The Management of a patient with a fragmented intrauterine device embedded within the cervical canal.

A 28-year-old woman presented with a malpositioned intrauterine device (IUD) that was fragmented and significantly entrenched within the cervical canal and myometrium. IUD malposition with concomitant device fragmentation and embedded segments, albeit rare, should be a consideration given the device's prevalence.

Inner myometrial laceration - an unusual presentation of antepartum and postpartum hemorrhage: case reports and review of the literature.

OBJECTIVE: The aim of this study is to evaluate the diagnostic criteria, treatment options and progression of cases who have antenatal or postpartum hemorrhage due to internal myometrial laceration (IML) and to review the literature. STUDY DESIGN: The files of eight patients who were diagnosed to have IML between August 2012 and July 2015 were evaluated retrospectively. RESULTS: The patient group consisted of four patients who had an emergency c-section due to massive bleeding during labor and four patients who had an emergency laparotomy due to uncontrolled bleeding after vaginal delivery after evaluation of the patient for signs of 4Ts (trauma, tissue retention, uterine tonus, and trombin). Primary suturation was the first-line treatment in all patients. In two of the patients, hysterectomy was performed after the defined surgical procedures were not successful in controling the bleeding. CONCLUSION: The presented case series is a pioneering study that describes IM which is a poorly defined reason of postpartum hemorrhage, as the cause of bleeding during labor. Primary suturation is the first-step, further surgery might be required in order to treat this life-threathening condition and the decision should be based on the age and the fertility status of the patient.

Malpositioned IUCD: the menace of postpartum IUCD insertion.

Use of a postpartum intrauterine contraceptive device (PPIUCD) is a highly effective, reversible and long-acting family planning method that can be initiated in the immediate postpartum period, especially in lactating women. PPIUCDs have been inserted in more than 65,000 women worldwide and the numbers are increasing with many countries introducing PPIUCDs as part of their family planning programme. As the numbers of PPIUCD insertions are increasing, we are getting wiser regarding complications of this procedure. One of the less-understood entities is a malpositioned PPIUCD, a situation where the IUCD is present inside the uterus but its placement is eccentric and a part or the whole of it may be embedded in the myometrium. It can present as lost strings or as a failure to remove the intrauterine device. We present a series of cases with malpositioned PPIUCDs and their management.

Greater surgical precision of a flexible carbon dioxide laser fiber compared to monopolar electrosurgery in porcine myometrium.

The objective of this experimental animal study was to compare the surgical precision of a flexible CO2 laser fiber with that of monopolar electrosurgery in porcine myometrium. The subjects were 6 live adult non-pregnant female pigs. Linear injury to the uterine horns was created using a flexible CO2 laser fiber at 5W, 10W, and 15W and with monopolar electrosurgery at 10W, 20W, 30W, and 40W in both cut and coagulation modes. Hysterectomy was then performed in the live animals. Cross-sections of the tissue were processed and stained using Masson trichrome to differentiate damaged from undamaged myometrium. Measurement means were compared using analysis of variance with Tukey honest significant difference correction; p <.05 indicated significance. Incision width of the laser at 5W and 10W was significantly less than both monopolar coagulation at all power settings and monopolar cut at 30W and 40W (all p <.01), at 5W was also significantly less than monopolar cut at 10W (p = .03), and at 15W was significantly less than monopolar coagulation at 40W (p = .001). Incision depth of the laser at 5W was significantly less than monopolar coagulation at 40W and laser at 15W (both p = .01), at 15W was significantly greater than monopolar coagulation at 10W and monopolar cut at 10, 20, and 30W (p ≤.01), and increased proportional to power for all 3 energy types. Collateral thermal damage width at all laser power settings was significantly less than at all monopolar coagulation power settings (p ≤.04) with the exception of the laser at 15W compared with monopolar coagulation at 10W (p = .30), and at all laser power settings was significantly less than at all monopolar coagulation power settings (p <.001). Collateral thermal damage depth of the laser at 5W and 10W was significantly less than monopolar cut at 30W (p ≤.002) and increased proportional to power in monopolar coagulation mode but remained constant with the laser. Incising efficiency of the laser at 5W was significantly greater than monopolar coagulation at 10W (p = .04), at 10W was significantly greater than at all monopolar power settings (p ≤.007) except cut at 40W (p = .29), and at 15W was significantly greater than that of every other energy type and power setting tested (p ≤.04). These findings support the hypothesis that CO2 laser energy delivered via a flexible fiber system would exhibit greater surgical precision than monopolar electrosurgery, in both cut and coagulation modes, as defined by 3 parameters: incising efficiency, changes in incision depth compared with width as power increases, and variability in the resulting incision measurements. Because increased thermal damage has been associated with delayed tissue necrosis and adhesion formation, these findings prompt the design of a comparative survival animal study to assess additional clinically relevant parameters.

