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OBGYNE
- 1. Davao Medical School Foundation Hospital Medical Drive, Bajada, Davao City [ OB- Gynecolo Kirbe A. Labarcon gy ACa s e
- 2. What is the True essence of Being A Woman? BIRTH
- 3. GENERAL DATA P.B. 29 G2P1 (1001) Married Bajada, Davao City DoA: May 28, 2012 9:40 PM
- 4. CHIEF COMPLAINT Vaginal Spotting LMP: September (2nd wk), 2011 5days X 2-3 pads/day PMP: August 2011 4-5 days X 2-3 pads/day
- 5. HISTORY OF PRESENT ILLNESS +Irregular, tolerable uterine In the Morning + Tolerable uterine contractions, +persistent uterine contraction contraction -Vaginal spotting + associated with fetal -no other associated +Routine PNCU movement symptoms IE= 1cm dilatation -Vaginal discharges + Routine PNCU IE=1cm dilatation (-)signs & symptoms +Advised admission -admission for x3 days scheduled CS -Consultation Metronidazole 500mg/tab BID Nifedipines 5mg/tab QID Duvadilan Tab TID
- 6. Work up Admitting Impression: PU 35 2/7 wks AOG, CILP, G2P1 (1001) A B C ABDOMEN: L1Breech L2Right L3Cephalic FH: 33cm EFW: 3.03kg FHT: 145-150bpm Cephalic presentation INTERAL EXAMINATION: External Genitalia: Grossly normal Cervix: Length: 3 cm Vagina: (+) thick whitish vaginal discharge Dilatation: 1 cm Effacement: Closed % Posterior IBOW Station -3 LABORATORIES: CBC, PC; UA; Gram Stain of Vaginal discharge; BPS FINAL DIAGNOSIS: PU 35-36 wks AOG, IPTL-Controlled, G2P1 (1001) Previous CS (Uterine Didelphys) Bacterial Vaginosis Fig.1 A) Ultrasound image B) Biophysical Score C) Ultrasound Report
- 7. ᵜBajada, Davao City ᵜMarried with 1daughter ᵜNon-smokers ᵜEmployed:Certified Public Accountant ᵜAbove minimum ᵜNon-smoker ᵜNon-alcoholic beverage drinker ᵜNo food preference or special diet regimen.
- 8. [ + ] HPN (Father – unknown maintenance med) INTERNAL [ + ] DM (Father – unknown maintenance med) [ - ] Heart Diseases [ - ] Asthma [ - ] No similar illness to that of the px
- 9. Medical (-) HPN (+) Allergies (-) DM + Meds: NSAIDS (-) Asthma - Foods Denies previous hospitalization Surgical Denies previous surgical operation Psychiatric No psychiatric history
- 10. Family Size : 4 Menarche : 18 yo Coitarche: 21yrs old X 1 sexual partner OCP: (-) usage Menstrual cycle: 28-35days X 5days X 3soaking pads/day OB-Score Pregnancy Pregnancy Gestation Present Year Sex Birthweight Complications Order Outcome Completed Status G1 LSTCS 2011 FT F 2.85kg Healthy none G2 -present pregnancy-
- 11. Present Pregnancy LMP: September 13, 2011 X 5days X 2-3soaking pads/day DATE OF QUICKENING : December, 2011 (~3mons AOG) EDD: June 20, 2012 AOG: 37 6/7 weeks ULTRASOUND : >5x (1st: October, 2011; ~8weeks AOG) (last: May 18, 2012; ~35 3/7wks AOG) PRENATAL VISIT: >x5 HEALTHCARE PROVIDER: OB-Gynecologist IMMUNIZATION: OCP: (-) Tetanus (-) Hep B (-) others Total Weight Gain: 65 -52 = 13klg BP: 120/80mmHg Hgb: 119 g/dL Urine Lab: Normal Sugar: Normal
- 12. REVIEW OF SYSTEM (-) MB (-) IUGR (+) Premature Labor (-) Infection LG Tract (-) Infertitlity 12days PTA (-) HPN (+) Uterine contraction (+) Genitourinary (-) Cardiac x 1mon 12days PTA (-) Renal (+) UTI Bacterial Vaginosis (-) DM/Metabolic 3mons AOG (+) Previous CS (-) Respiratory Cefalexin 500mg/cap 2011 (-) Fetal wastage 1cap TID x 7days(+)
- 13. PHYSICAL EXAM General: Patient came in per wheelchair. The patient was examined in lying position. She was awake, well-groomed, cooperative and not in respiratory distress BMI was 21.6, weighing 52kg and 5’1 standing
- 14. PHYSICAL EXAM A. Vital Signs Temperature: 36.30C (Afebrile) Blood Pressure: 120/70 mm Hg (Normotensive) Respiratory Rate: 22 breaths/min (Tachypneic). Cardiac Rate: 85bpm (Non-tachycardic).
