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A Case Report: Metroplasty of a Noncommunication Rudimentary Uterine Horn with Unicornuate Uterus
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Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159 2
Federation; Center for Women’s Care and Reproductive Surgery, Atlanta, Georgia Study Objective: Improvement of diagnosis and results of treatment of malformations of uterus and vagina. Design: Analysis of 1460 cases of malformations managed by conventional or endoscopic surgical approaches. Setting: Scientific Center for Obstetrics, Gynecology and Perinatology. Patients: In 238 patients with vaginal and uterine aplasia, 36 women with vaginal aplasia and functional uterus, 198 women with uterine septum, 121 patients with rudimentary uterine horn, 7 women of bicornuate uterus malformations were diagnosed and managed by endoscopic approaches. Intervention: In all patients with vaginal and uterine aplasia neovagina was created from pelvic peritoneum by laparoscopically assisted transperineal approach. In 30 cases of vaginal aplasia with functional uterus laparoscopic hysterectomy was performed, while 6 analogous cases were successfully managed by creation of utero-perineal tunnel with preservation of uterus by combination of retrograde hysteroscopy, laparoscopy and perineal approach. Resectoscopy was used either alone for management of uterine septum, or together with laparoscopy for correction of bicornuate uterus by endoscopic metroplasty. Rudimentary horns were removed laparoscopically with concomitant adhesiolysis and elimination of endometriotic lesions. Measurements and Main Results: Combination of laparoscopy and hysteroscopy were crucial to establish correct diagnosis of malformation. Laparoscopically assisted colpopoiesis resulted in satisfactory neovagina capacity and normal epithelium morphology. Laparoscopic hysterectomy and creation of utero-perineal tunnel with preservation of uterus eliminated severe pelvic pain, chronic hemoperitoneum, distortion of prlvic anatomy. Endoscopic metroplasty resulted in complete restoration of endometrium and full-term pregnancy and natural delivery in 113 (57.0%) for uterine septum and in 71,4% pregnancy rate with cesarean section for bicornuate uterus. Conclusion: Malformations of uterus and vagina can be definitely and correctly diagnosed only with use of laparoscopy and hysteroscopy. In asymmetric anomalies laparoscopy provides minimally invasive approach both for radical and reconstructive treatment. Hysteroresectoscopy is the method of choice for correction of uterine septum, and the important step of combined hystero-laparoscopic metroplasty substantiated by encouraging reproductive outcomes.
520 Minimally Invasive Interventions during Pregnancy Adamyan LV, Martynov SA, Kiselev SI. Operative Gynecology, Scientific Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation Study Objective: To evaluate effectiveness and safety of surgical treatment by endoscopy during pregnancy. Design: Analysis of treatment of conditions requiring surgical interventions during pregnancy. Setting: Department of Operative Gynecology of the Scientific Center for Obstetrics, Gynecology & Perinatology. Patients: 173 pregnant patients (156 patients with adnexal masses, 5 patients with uterine myoma, 12 women with cervical pregnancy, one patient with pregnancy both in main and rudimentary uterine horns. Intervention: Laparoscopic myomectomy for growing or necrotic subserous myoma was permormed on 14the16th week of gestation. Adnexall masses were mainly (in 76% of patients) managed in the 2nd trimester, while 24% underwent surgery in the 1st trimester due to strong cancer suspicion or ovarian torsion or apoplexy. In one case rudimentary uterine horn was removed together with ectopic pregnancy. In all these cases pregnancy developed further on uneventfully and terminated with full-term delivery. 12 patients with cervical pregnancy were treated with methotrexate and leucovarin with subsequent hysteroresectoscopic chorion removal.
Measurements and Main Results: In all laparoscopic cases pregnancy developed further on uneventfully and terminated with full-term delivery. In cervical pregancy cases pregnancy terminated after medical treatment and hysteroscopic chorion removal. Conclusion: Laparoscopic approach allows to eliminate a disease requiring surgery no negative impact on pregnancy course and fetus health. Inclusion of hysteroresectoscopy into treatment strategy for cervical pregnancy provides an option for preservation of reproductive function with elimination of risk of development of trophoblastic disease.
