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
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
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
36.
37.
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.
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.
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.
Notas do Editor
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.