- 15. AS, PPC, -CLAD [-] Remarkable lesion AP, -murmur ECE, Resonant, CBS -Gross deformities Full range of Motion No Neurologic deficit
- 16. PHYSICALAbdomen EXAM Abdomen I : Globular, [+] Striae gravidarum [+] Previous CS scar A: Normal active bowel sound P: Tympanitic all over
- 17. PHYSICALAbdomen EXAM Abdomen P : LEOPOLD’s MANUEVER 29 cm L1= Breech L2= Right L3= Cephalic FH= 29cm EFW = 2.47klg FHT= 130-140bpm
- 18. PHYSICAL EXAM Internal Examination Internal Examination Grossly Normal PELVIMETRY? (I) : Admits 2 fingers with ease (C): 1-2cm dilatation Beginning effacement Intact bag of water Station -3 (U) : Enlarged to 8-9 months AOG (A) : Non-palpable (D) : No vaginal discharges
- 19. SALIENT FEATURES *29 G P (1001) 2 1 *Vaginal spotting *Amenorrhea *Hx of Preterm Labor PE: *Gravid abdomen GenitoUrinary & IE
- 20. ADMITTING IMPRESSION G2P1 (1001),Pregnancy Uterine 37 6/7 weeks Age of Gestation, Breech in latent phase of Labor S/P CS (Non-Reassuring Fetal Heart Rate Pattern)
- 21. Course in the WARD Course in the WARD On admission Please admit NPO post midnight Monitor VS q4o Monitor FHT & POL q4o and record Schedule for repeat CS tomorrow at 8AM Baseline EFM LABS: CBC, PC BT UA IVF: D5LR 1L at 120cc/hr Med: Cefazolin 1grm IVTT (-)ANST Ranitidine 50grm/amp, 1amp IVTT 1hr Prior to OR Metoclopramide 10grm/amp, 1amp IVTT
- 22. Course in the WARD Course in the WARD SURGERY: May 28 (1st HD) VS: 110/70mmHg 36.2oC 78bmp 19cpm Blood loss: <1000cc Preoperative Diagnosis: G2P1 (1001),Pregnancy Uterine 37 6/7 weeks Age of Gestation, Breech in latent phase of Labor S/P CS for NRFHRP Operation Done 10 LSTCS (Right Hemi-Uterus) secondary to Franck breech presentation
- 23. Course in the WARD Course in the WARD Basilio, 2012 Figure 2 . Didelphic uterus after fetal delivery.