521 A Case Report: Metroplasty of a Noncommunication Rudimentary Uterine Horn with Unicornuate Uterus Ahn SY, Shin HM, Kim MR. Obstetrics and Gynecology, The Catholic University of Seoul, Kangnam St. Mary’s Hospital, Seoul, Republic of Korea Study Objective: We have experienced a case of rudimentary uterine horn with unicornuate uterus, pelvic endometriosis in a 25 years old woman. and we treated by metroplasty surgery. Several cases of unicornuate uterus have been documented. However, there have been few reported cases of metroplasty of unicornuate uterus with rudimentary uterine horn. So we report this case with a review of literatures. Design: We operated in July 26, 2006 at the Catholic University of Seoul, Kangnam St. Mary’s Hospital. Setting: At the Catholic University of Seoul, Kangnam St’Mary’s Hospital. Patients: 25 years old woman who has rudimentary uterine horn with unicornuate uterus, pelvic endometriosis. Intervention: Under general anesthesia, we transabdominally approach. Measurements and Main Results: We treated by metroplasty surgery. We discharged her after 4 days without special problem, medicated progynova(8 mg) for 28 days to regenerate uterine endometrium. Conclusion: The unicornuate uterus is a rare type of the anomalous uteri, which is cause by failure of development of one of the mullerian ducts. This condition is usually associated with various degrees of rudimentary uterine horn. The unicornuate uterus with rudimentary horn is susceptible to many gynecologic and obstetric complications. We have experienced
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
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523 Ectopic Pregnancy Associated with the Use of Contraceptive Implant ImplanonÔ George SM,1 Thomas A,2 Thomas K.3 1Obstetrics & Gynaecology, Liverpool Womens Hospital, Liverpool, Merseyside, United Kingdom; 2 Obstetrics & Gynaecology, Whiston Hospital, Whiston, Merseyside, United Kingdom; 3Obstetrics & Gynaecology, Southport and Ormskirk Hospital, Ormskirk, Lancashire, United Kingdom Study Objective: We describe a case of ectopic pregnancy occurring in a patient with an etonogestrel contraceptive implant Implanon Ô. Design: Case report. Setting: A district general hospital in Northern England. Patients: 21-year-old nulliparous lady was seen in the accident and emergency department with increasing pain in the right lower abdomen associated with a brownish vaginal discharge and raised serum b HCG of 953 IU/L. She gave a history of having ImplanonÔ insertion two years previously and this was confirmed by the presence of the device in the left arm. She gave a history of being treated with carbamezapine and Levetiracetam for petit mal seizures. A vaginal ultrasound examination confirmed an empty uterus and a 25 mm clear cyst in the right ovary with a trace of free fluid adjacent. Laparoscopy confirmed the presence of a right sided unruptured tubal pregnancy with a corpus luteal cyst in the right ovary. The opposite adnexa and the pelvic peritoneum appeared normal and there were no pelvic or perihepatic adhesions. a rare case of rudimentary uterine horn with unicornuate uterus, pelvic endometriosis.
522 Transvaginal Pelvic Balloon Tamponade for Severe Pelvic Hemorrhage after Cesarean Hysterectomy Dabelea V,1 Bruno G,2 Ruderman J,2 Kronbach D,2 Schwebach L,2 Kandel E.2 1Obstetrics and Gynecology, Exempla Saint Joseph Hospital, Denver, Colorado; 2Obstetrics and Gynecology, Kaiser Permanente, Denver, Colorado Study Objective: Design: This communication provides a case report of an off label use of balloon tamponade to control pelvic hemorrhage after cesarean hysterectomy. Setting: Previously published cases report described the use of packing, ‘‘The Umbrella Pack’’, bowel bag, or inflatable devices to achieve hemostasis by pelvic tamponade. Patients: Our case is a 24-year-old woman G3P1020 at 39.6 weeks, admitted to L&D in labor. An emergent cesarean delivery was performed for nonreassuring fetal heart tones and arrest of descent. The patient was taken back to OR from PACU because of severe postpartum hemorrhage. Dilation and curettage, O’Leary and B-Lynch stitches were not successful in controlling the bleeding and a supracervical hysterectomy was performed. The patient was transferred to the ICU, and noted to have continued bleeding and developed DIC. The decision made to return to OR. Exploratory laparotomy and trachelectomy was performed. Significant bleeding continued from denuded tissue in lower pelvis, lateral apical vagina and vaginal cuff. All attempts to achieve surgical hemostasis were unsuccessful. SOS Bakri Balloon catheter (Cook Medical Inc.) was advanced transvaginally in the lower pelvis and progressively inflated with saline until excellent hemostasis was achieved; the total amount of saline used to inflate the balloon was 300 cc. The pelvis and vagina were packed to hold the Bakri catheter in place. 24 hours later the Bakri catheter and the abdominal and vaginal packs were removed with no further bleeding. Prior to pelvic balloon tamponade the patient required 22 units of PRBC, 12 units of FFP and 6 packs of Platelets (10 hours time frame from delivery to balloon tamponade). Conclusion: Transvaginal pelvic balloon tamponade was successful in controlling intractable severe pelvic hemorrhage in this case.