A look at uterine wound healing through a histopathological study of uterine scars.

BACKGROUND: Few histopathologic studies of uterine wound healing have been published compared with similar healing in other tissues. Our objective was to examine the histopathology resulting from iatrogenic trauma to the myometrium to acquire a better understanding of possible aberrations in uterine wound healing. METHODS: We studied paired injured myometrium and uninvolved myometrium from 7 hysterectomy specimens. All subjects had either abnormal bleeding or chronic pain following an iatrogenic injury to the myometrium. The time between the initial injury and hysterectomy ranged from 2 months to 13 years. Tissue was evaluated with hematoxylin and eosin (H&E) followed by Masson Trichrome staining for collagen, Weigert-Van Gieson elastic staining, and/or Kreyberg staining for fibrin and glycosaminoglycans or MIB-1 (Ki-67) immunhistochemistry for cell proliferation. RESULTS: Histopathologic examination of the 7 paired tissues revealed evidence of altered healing including myofiber disarray, elastosis, tissue edema, and inflammation. Small fibroids, myometrial hyperplasia, a keloid-like region of scar and adenomyosis were also observed. CONCLUSIONS: Myofiber disarray and elastosis may be markers of aberrancy in wound healing after iatrogenic uterine trauma. Altered myometrial scarring in these cases may have contributed to the clinical outcome necessitating hysterectomies. Myometrial hyperplasia in the region of the scars might also contribute to the clinical presentation as well. Small fibroids found within scars and evidence of a keloid-like structure may also represent alterations in uterine wound healing.

Focal myometrial defect and partial placenta accreta in a pregnancy following bilateral uterine artery embolization.

A 29-year-old nulliparous patient was treated with uterine artery embolization (UAE) for a large symptomatic uterine fibroid, resulting in a marked reduction of the tumor volume. She subsequently conceived and progressed through pregnancy uneventfully. At cesarean section for breech presentation at term, a large fundal myometrial defect was encountered. In addition, the patient presented with unexpected partial placenta accreta, which resulted in massive atonic uterine bleeding. It is suggested that UAE was implicated in the pathogenesis of myometrial damage and abnormal placentation. It is proposed that the antenatal care of pregnancies after UAE include careful imaging of the placenta, its vasculature, and the thickness of overlying uterine wall so peripartum management can be appropriately planned.

Inner myometrial laceration causing a massive postpartum hemorrhage: a case report.

BACKGROUND: Postpartum hemorrhage has many well-established etiologies. It may also be secondary to an inner myometrial laceration, a less frequent and more difficult entity to diagnose. CASE: A 31-year-old, white woman, gravida 4, para 2012, at term underwent an uncomplicated spontaneous vaginal delivery. She gave birth to a 3,600-g female infant. An immediate massive postpartum hemorrhage ensued, unresponsive to medical therapy. No cervicovaginal lacerations or retained placental tissue was found. Uterine packing failed to control the bleeding. During laparotomy, exploration of the uterine cavity revealed a 4-cm, posterior and longitudinal inner myometrial laceration involving an actively bleeding large vessel. Repairing the laceration controlled the hemorrhage. CONCLUSION: Inner myometrial lacerations must be considered in the differential diagnosis of postpartum hemorrhage when all other commonly established causes have been excluded. During laparotomy and hysterotomy, evaluation and repair of an inner myometrial laceration controls the bleeding and avoids a hysterectomy.