- 24. Course in the WARD Course in the WARD 1st PostOP S/O > + minimal vaginal bleeding P> + well contracted uterus + adequate urine output + stable VS + Flattus 2nd POSTOP, 19HD S/O > + minimal vaginal bleeding P> + well contracted uterus + adequate urine output + stable VS + Flattus
- 25. FINAL 1) G P (2002), PUFT DIAGNOSISby 1 LSTCS (Right 2 2 Franck Breech presentation, delivered 0 Hemi-Uterus) to a live birth Baby boy with AS 9,10; BS 38wks; BW 2.85; BL 51cm 2) S/P Cesarean Section (Left Hemi Uterus) secondary to NRFHRP 3) Uterine didelphys 4) Paratubal cyst, Right
- 26. UTERUS
- 27. 2.5 cm 5 cm 7.5 cm Wt: 30 - 40 gm
- 28. Fundus uteri Facies vesicalis Facies intestinalis Margo lateralis
- 29. 8 LIGAMENTS 1 anterior vesicouterine 1 posterior rectovaginal 2 broad/lateral (ligamentu latum uteri) 2 uterosacral 2 round ligaments
- 31. 2003-11-3 31
- 34. 2003-11-3 34
- 35. Columbo reported the first documented 300 case BC Strassman 0.1 -3.5 % et al 1961 Grimbizi 4.3 % 2001 2003-11-3 35
- 38. Class III- Uterine Didelphys • Midline fusion of the müllerian ducts is arrested, • ~ 5% of mullerian duct anomalies ( ) • ~11% are didelphys uterus ( ) • Characterized by 2 hemiuteri, 2 endocervical canals with cervices fused at the lower uterine segment.
- 39. 75% ( )
- 40. Reported Association with Other Anomalies • ~20% Renal agenesis most commonly ( ) • Obstructed unilateral vagina (Wunderlich-Herlyn- Werner syndrome) ( ) • Bladder exstrophy with or without vaginal hypoplasia • Congenital vesicovaginal fistula with hypoplastic kidney ( ) • Cervical agenesis ( ) • Malignancies ( )
- 41. Reported Association with Other Anomalies • According to Zhang et al. 2010 Infertility treatment & reproductive performance is poor • Study of 59 (68.6%) live births 21 (24.4%) preterm deliveries 18 (20.9%) spontaneous abortions 2 (2.3%) ectopics,
- 42. Diagnosis of Uterine Didelphys • The most frequent complaint ( ). Failure of tampons to obstruct menstrual flow. T Initial pelvic examination Second-trimester spontaneous abortion
- 43. Figure 1: Speculum examination reveals a double vagina with two cervices (the right cervix is partly visible) Bhattacharya et al. 2011
- 44. Diagnosis of Uterine Didelphys • Hemivaginal obstruction: Onset of dysmenorrhea ( ) Progressive pelvic pain ( ) Unilateral pelvic mass ( ) Marked rectal pain and constipation ( )
- 45. Diagnostic Modalities 3) Ultrasound 2) MRI 1) HSG 4) IVP Fig Uterus didelphysTransverse fast spin-echo T2-weighted MR images show complete Fig Fig Uterus didelphys in Ultrasound of two separate degree ofwith opacification of two .HSG of uterine horns (short arrows), duplication images show catheterization with partial cervices fusion of adjacent cervices (longdivergent noncommunicating endometrial cavities (arrow). widely arrows).
- 46. Surgical Procedures •obstructed unilateral vagina Full excision and marsupialization of the vaginal septum ( ) •Hemihysterectomy with or without salpingo- oophorectomy ( ) •Strassmann metroplasty ( )
- 47. PostOperative Management Vaginal adenosis is a risk after the septum is removed. Definitive guidelines that monitor for this condition have not been established, though some experts recommend serial pap smears and colposcopy.
- 48. 2003-11-3 48
- 49. 2003-11-3 49
- 50. D-SURGICAL MEASURES • Musich JR, Behrman SJ. Obsteric outcome before and after metroplasty in women with uterine anomalies. Obstet Gynecol.1978;52:63. • Management and outcome of patients with combined vaginal septum, bifid uterus, and ipsilateral renal agenesis (Herlyn-Werner-Wunderlich syndrome). Gholoum S, Puligandla PS, Hui T, Su W, Quiros E, Laberge JM. J Pediatr Surg. 2006 May;41(5):987-92. • Heinohen PK, Saarikoski S, Pystynen P. Reproductive performance of women with uterine anomalies. Acta Obstet gynecol Scand 1982;61:157.
