Posterior Uterine Wall Research Articles

EP25.12: Abdominopelvic actinomycosis associated with an intrauterine device: a case report

Actinomycosis is a rare chronic granulomatous suppurative infection caused by an anerobic Gram-positive bacterium, Actinomyces Israelii. Its capacity to invade surrounding tissues and to form masses might mimic other diseases. A 44-year-old woman with an intrauterine device placed 6 years ago, presents with one month history of lower abdominal pain, dyspareunia and fever. Her past medical history was unremarkable, and she had no history of previous abdominal or pelvic surgeries. Physical examination demonstrated generalised abdominal tenderness but no rigidity or guarding. Pelvic examination revealed a tender, solid, fixed pelvic mass, and no vaginal discharge. The patient was febrile. Laboratory investigations demonstrated leucocytosis, positive inflammatory markers and anemia. Transvaginal ultrasound revealed two irregular, heterogeneous, no vascularised, solid masses, one of 70x38x63 mm and other of 62x46x33mm adhered to the posterior uterine wall with apparently normal ovarian parenchyma. Thickening of the sigmoid colonic was also found and posteriorly confirmed by a CT scan, which additionally reported a bilateral hydronephrosis and left paraaortic lymphadenopathy. The main differential diagnoses proposed for the patient were and abdominopelvic actinomycosis or advanced ovarian cancer. The patient underwent laparoscopic surgery. Intraoperative findings confirmed the radiographic diagnosis. Histological results suggested actinomycosis infectious, and no evidence of malignant process. It was performed a partial right adnexectomy and an internal double-J ureteral stents was placed. Subsequently, the patient was treated with intravenous (IV) antibiotic for 6 weeks presenting notorious improvement and was advised to continue gynecological and urological clinical follow up.

Spontaneous first trimester posterior uterine rupture in a multiparous woman with scarred uterus: A case report

Abstract Uterine rupture (UR) is a life threatening peripartum complication with high incidence of maternal morbidity and mortality. Posterior wall uterine rupture is a rare presentation especially in the first trimester. Herein, we experienced a case of spontaneous UR in a 24-year-old gravida 3 para 2 pregnant woman at gestational age of 10 weeks presented with acute abdomen. Clinical and ultrasonographic findings were suspicious towards ruptured ectopic pregnancy. However, abdominal exploration revealed posterior wall UR away from the site of lower segment cesarean scar. The tear was repaired in three layers and the patient was discharged after 4 days of hospital stay. UR should be considered in any pregnant woman with hemoperitoneum, Posterior uterine wall rupture is a rare presentation in the first trimester, but must be kept in mind as early intervention is the only way to save the mother's life.

Sonohysterography in a suspected case of uterine perforation after dilatation and curettage for retained placenta

Abstract A 35-year-old woman, gravida 3, para 2, spontaneously delivered an infant without any major complications. On the 38th day after delivery, she returned to the hospital due to irregular bleeding. Transvaginal ultrasound showed a mass in the cervix; therefore, dilatation and curettage was performed, using placental forceps, to remove the retained placenta. During the procedure, a uterine perforation was suspected. Sonohysterography was performed in order to confirm the uterine perforation. The sonohysterogram revealed that the high echogenic mass that was suspected to be retained placenta was adhered on the posterior uterine myometrium. Saline that had been injected into the uterine cavity escaped into the Douglas pouch via a small hole in the posterior uterine wall. An emergency laparotomy was performed. Pathological examination of the removed uterus revealed placenta increta in the posterior wall, as well as an adjacent perforated fistula. Sonohysterographic diagnosis of uterine perforation in the present case was not only validated with diagnosis, but also the residual placenta was clearly visible. The use of sonohysterography for detection of a suspected case of uterine perforation after dilatation and curettage was accurate and provided a safe procedure for fast evaluation.