Intervention: A laproscopic salpingectomy and aspiration of the ovarian cyst were performed. Implanon was removed and she was discharged home the following day with contraceptive advice. Conclusion: Unintended pregnancies with the use of implanon have been associated with poor technique, high body mass index in patients and concomitant use of enzyme inducing drugs. Hepatic enzyme inducing drugs such as carbamezapine can reduce the efficacy of implantable contraceptives by reducing plasma concentrations of etonogestrel. Maximal enzyme induction last from two weeks after commencement of these drugs upto four weeks after cessation of therapy. Women may continue with progestogen-only implants with additional barrier contraceptives when taking liver enzyme-inducers and for 4 weeks after they are stopped. Information should be given on the use of alternative contraceptive methods if liver enzyme-inducing drugs are to be used long term.
524 Internalization of Thoracoamniotic Shunt of Fetal Bilateral Chylothorax at 23 Weeks of Pregnancy Kim S. Obstetrics and Gynecolgy, Catholic University, Bucheon, Kyungido, Republic of Korea Study Objective: For internalizatio of horachoamniotic shunt of fetal bilateral chylothorax.
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159 2
Federation; Center for Women’s Care and Reproductive Surgery, Atlanta, Georgia Study Objective: Improvement of diagnosis and results of treatment of malformations of uterus and vagina. Design: Analysis of 1460 cases of malformations managed by conventional or endoscopic surgical approaches. Setting: Scientific Center for Obstetrics, Gynecology and Perinatology. Patients: In 238 patients with vaginal and uterine aplasia, 36 women with vaginal aplasia and functional uterus, 198 women with uterine septum, 121 patients with rudimentary uterine horn, 7 women of bicornuate uterus malformations were diagnosed and managed by endoscopic approaches. Intervention: In all patients with vaginal and uterine aplasia neovagina was created from pelvic peritoneum by laparoscopically assisted transperineal approach. In 30 cases of vaginal aplasia with functional uterus laparoscopic hysterectomy was performed, while 6 analogous cases were successfully managed by creation of utero-perineal tunnel with preservation of uterus by combination of retrograde hysteroscopy, laparoscopy and perineal approach. Resectoscopy was used either alone for management of uterine septum, or together with laparoscopy for correction of bicornuate uterus by endoscopic metroplasty. Rudimentary horns were removed laparoscopically with concomitant adhesiolysis and elimination of endometriotic lesions. Measurements and Main Results: Combination of laparoscopy and hysteroscopy were crucial to establish correct diagnosis of malformation. Laparoscopically assisted colpopoiesis resulted in satisfactory neovagina capacity and normal epithelium morphology. Laparoscopic hysterectomy and creation of utero-perineal tunnel with preservation of uterus eliminated severe pelvic pain, chronic hemoperitoneum, distortion of prlvic anatomy. Endoscopic metroplasty resulted in complete restoration of endometrium and full-term pregnancy and natural delivery in 113 (57.0%) for uterine septum and in 71,4% pregnancy rate with cesarean section for bicornuate uterus. Conclusion: Malformations of uterus and vagina can be definitely and correctly diagnosed only with use of laparoscopy and hysteroscopy. In asymmetric anomalies laparoscopy provides minimally invasive approach both for radical and reconstructive treatment. Hysteroresectoscopy is the method of choice for correction of uterine septum, and the important step of combined hystero-laparoscopic metroplasty substantiated by encouraging reproductive outcomes.
