We welcome the above comments regarding the incidence of uterine perforation and our management protocol.
With regard to the first comment, surgical termination of pregnancy (TOP) is the most common procedure associated with uterine perforation. In the England and Wales 2012 statistics for TOP, 96 263 surgical TOPs were performed. We are not stating that TOP has the highest incidence of perforation. Indeed if one reads the ‘High risk surgery’ section of our article, the incidence associated with each procedure is described, and we acknowledge in this section that surgical TOP does not have the highest incidence.
With regard to the second point of a perforation caused by a polyp forceps, no laparoscopy is required if avulsion has not taken place. There are times when introduction of the polyp forceps causes the perforation without any avulsion being attempted. If however, avulsion is attempted then a laparoscopy should be performed. Both these points are clearly highlighted in the ‘Management’ section of our article and in Figure 1.
In response to the third point, if a perforation has associated injuries then patients should be admitted. Our management protocol agrees with the fact that small perforations, if managed appropriately can be discharged the same day if stable, at the gynaecologist's discretion. This is clearly displayed on Figure 1.
Finally, if a perforation has occurred and requires suturing then every effort, within safe limits should be made to ensure that this is performed laparoscopically. The benefits of laparoscopic surgery are well established and if it is identified within a unit that more training is required, then several advanced laparoscopic surgery courses are available to attend. The majority of these include laparoscopic suturing, which is a skill that can be learnt by most. If, however, at the time of perforation, a laparoscopic surgeon is not readily available or the injuries are so severe, then a laparotomy should be performed as highlighted clearly in the ‘Management’ section of our article and in Figure 1.