Uterine Arteriovenous Malformation Treated with Hysteroscopic Roller Ablation

Abstract Background: With the increasing rate of abortion and other intrauterine operations, uterine arteriovenous malformation (AVM) is no longer a rare entity. It can cause irregular uterine bleeding with subsequent anemia and even massive life-threatening uterine hemorrhage. Selective arterial embolization is often used as first-line treatment for this condition. Case: A 29-year-old women, gravida 5, para 1, had lower abdominal pain and intermittent vaginal bleeding. She had had one cesarean section and four artificial abortions. Thirteen days prior to presentation, she had undergone an artificial abortion via intrauterine aspiration. Ultrasound examination revealed an area of increased vascularity in her posterior uterine wall, which measured 18 mm × 15 mm × 7 mm. Hysteroscopy revealed a reddish spongy area in the posterior uterine wall. The patient was treated successfully with hysteroscopic roller ablation of the vascular mass, which was dehydrated and then separated from the uterine wall. Results: ...

Risk factors for massive postpartum bleeding in pregnancies in which incomplete placenta previa are located on the posterior uterine wall.

ObjectiveTo identify factors associated with massive postpartum bleeding in pregnancies complicated by incomplete placenta previa located on the posterior uterine wall.MethodsA retrospective case-control study was performed. We identified 210 healthy singleton pregnancies with incomplete placenta previa located on the posterior uterine wall, who underwent elective or emergency cesarean section after 24 weeks of gestation between January 2006 and April 2016. The cases with intraoperative blood loss (≥2,000 mL) or transfusion of packed red blood cells (≥4) or uterine artery embolization or hysterectomy were defined as massive bleeding.ResultsTwenty-three women experienced postpartum profuse bleeding (11.0%). After multivariable analysis, 4 variables were associated with massive postpartum hemorrhage (PPH): experience of 2 or more prior uterine curettage (adjusted odds ratio [aOR], 4.47; 95% confidence interval [CI], 1.29 to 15.48; P=0.018), short cervical length before delivery (<2.0 cm) (aOR, 7.13; 95% CI, 1.01 to 50.25; P=0.049), fetal non-cephalic presentation (aOR, 12.48; 95% CI, 1.29 to 121.24; P=0.030), and uteroplacental hypervascularity (aOR, 6.23; 95% CI, 2.30 to 8.83; P=0.001).ConclusionThis is the first study of cases with incomplete placenta previa located on the posterior uterine wall, which were complicated by massive PPH. Our findings might be helpful to guide obstetric management and provide useful information for prediction of massive PPH in pregnancies with incomplete placenta previa located on the posterior uterine wall.

A case report of delayed diagnosis of uterine rupture following vaginal delivery

Introduction: A uterine rupture is still a rare event but its incidence appears to be increasing, even in the unscarred uterus. In our case, the uterine rupture presented itself in an unscarred uterus and after a vaginal delivery. Case report: A 36 years old women with three previous normal deliveries, comes to our hospital for assistance at 32 weeks with a poor pregnancy surveillance. After diagnosing Gestational Diabetes, she is admitted for therapeutic adjustment. She is discharged after achieving metabolic control but comes back a few days later with a stillbirth, born by vaginal delivery. Six days later she presents with: fever and pain; anemia leukocytosis and a heterogeneous image on ultrasound. However, was decided to start intravenous antibiotics before choosing for surgery. Her condition worsens and an exploratory laparotomy is done: a posterior uterine wall rupture that required a hysterectomy. Conclusion: Risk factors for uterine rupture were present (maternal age over 35, higher parity, fetal macrosomia) but the absence of any symptom, the normal examination after delivery, and mostly, an unscarred uterus, resulted in a delay in the diagnosis of more than one week, leading to catastrophic consequences: hysterectomy. This case reminds us that uterine rupture happens not only in case of previous uterine surgery, and these cases seem to be increasing because of the increase in other risk factors: advanced maternal age and diabetes with resulting fetal macrosomia.

