Hysteroscopic Lysis of Complex Uterine Adhesions After Interventional Radiology-Guided Access.

OBJECTIVE: To demonstrate a novel surgical technique using hysteroscopic lysis of adhesions after interventional radiology (IR)-guided access in patients with severe intrauterine adhesions and challenging uterine access. DESIGN: This video illustrates the technique of the safe division of intrauterine adhesions after IR-guided access. SETTING: Conventional hysteroscopic adhesiolysis might be inadequate or risky in cases of severely narrowed or obstructed uterine flow tract, possibly resulting in incomplete adhesiolysis, false passages, or uterine perforation. This video presents 2 cases from a tertiary center involving a multidisciplinary team of a reproductive surgeon and an interventional radiologist. The first case involves a 38-year-old with severe Asherman syndrome, who experienced unsuccessful attempt to treat adhesions that was complicated by a false passage. The second case involves a 39-year-old with recurrent severe Asherman syndrome and a history of unsuccessful attempts at hysterosalpingogram and conventional hysteroscopic lysis of adhesions. INTERVENTIONS: In the IR suite, the patient was put in a lithotomy position on the fluoroscopy table. A vaginal speculum was inserted exposing the cervix. The procedure was performed using intravenous sedation and topical anesthetic spray applied to the cervix. Using fluoroscopy, a balloon cannula was inserted through the cervix, followed by contrast injection to assess uterine access. If there is no route, transvaginal ultrasound-guided needle cannulation of the main portion of the uterine cavity would be performed, approximating as closely as possible to the expected route of the cervical canal. A guidewire followed by a locked loop catheter was advanced through adhesions into the uterine cavity. The catheter was left protruding from the cervix to guide the hysteroscope. The patient was then transferred to the operating room for the hysteroscopic procedure. Under the guidance of the intrauterine catheter, the adhesions were carefully lysed using cold scissors. The endometrial cavity and tubal openings were inspected to ensure complete adhesiolysis and exclusion of any other copathologies. CONCLUSION: IR guidance can provide a safe and effective approach to hysteroscopic lysis of adhesions in patients with challenging intrauterine adhesions and difficult uterine access, such as patients with severe Asherman syndrome, intractable cervical stenosis, uterine wall agglutination, previous adhesiolysis failure, marked fixed retroverted retroflexed uteri, and previous false passage or uterine perforation.

Intestinal obstruction in pregnancy-a rare presentation of uterine perforation.

BACKGROUND: Intestinal obstruction is an uncommon non-obstetric condition during pregnancy which may cause maternal and fetal mortality. Clinicians are confronted with challenges in diagnosis and treatment of intestinal obstruction due to the overlapping symptoms, concerns over radiological evaluation, and surgical risks. CASE PRESENTATION: We reported a 39-year old, gravida 7, para 2, woman who suffered from acute intestinal obstruction at 34 weeks of gestation. Ultrasonography and abdominal computed tomography were applied for intestinal obstruction diagnose. Conservative treatment was initially attempted. But following ultrasound found the absence of fluid in the amniotic sac and the patient showed no improvement in clinical symptoms. An emergency caesarean section was then performed. Intra-operative assessment showed dense adhesion between the left wall of uterus and omentum, descending colon, and sigmoid colon. After adhesion dialysis, uterine rupture with complete opening of the uterine wall at the site of left uterine cornua was found without active bleeding. The uterine rupture was then repaired. CONCLUSIONS: Although uncommon during pregnancy, clinical suspicion of bowel obstruction is necessary especially in women with a history of abdominal surgery. Surgical intervention is indicated when conservative therapy fails and when there are signs of abnormal fetal conditions and worsened symptoms.

Safety and efficacy of microwave endometrial ablation for patients with previous uterine surgery: a pilot study.

