first case and a flat abdomen devoid of its bowel loops in the second, in line with descriptions from other authors [5]. Additional presentations, such as acute peritonitis, pelvic peritonitis, or acute gastroenteritis, have been documented [3]-[5].

Radiological evaluation, performed only for the first patient, was highly contributive. CT scan provided a clear diagnosis of bowel incarceration through uterine perforation, consistent with the observations of Grossman et al. [8] and Diop et al. [9]. Although pelvic ultrasound is frequently used in African settings, its diagnostic yield for incarcerated perforation requires meticulous interpretation [5].

In the second case, externalized bowel loops made imaging unnecessary, as similarly reported by Efuetnkeng Bechem et al. [4].

Laparoscopy is the diagnostic modality of choice for direct visualization and management planning [10], but remains limited in many low-resource settings.

Operator inexperience is consistently identified as the primary risk factor for perforation. Amarin and Badria [6], in a series of 8400 MIUA procedures, found that all 28 perforations were performed by trainees. In our study, both procedures were performed by midwives. Other risk factors include advanced age, nulliparity or multiparity, menopause, retroverted uterus, excessive force, cervical stenosis, or use of GnRH agonists [6][7].

Surgery is the cornerstone of management, supported by fluid resuscitation and broad-spectrum antibiotics [11]. Laparotomy remains the most widely used approach because laparoscopy is less accessible in resource-limited settings [12]. Surgical technique depends on the extent of injury, fertility desires, hemodynamic status, severity of bowel involvement, and delay in diagnosis [13]. Conservative surgery should be prioritized whenever feasible [14].

In our first case, conservative uterine repair was possible, whereas in the second case hysterectomy was mandatory due to necrosis. Prognosis is favorable with timely intervention; delays may lead to peritonitis, reoperation, or death. Mortality rates up to 21.8% have been reported in Madagascar, mainly due to septic shock [15].

Uterine perforation remains one of the most severe complications of manual intrauterine aspiration. Early recognition, timely referral, and appropriate surgical management are crucial to reducing morbidity and mortality. Strengthening provider training, improving access to emergency surgical care, and promoting safe abortion practices are essential in preventing such complications, particularly in low-resource settings.