Laparoscopic Management of an Invasive Mole Perforating the Uterus

Study ObjectiveTo show the possibility of conservative laparoscopic management in a case of invasive mole perforating the uterus. DesignVideo with explanations. SettingAn invasive mole is a potentially life-threatening complication of gestational trophoblastic disease [1]. This is a case of a 24-year-old female presenting with abdominal pain and vaginal bleeding. There have been several previous reports of cases of uterine perforation by an invasive mole, all of which were managed with abdominal hysterectomy [2–7]. To our knowledge, this is the first report of an invasive mole perforation with active bleeding managed by laparoscopy without hysterectomy. InterventionsSonography revealed a large amount of fluid and a 3 × 3-cm heterogeneous lesion next to the posterior uterine wall. Her hemoglobin level dropped from 10.6 mg/dL to 8.6 mg/dL, and her β-human chorionic gonadotropin level was 19,004 mIU/mL. On laparoscopy, ∼2500 mL of hemoperitoneum was found, along with an actively bleeding bulging mass in the posterior uterine wall. This mass was dissected, and hemostasis was secured with sutures and electrocoagulation. Pathology confirmed the diagnosis of a complete mole. After surgery, the patient was treated with 5 courses of a methotrexate-folinic acid regimen. Her recovery was uneventful. ConclusionUterine perforation by an invasive mole can be managed conservatively with laparoscopic surgery and postoperative chemotherapy. The transmural lesion will increase the risk of future uterine rupture during pregnancy in this patient.

Management of Amniotic Sheet with a Hammock-like Placenta

An amniotic sheet is a septation in the amniotic cavity with a perforation that allows amniotic fluid to pass through. Although the incidence of abnormal placental implantation is higher in such cases, the management recommendations remain unclear. We report a case of an amniotic sheet with a hammock-like placenta located in the center of the uterine cavity. A 25-year-old woman with a history of two dilation and curettage procedures was found to have an amniotic cavity separated by a septum that contained part of the placenta. At gestational Week 32, magnetic resonance images revealed that the placenta was attached from the anterior to posterior uterine walls and resembled a hammock hanging in the center of the uterus. Subsequently, continuous intravenous administration of ritodrine hydrochloride and magnesium sulfate were given. The pregnancy was extended to Week 36. Elective cesarean section was performed, and a 3212-g female infant was delivered. Thus, owing to the risk of umbilical cord complications and placental injury secondary to premature rupture of membranes, aggressive and careful perinatal management is required in such cases.

Performance of outpatient transvaginal hydrolaparoscopy.

What is the feasibility of performing transvaginal hydrolaparoscopy (THL) in an outpatient setting? It is feasible to perform THL in an outpatient setting, reflected by a low complication and failure rate and a high patients' satisfaction. THL is a safe method to investigate tubal patency and exploring the pelvis in subfertile women. Retrospective cohort study of 1127 subfertile women who underwent THL as primary diagnostic method for testing tubal patency in an outpatient setting. We studied all THL procedures performed as a primary diagnostic tubal patency test in an outpatient setting in subfertile women starting from the initial THL in four large hospitals. Baseline characteristics were obtained, as well as the outcome of the procedures in terms of success, complications and findings by examining medical records. We used a uniform visual analogue scale (VAS) score document to collect data on pain and acceptability prospectively and compared two methods of pain relief. We studied a total of 1103 women who underwent THL. Successful access to the pouch of Douglas was achieved in 1028 women (93.2%), and 1017 women had a complete evaluation (92.2%). Double-sided tubal patency was found in 844 women (83%), unilateral tubal patency in 127 women (12.5%), while in 46 women (4.5%) bilateral occluded tubes were diagnosed. Endometriosis alone was seen in 64 women (6.3%), adhesions alone in 87 women (8.6%) and both endometriosis and adhesions in 42 women (4.1%).Complications occurred in 29 (2.6%) women, including 10 perforations of the rectum (0.9%), 8 perforations of the posterior uterine wall (0.7%) and 5 infections/pelvic inflammatory diseases (PIDs) (0.5%). Bleeding of the vaginal wall requiring intervention and hospital admissions due to pain was seen in 4 (0.4%) and 2 women, respectively (0.2%). The average pain score was rated 4.0 (±2.4 SD) on a VAS from 0 to 10 with 0 meaning no pain at all with no difference in different types of pain relief. Acceptability was rated 1.5 (±2.1 SD). The main limitation of the study is its retrospective character and the fact that only a fourth of the women were asked for pain and acceptability scores. THL can be used as a primary method for tubal assessment in an outpatient setting. Further randomized studies are needed to assess whether THL is superior to other methods and strategies for tubal assessment in terms of prognostic capacity and cost-effectiveness. No external funding was either sought or obtained for this study. The authors have no competing interests to declare.