MEA (microwave endometrial ablation) is a treatment that can control hypermenorrhea. With the increase in the number of caesarean sections and myomectomies, an increasing number of patients with MEA have undergone previous incision of the uterine myometrium. Uterine perforation is major complication. Here we compared the incidence of complications and recurrence between groups with or without previous uterine surgery. 35 patients who underwent MEA were enrolled in the study. We assessed the thickness of uterine myometrium by MRI and transvaginal ultrasonography (TV-US). 12 patients (34%) had previous uterine surgery; Among 12 patients with previous uterine surgery, 6 (50%) showed thinning of the myometrium. No patient showed any complications. There was no difference in recurrence rate between two groups (1/12 = 8% and 2/23 = 8%, respectively). MEA can be performed safely and effectively even for patients with previous uterine surgery.IMPACT STATEMENTWhat is already known on this subject? MEA (microwave endometrial ablation) is a treatment that can control hypermenorrhea.A few serious complications have been reported, including uterine perforation and intestinal injury. There have been no collective reports on women with a history of uterine surgery, and the decision to perform MEA and the detailed procedures have not been clarified.What do the results of this study add? No patient who received MEA showed any complication regardless of previous uterine surgery. There was no difference in recurrence rate of hypermenorrhea between groups with and without previous uterine surgery. MEA could be performed safely and effectively in patients with previous uterine surgery preoperative imaging and intraoperative ultrasoundsWhat are the implications of these findings for clinical practice and/or further research? Curently, with the increase in the number of caesarean sections and myomectomies, the increasing number of patients with MEA have undergone previous incision of the uterine myometrium and this causes thinning of the myometrium. MEA can be safely performed without losing any therapeutic effect, even in patients with a history of uterine surgery, by using MRI and TV-US as preoperative evaluations.

The effect of different diagnostic timings and types of placenta accreta on the pregnancy outcome.

OBJECTIVES: To explore the effects of maternal and fetal outcomes after different diagnostic timings of placenta accreta and its types. METHODS: We retrospectively collected the clinical information of 1178 pregnant women with placenta accreta in Fujian Maternity and Children Health Hospital from January 2012 to January 2017. According to the different diagnostic timings of placenta accreta, they were divided into groups of prenatal diagnosis and postpartum diagnosis; and according to the types of placenta accreta, they were divided into groups of accreta group, increta group, and percreta group. RESULTS: 1. Women with antenatal diagnosis more often had placenta previa and history of previous cesarean section. 2. Women with antenatal diagnosis had a higher rate in blood loss and blood transfusion. 3. The rate of blood loss, blood transfusion, infection,disseminated intravascular coagulation (DIC), secondary laparotomy, hysterectomy had statistically significant differences (P < 0.05) in different types of placenta accreta. The deeper of placenta accreta, the higher the incidence of complications. CONCLUSION: It is important to pay attention for risk factors of the placenta accreta, then improve prenatal diagnostic rate of the placenta accreta and its types, which can forecast the severity of illness to improve maternal and fetal outcomes.

Generalized peritonitis secondary to spontaneously perforated pyometra in elderly women:two cases with different clinical courses and surgical approaches and review of the literature.

We describe two cases of spontaneously perforated pyometra (SPP) in elderly women treated with two different surgical approaches. An 88-year-old woman underwent emergency laparotomy for presumed diagnosis of gastrointestinal (GI) tract perforation. During surgery, SPP and a tumor of the sigmoid colon were identified. Total hysterectomy and sigmoid colon resection were performed. Despite exhaustive postoperative treatments, the patient died on postoperative day (POD) 189 due to peritonitis and pneumonia. A 93-year-old woman with acute abdomen was diagnosed with severe pyometra and primarily treated with transcervical drainage. Due to progression of generalized peritonitis, laparoscopic surgery was performed. Intraoperatively, scar from a uterine body perforation was identified, leading to the diagnosis of SPP. Only peritoneal irrigation and drainage were performed, in consideration of her advanced age. She improved and was discharged from the hospital on POD 35. The prognosis for SPP is sometimes poor, especially in older women. Minimally invasive surgical intervention might be considered for primary treatment in such cases.

Uterine rupture in pregnancy after an intervention complicated by uterine perforation: Case report and systematic review of literature.

OBJECTIVES: The present study is a descriptive study of characteristics of women who had a uterine rupture during pregnancy with a history of uterine perforation and no previous caesarean section. STUDY DESIGN: We present a case report of a woman with a uterine rupture in pregnancy subsequent to a perforation made by uterine sounding and we performed a systematic review including all case-reports of uterine ruptures after perforation during dilatation and curettage or due to uterine sounding. RESULTS: 14 case-reports were included in this review. 12 out of 14 women presented with abdominal pain prior to the uterine rupture. In eight out of 14 cases an abdominal ultrasound was performed and in five ultrasounds a uterine wall defect was detected, in two other cases free fluid was visible and in one case fetal bradycardia was seen. Neonatal outcome was uneventful in six cases, there where two immature fetuses born and in two cases there was fetal demise. CONCLUSION: Uterine rupture in a (supposed) unscarred uterus is a relatively unknown complication. We recommend clinicians to be aware of uterine rupture in pregnant women with abdominal pain and a history of uterine manipulation. When a uterine rupture is suspected and mother and fetus are in suspected good condition, an ultrasound examination could be an easy and fast next step.