Notes de l'éditeur
- 3weeks PTA + UC X 20-30 sec x moderate
- The uterus is a hollow, thick-walled, muscular organ situated deeply in the pelvic cavity between the bladder and rectum. Into its upper part the uterine tubes open, one on either side, while below, its cavity communicates with that of the vagina. When the ova are discharged from the ovaries they are carried to the uterine cavity through the uterine tubes The uterus measures about 7.5 cm. in length, 5 cm. in breadth, at its upper part, and nearly 2.5 cm. in thickness; it weighs from 30 to 40 gm. The fundus ( fundus uteri ) is convex in all directions, and covered by peritoneum continuous with that on the vesical and intestinal surfaces
- Body ( corpus uteri ). —The body gradually narrows from the fundus to the isthmus. The vesical or anterior surface ( facies vesicalis ) is flattened and covered by peritoneum, which is reflected on to the bladder to form the vesicouterine excavation. The surface lies in apposition with the bladder. The intestinal or posterior surface ( facies intestinalis ) is convex transversely and is covered by peritoneum, which is continued down on to the cervix and vagina. It is in relation with the sigmoid colon, from which it is usually separated by some coils of small intestine. The lateral margins ( margo lateralis ) are slightly convex. At the upper end of each the uterine tube pierces the uterine wall. Below and in front of this point the round ligament of the uterus is fixed, while behind it is the attachment of the ligament of the ovary
- Ligaments. —The ligaments of the uterus are eight in number: one anterior; one posterior; two lateral or broad; two uterosacral; and two round ligaments. The anterior ligament consists of the vesicouterine fold of peritoneum, which is reflected on to the bladder from the front of the uterus, at the junction of the cervix and body. The posterior ligament consists of the rectovaginal fold of peritoneum, which is reflected from the back of the posterior fornix of the vagina on to the front of the rectum. It forms the bottom of a deep pouch called the rectouterine excavation, which is bounded in front by the posterior wall of the uterus, the supravaginal cervix, and the posterior fornix of the vagina; behind, by the rectum; and laterally by two crescentic folds of peritoneum which pass backward from the cervix uteri on either side of the rectum to the posterior wall of the pelvis. These folds are named the sacrogenital or rectouterine folds. They contain a considerable amount of fibrous tissue and non-striped muscular fibers which are attached to the front of the sacrum and constitute the uterosacral ligaments. The two lateral or broad ligaments ( ligamentum latum uteri ) pass from the sides of the uterus to the lateral walls of the pelvis. Together with the uterus they form a septum across the female pelvis, dividing that cavity into two portions. In the anterior part is contained the bladder; in the posterior part the rectum, and in certain conditions some coils of the small intestine and a part of the sigmoid colon. Between the two layers of each broad ligament are contained: (1) the uterine tube superiorly; (2) the round ligament of the uterus; (3) the ovary and its ligament; (4) the epoöphoron and paroöphoron; (5) connective tissue; (6) unstriped muscular fibers; and (7) bloodvessels and nerves. T The portion of the broad ligament which stretches from the uterine tube to the level of the ovary is known by the name of the mesosalpinx. Between the fimbriated extremity of the tube and the lower attachment of the broad ligament is a concave rounded margin, called the infundibulopelvic ligament. 21 The round ligaments ( ligamentum teres uteri ) are two flattened bands between 10 and 12 cm. in length, situated between the layers of the broad ligament in front of and below the uterine tubes. Commencing on either side at the lateral angle of the uterus, this ligament is directed forward, upward, and lateralward over the external iliac vessels. It then passes through the abdominal inguinal ring and along the inguinal canal to the labium majus, in which it becomes lost. The round ligaments consists principally of muscular tissue, prolonged from the uterus; also of some fibrous and areolar tissue, besides bloodvessels, lymphatics; and nerves, enclosed in a duplicature of peritoneum, which, in the fetus, is prolonged in the form of a tubular process for a short distance into the inguinal canal. This process is called the canal of Nuck. It is generally obliterated in the adult, but sometimes remains pervious even in advanced life. It is analogous to the saccus vaginalis, which precedes the descent of the testis. 22 In addition to the ligaments just described, there is a band named the ligamentum transversalis colli (Mackenrodt) on either side of the cervix uteri. It is attached to the side of the cervix uteri and to the vault and lateral fornix of the vagina, and is continuous externally with the fibrous tissue which surrounds the pelvic bloodvessels.