Repeatability of Junctional Zone Measurements Using 3-Dimensional Transvaginal Sonography in Healthy Fertile Women.

To describe the junctional zone and determine the intraobserver and interobserver repeatability of junctional zone measurements using 3-dimensional (3D) transvaginal sonography in healthy fertile women. We examined 82 consecutive women with 3D transvaginal sonography. The maximum and minimum junctional zone thickness was measured in all uterine walls. The difference between maximum and minimum thickness and average measurements (maximum thickness + minimum thickness/2) of the anterior, posterior, fundal, and lateral walls were calculated. Among the first 40 consecutive women, intraobserver and interobserver repeatability was evaluated according to the Bland-Altman method and expressed as a coefficient of repeatability. Using 3D transvaginal sonography, we visualized a thin and regular junctional zone in most women. The posterior uterine wall had the largest median maximum junctional zone thickness value of 5.2 (interquartile range, 3.8-6.5) mm. Ten women (12%) had maximum thickness values of 8.0 to 12.0 mm. The maximum thickness in each uterine wall had intraobserver and interobserver coefficients of repeatability of ±2.1 to ±3.4 and ±2.6 to ±3.9 mm, respectively, which were reduced by average measurements: ±1.9 and ±2.0 mm (anterior and posterior walls) and ±1.5 mm (fundal and lateral walls) for intraobserver and interobserver values. Correlations between measurements were poor in the narrow range of junctional zone thickness. The junctional zone has an indistinct outline on 3D transvaginal sonography, resulting in measurement errors within a broad range of ±2 to ±4 mm, which were only reduced to some extent by average measurements. The thickness of the junctional zone varied within a narrow range in this healthy fertile population, and reliability measurements of junctional zone thickness have to be evaluated in women with a wider range of thickness. The observer repeatability and reliability of junctional zone measurements need to be further evaluated and refined before applying this method in clinical practice.

Miracle Baby: very Rare Case of Heterotopic Pregnancy with Cervical Ectopic in Elderly Primigravida with very Poor Ovarian Reserve with Oligoastheno-Terato-Zoospermia Conceived with IVF

A 42 year old with primary infertility over 2 years with poor ovarian reserve (AMH 0.02) with an Oligoastheno-terato-zoospermia had 3 attempts of embryo transfer with her own egg. USG showed a heterotopic pregnancy with fundal 5-6 weeks intrauterine gestational sac with a cervical ectopic with small subchorionic collection along with posterior uterine wall. Despite embryo reduction, it still showed a persistent heterotopic pregnancy with an increasing subchorionic collection in the cervical canal. There was PROM at 27 weeks and under adequate antibiotic and steroid cover, classical caesarean section was done. Due to an adherent cervical pregnancy remnant, bilateral internal iliac artery ligation with an obstetric hysterectomy was done. As few cases exist in literature, there are no specific and no universally accepted treatment modality for heterotopic cervical pregnancy and treatment depends on experience, equipment of medical team and maternal conditions.

Uterine Torsion in Third Trimester Pregnancy

The preoperative diagnosis of uterine torsion is very difficult due to the rarity of this disorder and its nonspecific clinical course. A primigravida woman visited our hospital with severe abdominal pain at 34 weeks of gestation. Emergency cesarean section was carried out due to development of fetal distress and severe abdominal pain. During the cesarean section, we noticed the uterus was rotated 180 degrees and the torsion was corrected after the delivery by making a vertical incision at the posterior uterine wall. High degree of suspicion and prompt management are important factors contributing to good prognosis of uterine torsion.