520 Minimally Invasive Interventions during Pregnancy Adamyan LV, Martynov SA, Kiselev SI. Operative Gynecology, Scientific Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation Study Objective: To evaluate effectiveness and safety of surgical treatment by endoscopy during pregnancy. Design: Analysis of treatment of conditions requiring surgical interventions during pregnancy. Setting: Department of Operative Gynecology of the Scientific Center for Obstetrics, Gynecology & Perinatology. Patients: 173 pregnant patients (156 patients with adnexal masses, 5 patients with uterine myoma, 12 women with cervical pregnancy, one patient with pregnancy both in main and rudimentary uterine horns. Intervention: Laparoscopic myomectomy for growing or necrotic subserous myoma was permormed on 14the16th week of gestation. Adnexall masses were mainly (in 76% of patients) managed in the 2nd trimester, while 24% underwent surgery in the 1st trimester due to strong cancer suspicion or ovarian torsion or apoplexy. In one case rudimentary uterine horn was removed together with ectopic pregnancy. In all these cases pregnancy developed further on uneventfully and terminated with full-term delivery. 12 patients with cervical pregnancy were treated with methotrexate and leucovarin with subsequent hysteroresectoscopic chorion removal.
Measurements and Main Results: In all laparoscopic cases pregnancy developed further on uneventfully and terminated with full-term delivery. In cervical pregancy cases pregnancy terminated after medical treatment and hysteroscopic chorion removal. Conclusion: Laparoscopic approach allows to eliminate a disease requiring surgery no negative impact on pregnancy course and fetus health. Inclusion of hysteroresectoscopy into treatment strategy for cervical pregnancy provides an option for preservation of reproductive function with elimination of risk of development of trophoblastic disease.
521 A Case Report: Metroplasty of a Noncommunication Rudimentary Uterine Horn with Unicornuate Uterus Ahn SY, Shin HM, Kim MR. Obstetrics and Gynecology, The Catholic University of Seoul, Kangnam St. Mary’s Hospital, Seoul, Republic of Korea Study Objective: We have experienced a case of rudimentary uterine horn with unicornuate uterus, pelvic endometriosis in a 25 years old woman. and we treated by metroplasty surgery. Several cases of unicornuate uterus have been documented. However, there have been few reported cases of metroplasty of unicornuate uterus with rudimentary uterine horn. So we report this case with a review of literatures. Design: We operated in July 26, 2006 at the Catholic University of Seoul, Kangnam St. Mary’s Hospital. Setting: At the Catholic University of Seoul, Kangnam St’Mary’s Hospital. Patients: 25 years old woman who has rudimentary uterine horn with unicornuate uterus, pelvic endometriosis. Intervention: Under general anesthesia, we transabdominally approach. Measurements and Main Results: We treated by metroplasty surgery. We discharged her after 4 days without special problem, medicated progynova(8 mg) for 28 days to regenerate uterine endometrium. Conclusion: The unicornuate uterus is a rare type of the anomalous uteri, which is cause by failure of development of one of the mullerian ducts. This condition is usually associated with various degrees of rudimentary uterine horn. The unicornuate uterus with rudimentary horn is susceptible to many gynecologic and obstetric complications. We have experienced
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
S145
523 Ectopic Pregnancy Associated with the Use of Contraceptive Implant ImplanonÔ George SM,1 Thomas A,2 Thomas K.3 1Obstetrics & Gynaecology, Liverpool Womens Hospital, Liverpool, Merseyside, United Kingdom; 2 Obstetrics & Gynaecology, Whiston Hospital, Whiston, Merseyside, United Kingdom; 3Obstetrics & Gynaecology, Southport and Ormskirk Hospital, Ormskirk, Lancashire, United Kingdom Study Objective: We describe a case of ectopic pregnancy occurring in a patient with an etonogestrel contraceptive implant Implanon Ô. Design: Case report. Setting: A district general hospital in Northern England. Patients: 21-year-old nulliparous lady was seen in the accident and emergency department with increasing pain in the right lower abdomen associated with a brownish vaginal discharge and raised serum b HCG of 953 IU/L. She gave a history of having ImplanonÔ insertion two years previously and this was confirmed by the presence of the device in the left arm. She gave a history of being treated with carbamezapine and Levetiracetam for petit mal seizures. A vaginal ultrasound examination confirmed an empty uterus and a 25 mm clear cyst in the right ovary with a trace of free fluid adjacent. Laparoscopy confirmed the presence of a right sided unruptured tubal pregnancy with a corpus luteal cyst in the right ovary. The opposite adnexa and the pelvic peritoneum appeared normal and there were no pelvic or perihepatic adhesions. a rare case of rudimentary uterine horn with unicornuate uterus, pelvic endometriosis.