Is endomyometrial injury during termination of pregnancy or curettage following miscarriage the precursor to placenta accreta?

AIMS: To determine the frequency with which myometrium is removed during vacuum terminations of pregnancy or dilatation and curettage after miscarriage, and to relate these findings to subsequent placenta accreta or its proxies. METHODS: Archival tissues from vacuum termination of pregnancy or dilatation and blunt curettage after miscarriage were examined for the presence of myometrium. The subsequent obstetric histories were scrutinised for manual removal of placenta, postpartum haemorrhage, or retained placenta. A retrospective study comparing the frequency of miscarriage and termination in women who had or did not have a manual removal was also performed. RESULTS: Myometrium was seen in the products of conception in 44% and 35% of termination and miscarriage tissues, respectively. One of nine women with myometrium at miscarriage had a postpartum haemorrhage in a subsequent pregnancy whereas, of the 21 women without myometrium at miscarriage, three required manual removal and seven had a postpartum haemorrhage afterwards. A past history of termination and/or miscarriage was more frequent in multigravid women who had a manual removal than those who did not. CONCLUSIONS: Endomyometrial injury is frequent at termination or dilatation and curettage after miscarriage, but the relation to subsequent placenta accreta remains unclear. Women requiring a manual removal of the placenta were likely to have had a past history of termination and/or miscarriage.

A hypothesis to explain the occurence of inner myometrial laceration causing massive postpartum hemorrhage.

BACKGROUND: Inner myometrial lacerations were found in three patients who developed uncontrollable postpartum massive bleeding despite the usual treatment for uterine atony. Because all the patients suffered from hemorrhage shock and their medical status deteriorated, their uteri were surgically removed to stop bleeding. After removal, one of them died. Postpartum hemorrhage was caused by inner myometrial laceration. We hypothesized a cause of inner myometrial laceration, using the three resected uteri, an assumed model of the uterine body, and 34 women. METHODS: The subjects were 37 women, of whom three were patients with inner myometrial laceration, 23 were women without inner myometrial laceration who underwent cesarean section, and 11 were women in the first stage of labor. The three resected uteri were examined both macroscopically and microscopically. We measured the thickness of the wall of the uterine muscle at the widest point of the uterine corpus and the thickness of the myometrial wall at a transverse section of the uterine cervix, as well as the radius of the inner lumen at the widest point of the uterus in 23 women during cesarean section. We also measured the thickness of the myometrial wall at the widest point of the uterine corpus in 11 women at the end of the first stage of labor during ultrasonic examination. The data were then used to estimate the stress on the uterine muscle. RESULTS: The stress on the uterine cervix was stronger than that on the uterine corpus during labor. When the stress on the uterine muscle is stronger than a specific value, inner myometrial lacerations develop on the right and/or left side of the uterine cervix. These lacerations may involve large vessels. CONCLUSIONS: We have discovered another cause of postpartum hemorrhage which we have named inner myometrial laceration. These lacerations appeared to result from a strong stress on the uterine cervix caused by an abnormal rise in intrauterine pressure during labor.

Late uterine perforation with an anchored IUD, the Gynefix: a case report.

A case of uterine perforation which occurred two months after the insertion of a Gynefix, a frameless filiform copper intrauterine device fixed into the fundal myometrium is described. Laparoscopic removal of the device had to be performed. The incidence of this complication is unknown. The appropriateness or need of assessing echo-graphically the myometrial thickness before the insertion and of controlling its correct position after the insertion remains uncertain.

PIP: This article describes a case of uterine perforation which occurred 2 months after the insertion of a Gynefix, a frameless filiform copper IUD inserted into the fundal myometrium. This occurred in 1996 in a 21-year-old female, nulligravida, who was in a stable relationship and was chlamydia-negative. A few weeks after insertion, the patient complained of increasing abdominal pain. Subsequently, the device was not seen in the uterus upon transvaginal echography. Instead, an x-ray showed it to be in the lower abdominal cavity. Laparoscopic removal of the IUD, which was adherent to the colon, had to be performed. The appropriateness or need of assessing echographically the myometrial thickness before IUD insertion and of controlling its correct position after the insertion remains uncertain.