Torsion of a Subserosal Myoma Managed by Gasless Laparoendoscopic Single-Site Myomectomy with In-Bag Manual Extraction.

Acute torsion of a subserosal myoma is a rare surgical emergency that is infrequently diagnosed preoperatively. Furthermore, laparoendoscopic single-site (LESS) myomectomy with in-bag tissue extraction for the management of this disorder has not yet been described. A 43-year-old, gravida 1, para 1 woman was referred to our department due to a solid pelvic mass associated with persistent abdominal pain. A pedunculated subserosal myoma with torsion was strongly suspected based on ultrasonography and magnetic resonance imaging. Emergency LESS surgery showed that the subserosal myoma arising from the posterior uterine wall torted at its pedicle in the cul-de-sac. The twisted myoma node was excised by coagulation and cut using a LigaSure Atlas, followed by in-bag manual morcellation and extraction through an umbilical wound. The present case report emphasizes that LESS myomectomy with in-bag tissue extraction is a feasible minimally invasive surgical option for the management of subserosal myoma with torsion after a precise imaging-based diagnostic evaluation.

Intrapartal uterine avulsion with posterior cervical rupture

In this case study we describe an obstetric emergency of complete intrapartum left-lateral uterine avulsion, with posterior cervical rupture in a 31-year-old secundipara, following vacuum extraction. To the best of our knowledge, a similar case has not been previously reported in the literature. A live macrosomic male neonate was delivered by two tractions, with lateral episiotomy, and with shoulder dystocia that was relieved by McRoberts’ and Resnik’s maneuvers (Apgar score 7.8, birth weight/length 4640/57).In our patient, the risk factors for avulsion and concomitant posterior cervical rupture included prolonged second stage of labor, delivering a macrosomic neonate in a secundipara with deflexion (parietal) in a cephalic presentation along the distended and thinned posterior uterine wall. Urgent total hysterectomy was performed in dramatical circumstances due to complete unilateral avulsion and cervical rupture, with continuous aortal compression, volume replacement and intact coagulation, which certainly contributed to the good final maternal outcome.

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies.

What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system? The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented. Accurate diagnosis of congenital anomalies still remains a clinical challenge due to the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, with some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available, enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes. The ESHRE/ESGE Congenital Uterine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project. The consensus is developed based on (1) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy performing a systematic review of evidence and (2) consensus for (a) the definition of where and how to measure uterine wall thickness and (b) the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method. Uterine wall thickness is defined as the distance between interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynaecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional ultrasound (3D US) is recommended for the diagnosis of female genital anomalies in “symptomatic” patients belonging to high-risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine avaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the sub-group of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopy. The various diagnostic methods should be used in a proper way and evaluated by experts to avoid mis-, over- and underdiagnosis. The role of a combined ultrasound examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity.

Reproductive outcomes following hysteroscopic resection of endometrial polyps of different location, number and size in patients with infertility

We aimed to assess the pregnancy rates after hysteroscopic polypectomy in infertility patients with endometrial polyps and to compare pregnancy rates among subgroups with polyps of different location, size and number. All patients who underwent hysteroscopic evaluation which revealed endometrial polyps were included. Patients with any intrauterine pathology other than polyp and those undergoing frozen embryo transfer (ET) cycles were excluded. Patients were evaluated according to polyp location, size and number. Rates of β-hCG positivity and clinical pregnancy were compared. Clinical pregnancy rates after polypectomy was 41.7% for multiple polyps, 30.8% for isthmus zone polyps, 28.6% for anterior wall polyps, 27.3% for cornual zone, 22.2% for posterior uterine wall polyps and 11.8% for fundal polyps (p = 0.532). There appears no difference regarding reproductive outcomes after hysteroscopic resection of polyps situated in different intrauterine locations. Similarly, chance of conceiving seems not to change after hysteroscopic treatment of polyps of different size and number.