522 Transvaginal Pelvic Balloon Tamponade for Severe Pelvic Hemorrhage after Cesarean Hysterectomy Dabelea V,1 Bruno G,2 Ruderman J,2 Kronbach D,2 Schwebach L,2 Kandel E.2 1Obstetrics and Gynecology, Exempla Saint Joseph Hospital, Denver, Colorado; 2Obstetrics and Gynecology, Kaiser Permanente, Denver, Colorado Study Objective: Design: This communication provides a case report of an off label use of balloon tamponade to control pelvic hemorrhage after cesarean hysterectomy. Setting: Previously published cases report described the use of packing, ‘‘The Umbrella Pack’’, bowel bag, or inflatable devices to achieve hemostasis by pelvic tamponade. Patients: Our case is a 24-year-old woman G3P1020 at 39.6 weeks, admitted to L&D in labor. An emergent cesarean delivery was performed for nonreassuring fetal heart tones and arrest of descent. The patient was taken back to OR from PACU because of severe postpartum hemorrhage. Dilation and curettage, O’Leary and B-Lynch stitches were not successful in controlling the bleeding and a supracervical hysterectomy was performed. The patient was transferred to the ICU, and noted to have continued bleeding and developed DIC. The decision made to return to OR. Exploratory laparotomy and trachelectomy was performed. Significant bleeding continued from denuded tissue in lower pelvis, lateral apical vagina and vaginal cuff. All attempts to achieve surgical hemostasis were unsuccessful. SOS Bakri Balloon catheter (Cook Medical Inc.) was advanced transvaginally in the lower pelvis and progressively inflated with saline until excellent hemostasis was achieved; the total amount of saline used to inflate the balloon was 300 cc. The pelvis and vagina were packed to hold the Bakri catheter in place. 24 hours later the Bakri catheter and the abdominal and vaginal packs were removed with no further bleeding. Prior to pelvic balloon tamponade the patient required 22 units of PRBC, 12 units of FFP and 6 packs of Platelets (10 hours time frame from delivery to balloon tamponade). Conclusion: Transvaginal pelvic balloon tamponade was successful in controlling intractable severe pelvic hemorrhage in this case.
Intervention: A laproscopic salpingectomy and aspiration of the ovarian cyst were performed. Implanon was removed and she was discharged home the following day with contraceptive advice. Conclusion: Unintended pregnancies with the use of implanon have been associated with poor technique, high body mass index in patients and concomitant use of enzyme inducing drugs. Hepatic enzyme inducing drugs such as carbamezapine can reduce the efficacy of implantable contraceptives by reducing plasma concentrations of etonogestrel. Maximal enzyme induction last from two weeks after commencement of these drugs upto four weeks after cessation of therapy. Women may continue with progestogen-only implants with additional barrier contraceptives when taking liver enzyme-inducers and for 4 weeks after they are stopped. Information should be given on the use of alternative contraceptive methods if liver enzyme-inducing drugs are to be used long term.
524 Internalization of Thoracoamniotic Shunt of Fetal Bilateral Chylothorax at 23 Weeks of Pregnancy Kim S. Obstetrics and Gynecolgy, Catholic University, Bucheon, Kyungido, Republic of Korea Study Objective: For internalizatio of horachoamniotic shunt of fetal bilateral chylothorax.