Specific small bowel injuries due to prolapse through vaginal introitus after transvaginal instrumental gravid uterus perforation: a review.

A small bowel prolapse through the vaginal introitus after a transvaginal instrumental gravid uterus perforation is a surgical emergency. To define the mechanisms of an irreversible, small bowel ischaemia due to small bowel prolapse through a vaginal introitus, ClinicalTrials.gov, PubMed, PubMed Central, and Google Scholar were searched. Out of the 81 articles screened, 28 cases of a small bowel evisceration through vaginal introitus were included. A small bowel obstruction severity grading was defined with risk factors; potential mechanisms of different severity grades after a transvaginal instrumental gravid uterine perforation with a vaginal evisceration. The duration of symptoms or a delay in the diagnosis did not change the incidence of the two most severe grades-mesenteric stripping and a small bowel degloving. Both obstruction types develop immediately during an instrumental abortion. The severity of obstruction does not influence the maternal outcome.

Hysteroscopic Diagnosis of Omentum Incarceration Subsequent to an Iatrogenic Uterine Perforation.

STUDY OBJECTIVE: To present and discuss the hysteroscopic aspects of incarcerated omentum through uterine perforation caused by previous dilation and curettage (D&C) for an incomplete first-trimester abortion. DESIGN: A case report. SETTING: Constantine University Hospital, Constantine, Algeria. PATIENT: A 40-year-old, gravida 3, para 2 patient, with a history of an incomplete first-trimester spontaneous abortion treated 6 months before by D&C requiring medical assistance because of moderate, chronic pelvic pain. No other clinical or biological alteration was found. The ultrasound showed intracavitary hyperechogenic formation infiltrating the myometrium posteriorly. INTERVENTIONS: Hysteroscopy revealed a fatlike lesion arousing suspicion of a residual trophoblast; the differential diagnosis included intramyometrial fat metaplasia as well [1]. A mechanical cold loop resection was initiated. Instrumental manipulation of the mass released yellow drops, probably of lipid nature, subsequently leading to the discovery of a uterine perforation giving passage to the omentum. Histologic examination confirmed fat tissue. There was immediate resolution of symptoms. Laparoscopic repair was subsequently performed and consisted of suturing the defect. There were no further complications. MEASUREMENTS AND MAIN RESULTS: Few cases of omentum incarceration in a perforated uterus diagnosed during laparotomy or by magnetic resonance imaging have previously been reported [2-4]. To our knowledge, this is the first case revealed through hysteroscopy. CONCLUSION: In women with a history of intracavitary interventions such as D&C, omentum incarceration should be considered when hysteroscopy demonstrates a fatlike formation and yellow droplets released by pressing or mobilizing the formation. Surgeons should be cautious, never using electrosurgery on formations whose origin arouses suspicion.

Dolor abdominal en puerperio. Perforación uterina y formación de pseudoquiste peritoneal / Abdominal pain in the puerperium. Uterine perforation and peritoneal pseudocyst formation

Debido al número creciente de la tasa de cesáreas, el riesgo de rotura uterina probablemente aumentará. La mayoría aparecen intraparto, siendo más raro un diagnóstico durante el postparto. Se presenta el caso de una mujer de 35 años de edad con antecedente de cesárea anterior hace 4 años que acude a urgencias con un cuadro de dolor abdominal y empeoramiento del estado general, tras parto instrumental 2 semanas antes (AU)

Due to increasing rate of cesarean deliveries, the risk of uterine rupture would probably rise. Most of them appear during labour, being less common a postpartum period diagnosis. Our case report describes a 35-year-old woman with previous caesarean section 4 years ago, who goes to emergency services with abdominal pain and poor performance status after having an instrumental delivery 2 weeks before (AU)

Delayed diagnosis and management of second trimester abdominal pregnancy.