Management of pancreatic ectopic pregnancy

Abdominal pregnancy is a rare and high-risk complication that ultimately requires laparotomy. Atrash et al estimated that there are 10.9 abdominal pregnancies per 100,000 births, and 9.2 abdominal pregnancies per 1000 ectopic pregnancies [1]. The most commonly reported sites of primary peritoneal implantation are the pouch of Douglas and the posterior uterine wall [2e4]. At present, we would like to report a case of pancreatic ectopic pregnancy in which laparoscopic resection of the pancreatic body and tail, and splenectomywere performed successfully without any complications. A 30-year-old, gravida 1, para 0, Chinese woman visited our unit complaining of epigastric and left abdominal pain. Her last menses was 36 days before she presented to the hospital. No contraception was used. She had no history of Pelvic Inflammatory Disease (PID), no prior Intra Uterine Device (IUD), no use of fertility drugs, and no pelvic surgery. Transvaginal ultrasound on September 12, 2014 demonstrated massive pelvic effusion (deepest point, 38 mm), and no gestational sac was detected in the uterine cavity. Her serum bhuman chorionic gonadotropin (HCG) level was 2500.09 mIU/mL, amylase was 336.8 U/L and lipase was 1671.4 U/L. Physical examination revealed stable vital signs: blood pressure of 110/70 mmHg and a pulse rate of 88 beats/min. There was no tenderness of the fornices upon vaginal examination. The patient had slight abdominal tenderness and rebound pain. A presumptive diagnosis of ectopic pregnancy complicated with acute pancreatitis was made. Later in our gynecology ward, conservative treatment was done with a single-dose methotrexate (MTX) injection (50 mg/m2). However, during the night, without a decrease in serum b-HCG level, a dramatic increase of serum amylase and abdominal tenderness were observed. The hemoglobin and hematocrit levels

Posterior Uterine Wall Rupture of an Unscarred Uterus in a Woman with History of Congenital Diaphragmatic Hernia Repair

Rupture of an unscarred uterus is an uncommon but potentially life-threatening event associated with maternal and fetal morbidity and mortality. Patients lacking common identifiable risk factors can lack appropriate cautions or lead to delayed diagnosis.

HDliveFlow with HDlive Silhouette Mode in Antenatal Diagnosis of Bilobed Placenta

ABSTRACT We present a case of bilobed placenta diagnosed by HDliveFlow with the HDlive silhouette mode early in the 2nd trimester of pregnancy. A 29-year-old Japanese pregnant woman, gravida 4, para 1, was referred to our hospital based on the patient's wish at 23 weeks and 3 days of gestation. Two-dimensional (2D) sonography showed a single live fetus with biometry consistent with the gestational age. Moreover, two separated parts of the placenta were noted at the anterior and posterior uterine walls. HDliveFlow with the HDlive silhouette mode clearly depicted two lobes of the placenta (near equal size), and the main umbilical cord attached to the periphery of the anterior part of the placenta. One large connecting vessel between these two placental parts was also clearly identified. Bilobed placenta was strongly suggested. After birth, the gross specimen of the placenta confirmed the diagnosis. HDliveFlow with the HDlive silhouette mode may be an adjunctive tool to 2D sonography to diagnose abnormalities of the placenta in utero. How to cite this article Yang P-Y, Kanenishi K, Ishibashi M, Mori N, Hata T. HDliveFlow with HDlive Silhouette Mode in Antenatal Diagnosis of Bilobed Placenta. Donald School J Ultrasound Obstet Gynecol 2016;10(4):415-417.

A Commentary on: "A New Removable Uterine Compression by a Brace Suture in the Management of Severe Postpartum Hemorrhage".

A Commentary on: "A New Removable Uterine Compression by a Brace Suture in the Management of Severe Postpartum Hemorrhage".