- Vessels and Nerves. —The arteries of the uterus are the uterine, from the hypogastric; and the ovarian, from the abdominal aorta They are remarkable for their tortuous course in the substance of the organ, and for their frequent anastomoses. The termination of the ovarian artery meets that of the uterine artery, and forms an anastomotic trunk from which branches are given off to supply the uterus, their disposition being circular. The veins are of large size, and correspond with the arteries. They end in the uterine plexuses. In the impregnated uterus the arteries carry the blood to, and the veins convey it away from, the intervillous space of the placenta (see page 63). The lymphatics are described on page 714. The nerves are derived from the hypogastric and ovarian plexuses, and from the third and fourth sacral nerves. 39
- Embryology In a female foetus, the uterus starts out as two small tubes - the mullerian ducts. As the development occurs, the tubes normally join to create one larger, hollow organ — the uterus
- References regarding the existence of müllerian defects date back to antiquity, around 300 BC. Columbo reported the first documented case of vaginal agenesis (uterus and vagina) in the 16th century. Steinmetz GP. Formation of artificial vagina. West J Surg . 1940;48:169-3. Our knowledge of their epidemiology has not paralleled the technical advances involved in their diagnoses and treatment Studies of Strassman et al 19611: showed ncidence rates vary widely and depend on the study. Most authors report incidences of 0.1-3.5%.In 2001, Grimbizis and colleagues reported that the mean incidence of uterine malformations was 4.3% for the general population and/or for fertile women
- References regarding the existence of müllerian defects date back to antiquity, around 300 BC. Columbo reported the first documented case of vaginal agenesis (uterus and vagina) in the 16th century. Steinmetz GP. Formation of artificial vagina. West J Surg . 1940;48:169-3. Our knowledge of their epidemiology has not paralleled the technical advances involved in their diagnoses and treatment Studies of Strassman et al 19611: showed I ncidence rates vary widely and depend on the study. Most authors report incidences of 0.1-3.5%.In 2001, Grimbizis and colleagues reported that the mean incidence of uterine malformations was 4.3% for the general population and/or for fertile women
- Didelphys uterus arises when midline fusion of the müllerian ducts is arrested, either completely or incompletely. Approximately 11% of uterine malformations are didelphys uterus. [ which constitutes approximately 5% of müllerian duct anomalies, is the result of nearly complete failure of fusion of the müllerian ducts.
- Each müllerian duct develops its own hemiuterus and cervix and demonstrates normal zonal anatomy with a minor degree of fusion at the level of the cervices. No communication is present between the duplicated endometrial cavities. A longitudinal vaginal septum is associated in 75% of these anomalies (71) Each hemiuteri is associated with one fallopian tube. Ovarian malposition may also be present. [126] The vagina may be single or double, with duplication a frequent component. The double vagina manifests as a longitudinal (horizontal) septum that extends either completely (complete septum) or partially (partial septum) from the cervices to the introitus. A complete longitudinal vaginal septum occurs in 75% of these anomalies, although vaginal septa can also coexist with other müllerian duct anomalies. [83, 108, 113] In some cases obstruction can be due to transverse vaginal septa.