Second trimester abdominal ectopic pregnancies are rare and life threatening. Early diagnosis and treatment are paramount in reducing maternal morbidity and mortality. We describe an unusually late diagnosis of abdominal pregnancy despite multiple ultrasounds beginning in early pregnancy. A 28-year-old G2P1001 sought pregnancy termination at 22 weeks' gestation after fetal anomalies were noted on an 18-week ultrasound during evaluation for elevated maternal serum alfa-fetoprotein. Due to abortion restrictions in her home state, she travelled over 500 miles for abortion care. During dilation and evacuation, suspected uterine perforation led to the finding of a previously undiagnosed abdominal pregnancy. At laparotomy, she underwent left salpingo-oophorectomy and removal of abdominal pregnancy and placenta. A multidisciplinary team approach was paramount in optimising the patient's outcome. Abortion restrictions requiring travel away from the patient's home community interrupted her continuity of care and created additional hardships, complicating management of an unexpected, rare and life-threatening condition.

Rectal perforation in a 42-year-old woman due to Henoch-Schönlein purpura: a case report.

Henoch-Schönlein purpura (HSP) is caused by deposition of IgA-containing immune complexes within the blood vessels. HSP mostly occurs in children and is less common in adults. In addition to palpable purpura, arthritis or arthralgia, renal disease and abdominal pain, gastrointestinal symptoms occur in 50% of children. These can be caused by gastrointestinal hemorrhage, bowel ischemia and necrosis, intussusception, and bowel perforation. In adults, intussusception is less frequent than in children. We report a 42-year-old woman referred to our hospital with acute abdominal pain. After laboratory and radiologic examinations, laparatomy was performed which revealed rectal perforation due to HSP. HSP is a multisystem disorder. Abdominal pain in patients with HSP may herald a serious gastrointestinal problem also in adult patients.

Laparoscopic removal of migrated intrauterine device.

Intrauterine device (IUD) is a popular long-acting reversible contraceptive device with an estimated rate of use of about 5.3%. It is highly effective but not without complications, one of which is uterine perforation. The patient was a 32-year-old female who presented with nausea, vomiting and right upper quadrant abdominal pain that was tender on palpation. CT scan was performed and they found signs of acute calculous cholecystitis with incidental finding of a migrated IUD in the left lateral mid-abdomen within the peritoneal cavity. She underwent a laparoscopic cholecystectomy followed by a successful IUD retrieval. Most uterine perforations occur at the time of insertion; however, partial perforation with subsequent delayed complete perforation may also occur. This case emphasises the importance of a full workup for a missing IUD and that, if incidentally found, IUDs can be removed safely laparoscopically in conjunction with another procedure.

Ectopic abdominal pregnancy due to uterine perforation after an attempt to terminate pregnancy: a case presentation. / Embarazo ectópico abdominal secundario a perforación uterina por interrupción voluntaria del embarazo: presentación de caso.

Secondary abdominal ectopic pregnancy is rare in clinical practice, but may lead to an increased maternal mortality. We present the case of a patient with an abdominal pregnancy secondary to a uterine perforation caused by a voluntary attempt to interrupt pregnancy that presented with nine weeks of abdominal pain and minimal vaginal bleeding which was mistakenly diagnosed as acute pelvic inflammatory disease, urinary tract infection, and post-abortion products of conception. Finally, the abdominal ultrasound test found an abdominal ectopic pregnancy. An exploratory laparotomy was performed and the fetus and placenta were removed without difficulties with a favorable postoperative course. It was concluded that uterine perforation during curettage of the cavity went unnoticed, leading to secondary abdominal implantation of pregnancy with a inconclusive clinical presentation, where ultrasound plays a fundamental diagnostic role. Laparotomy is indicated in most of these cases.

El embarazo ectópico abdominal secundario tiene una baja frecuencia de presentación en la práctica clínica, pero puede llevar al incremento de la mortalidad materna. Se presenta el caso de una paciente con embarazo abdominal secundario a una perforación uterina, causada por una interrupción voluntaria del embarazo. Este evolucionó durante nueve semanas con dolor abdominal y sangramiento vaginal escaso. A la paciente se le realizaron diagnósticos como enfermedad inflamatoria pélvica aguda, infección del tracto urinario, restos ovulares post aborto y definitivamente se concluyó como embarazo ectópico abdominal mediante ecografía abdominal. Se le realizó laparotomía exploradora y se extrajo el feto y la placenta sin dificultades con una evolución postoperatoria favorable hacia la curación. Se concluyó que la perforación uterina durante el curetaje de la cavidad pudo pasar inadvertida, llevando a implantación abdominal secundaria del embarazo con un cuadro clínico variable. En dicho cuadro, el ultrasonido juega un papel fundamental para su diagnóstico, siendo el manejo laparotómico el más apropiado en estos casos.

