Case report
Patient is a 31 yo para 0101 (previous low transverse cesarean delivery at 35 weeks for oligohydramnios and non-reassuring FHR) who was diagnosed with IUFD @ 10 weeks in her second pregnancy. She underwent a D&E by her original M.D. on 6/9/05 and experienced persistent postop uterine cramping, bleeding, and low grade fever to 102º, along with some rigors. Being a physician (internist), she self-diagnosed postop infection and self-Rx'd with broad spectrum oral antibiotics. Her febrile morbidity resolved, but she presented to me on postop day 6, 6/15/05 with persistent uterine cramping and bleeding with passage of clots. My exam showed a slightly tender retroverted uterus. My working diagnosis based on the above was possible postabortal syndrome, with perhaps some retained products of conception and maybe also endometritis. Vaginal ultrasound images were obtained, with the pictures below:
A schematic interpretation of the above images is available here
I suspected an anterior upper cervical canal perforation, and took her to the O.R. where I did a careful ultrasound-guided repeat vacuum aspiration with resolution of her clinical symptomatology, including pain, bleeding, and fever.
Path report on aspirate showed thrombotic debris and endometrium but no products of conception.
Patient comes in for consultation 8/25/05 regarding future pregnancy and assessment regarding any potential risk of uterine rupture or dehiscence, as well as attempt to document integrity of defect seen on the above sonograms. Ultrasound images were obtained before and after saline sonohysterography. See below:
Sagittal, before saline instillation
A schematic interpretation of the above images is available here
I believe this (probably subjacent to the hysterotomy incision) is a nearly full-thickness anterior defect, and may even be epithelialized.
Questions for the list:
Would any of you advise going in to place repair or reinforcing sutures to 'close' this?
If so, would anyone consider accessing this area laparoscopically, including suturing?
If so, would anyone use anything other than absorbable suture such as the Vicryl we use to routinely close hysterotomies?
If suturing advised, would anyone suggest excision of any epithelium from the defect, like when one trims to 'freshen the edges' in a tubal reanastomosis?
A concern has been raised about the tensile strength and rupture risk of uterine closures done at laparoscopic myomectomies. A recent representative citation is below:
Spontaneous uterine rupture at
27 weeks of pregnancy after laparoscopic myomectomy
Grande N, Catalano GF, Ferrari S, Marana R
The Journal of Minimally Invasive Gynecology- 2005 8 (Vol. 12, Issue 4)
All opinions appreciated and encouraged! Post to the Ob-Gyn-L list please.