- The low incidence of uterine didelphys is reflected in the literature by the paucity of data regarding reproductive performance. Compiled data from 2 studies that included didelphys uterus anomaly revealed the following outcomes for 86 pregnancies: 21 (24.4%) preterm deliveries; 59 (68.6%) live births; 2 (2.3%) ectopics, and 18 (20.9%) spontaneous abortions. [111] The poor reproductive outcomes are thought to be due to diminished uterine volumes and decreased perfusion of each hemiuteri
- Nonobstructive uterus didelphys is usually asymptomatic until menarche. The most frequent complaint is failure of tampons to obstruct menstrual flow. The diagnosis is often rendered during the initial pelvic examination, when 2 cervices are identified. A history of second-trimester spontaneous abortion is often a clue to this condition.
- In hemivaginal obstruction, the clinical presentations are variable and depend on the degree of obstruction and whether the obstruction has an opening. The most common presenting symptoms are onset of dysmenorrhea within the first years following menarche and progressive pelvic pain. A unilateral pelvic mass is detected on examination with the right affected nearly twice as frequently as the left. Presenting symptoms of marked rectal pain and constipation, secondary to hematocolpos impingement, have been reported in 1 case. [131]
- Diagnostic modalities are similar to those used for unicornuate uterus. Workup should include 1)HSG Uterus didelphys. HSG demonstrates two separate endocervical canals that open into separate fusiform endometrial cavities, with no communication between the two horns. Each endometrial cavity ends in a solitary fallopian tube. However, if the anomaly is associated with an obstructed longitudinal vaginal septum, only one cervical os may be depicted, and it may be cannulated with the endometrial configuration mimicking a unicornuate uterus HSG images show catheterization of two separate cervices with opacification of two widely divergent noncommunicating endometrial cavities (arrow). 2) MRI, MR imaging demonstrates two separate uteri with widely divergent apices, two separate cervices, and usually an upper vaginal longitudinal septum. In each uterus, the endometrial-to-myometrial width and ratio are preserved, as is normal uterine zonal anatomy (34,35,42). An obstructed unilateral vaginal septum may cause apparent marked deformity of the uterus according to the degree of associated hematometrocolpos IVP to confirm or exclude associated urinary tract anomalies. MRI reveals 2 widely separated uterine horns, and 2 cervices are typically identified. The intercornual angle is >60°. The zonal anatomy is preserved within each hemiuterus. [117, 118] A TVS is usually observed. [73] Obstructions are represented by variable dilation of the vaginal component and diminished endometrial dilation. [147] Ultrasonography may be a valuable adjunct. [148, 149, 45, 71]
- Surgical techniques Uterine didelphys with obstructed unilateral vagina Full excision and marsupialization of the vaginal septum is the preferred approach and is performed as a single procedure. After the septum has been excised, laparoscopy can be performed for potential treatment of associated endometriosis, adhesions, or both. [151] Excision of an obstructed vaginal septum during pregnancy requires leaving a generous pedicle to help minimize potential bleeding should the vaginal mucosa retract. [108] Hemihysterectomy with or without salpingo-oophorectomy is rarely indicated and should be avoided to provide the best opportunity for a successful reproductive outcome. Uterus didelphys, nonobstructed As previously stated, indications for septum resection in the nonobstructed didelphys uterus are limited. These patients are not candidates for surgical unification. Fortunately, few fertility-associated problems occur in this group. If the woman carries a pregnancy to term, obstetric complications are usually minimal. The decision to perform metroplasty should be individualized, and only selected patients may benefit from surgical reconstruction. Most reports of metroplasty in this setting are anecdotal and the apparent benefits of surgery are not clear. This stated, the recommended procedure is the Strassmann metroplasty. [5] This method unifies the uterine cavities at the fundus, while the cervices are left intact. This procedure is detailed further in Surgical techniques for bicornuate uterus below.