Uterine perforation following a fractional curettage successfully treated with the modified polysaccharide 4DryField® PH: a case report.

BACKGROUND: Uterine perforation is the most common complication of curettage and may result in bleeding. Therefore, urgent control of bleeding from the uterine wall perforation is necessary to avoid an emergency hysterectomy or blood transfusion, to prevent peritoneal adhesion formation, possible chronic pelvic pain, and infertility. In the present case, an active bleeding secondary to a perforation of the uterus during curettage, for diagnosis of endometrial carcinoma, was instantaneously and successfully treated with only the application of a novel modified polysaccharide powder. This is, to the best of our knowledge, the first time that the agent 4DryField® has been used for this purpose. CASE PRESENTATION: A 71-year-old German woman with serometra and endometrial hyperplasia suffered a perforation of the anterior wall of the uterus during the hysteroscopic resection of submucosal polyps and a fractional curettage. Subsequently, an immediate laparoscopy showed an active bleeding from the wound, which was promptly stopped with only the application of the hemostatic and anti-adhesion polysaccharide powder, 4DryField®. There were no postoperative complications. Nine weeks later, a laparoscopic hysterectomy with bilateral salpingoophorectomy for endometrial carcinoma (histology: stage IA, pT1a, cN0, L0 V0 M0/G2) was performed. The former injured area looked slightly prominent, was completely healed, and showed a shiny serosa. All her pelvic organs were free of adhesions, and there was one 0.5-mm calcified granuloma in the Douglas pouch. CONCLUSIONS: The efficient hemostasis combined with the adhesion prevention effect of 4DryField®, allowed a fast control of the uterine wall bleeding, saved operation time, avoided the risks of other procedures for bleeding control and contributed to the normal healing of the uterine wall without any adhesion formation.

[Acute generalized peritonitis due to uterine perforation following abortion: case study observation]. / Péritonite aigue généralisée par perforation utérine post abortum à propos d'une observation.

UNLABELLED: Clandestine abortion is known to be a major contributor to maternal mortality. We report a case of a 25-year old patient in her 12th week of amenorrhea with peritonitis due to uterine perforation following abortion, admitted with abdomen and pelvis pain, vomiting and diarrhea. Clinical examination on admission showed asthenic peritonitis. Surgical exploration showed widespread acute peritonitis secondary to a perforation of the uterine dome, with collection of 1500 cc of purulent material, dilated bowel loops and multiple false membranes. SURGERY: pus aspiration, peritoneal lavage; uterine suture, drainage. The postoperative course was uneventful, the patient was discharged after 15 days.

Removal of an incarcerated intrauterine device in the sigmoid colon under the assistance of hysteroscope and laparoscope: a case report.

BACKGROUND/AIMS: To explore the value of hysteroscope and laparoscope in removing an incarcerated or ectopic intrauterine device (IUD). MATERIALS AND METHODS: A 33-year-old woman was admitted to the present hospital on May 22nd, 2013. An incarcerated IUD was proven by ultrasonography. An IUD had been implanted in October 2011. Clinical case report of an incarcerated IUD in the sigmoid colon. RESULTS: An IUD was successfully removed with the assistance of hysteroscope and laparoscope. CONCLUSION: Ultrasonography should be performed in the follow-up of the patients after IUD implantation. Ectopic or incarcerated IUD can be successfully removed with the assistance of hysteroscope and laparoscope with minimal trauma.

Implementation of Mass Transfusion Protocol in the Outpatient Operating Room Setting: A Case Study.

The current definition of massive transfusion is replacement of 5 U of packed red blood cells in 3 hours because of uncontrolled hemorrhage or replacement of the entire blood volume within a 24-hour period. The prompt activation of a transfusion protocol can quickly restore hemodynamic stability. Effective teamwork and communication is critical for a favorable patient outcome. This case study demonstrates the effectiveness of using a massive transfusion protocol in an outpatient setting.