Eosinophilic endomyometritis associated with diagnostic curettage.

Histological study of hysterectomy specimens removed for noninflammatory and nonneoplastic disease revealed 15 severe cases and many more slight cases of eosinophil leukocytic endomyometritis, the degree of which appeared to correlate with injury from preoperative diagnostic curettage. In each case of severe eosinophilic endomyometritis, circumferential mucosal and extensive myometrial damage together with an occluding blood clot at the level of the inner orifice was confirmed. The massive eosinophilia appeared any time between 18 h and 21 days after curettage, and it is proposed that the probable causative agents are eosinophil chemotactic substances liberated from the myometrial mast cells and from the degrading blood clot filling the uterine cavity. There were no clinical signs or symptoms that appeared to correlate with the histological changes observed in this study. This phenomenon may serve as a model for studying the dynamics and functions of eosinophilic leukocytes in humans.

Aspectos morfológicos do processo de reparaçäo do miométrio de ratas albinas pós-perfuraçäo / Morphological aspects of the repairing process of the myometrium of albino rats after perforation

Realizou-se um estudo morfológico do processo de reparaçäo do miométrio de ratas 7, 14 e 21 dias após perfuraçäo. Observou-se que, durante o evoluir do processo de reparaçäo, ocorre uma remodelaçäo do local da lesäo, a partir da substituiçäo dos fibroblastos e do colágeno por fibras musculares lisas

Processo de reparaçäo do miométrio de ratas albinas pós-perfuraçäo: aspectos morfométrios / Healing process of the myometrium of albino rats after perfuration: morphometric aspects

Os autores estudaram o processo de reparaçäo do miométrio de ratas 7, 14 e 21 dias pós-perfuraçäo, realizando estudo morfométrico dos fibroblastos, das fibras colágenas e dos leiomiócitos. A histometria revelou maior número de fibroblastos aos 7 dias e de fibras colágenas aos 14 dias, sendo que a proporçäo de leiomiócitos aumenta com o decorrer do processo de reparaçäo, atingindo o máximo no 21§ dia. O miométrio apresentou-se reconstituído no 21§ dia após a lesäo

Aetiological factors in placenta praevia--a case controlled study.

The obstetric and gynaecological histories of 80 women with proven placenta praevia have been reviewed together with case controls matched for age and parity. There was a significant relation between placenta praevia and previous caesarean section (P less than 0.05), dilatation and curettage (P less than 0.01), spontaneous abortion (P less than 0.05) and evacuation of retained products of conception (P less than 0.05). Repeated uterine instrumentation was associated with increased risk of placenta praevia (P less than 0.001). We were unable to show any influence of previous termination of pregnancy. These findings are consistent with the hypothesis that endometrial/myometrium damage is a significant aetiological factor in low placental implantation.

Asymptomatic perforation of the small intestine by a copper-7 intrauterine device.

PIP: The case of a 32-year old woman (gravida 3 para 2) in whom a Copper-7 IUD perforated the uterus, lodging both within the myometrium and the lumen of the small intestine is described. The patient presented in the emergency room 18 months after IUD insertion with heavy vaginal bleeding and passage of tissue. A diagnosis of spontaneous abortion was made. In this case, the small bowel had to be resected and side-to-side anastomosis was performed. This patient was asymptomatic until 3 weeks prior to admission. Other cases demonstrate acute symptoms of peritonitis and intestinal obstruction or more chronic complaints of vague abdominal pain and diarrhea. An IUD string that is not visible at the external os of the cervix generally reflects upward retraction of the string or unnoted spontaneous expulsion of the IUD. However, on occasion it can be associated with uterine or even intestinal perforation, as occurred in this case. Pain on insertion, also noted in this case, can serve as a warning sign of perforation. In this patient, the device was inserted 5 weeks after delivery, lending support to the recommendation that puerperal insertion be avoided. It is important to know the exact location of an ectopic IUD to prevent dangerous attempts at removal through the vagina. Laparoscopy and ultrasound are generally helpful in localizing the IUD and preparing the patient for laparotomy and possible bowel resection.^ieng