Young woman with severe abdominal pain: conclusion

A 17-year-old girl presented to a fire station complaining of severe abdominal pain one afternoon. The patient appeared acutely ill and had an initial blood pressure of 62 mmHg by palpation and a heart rate of 110 beats per minute. A flight crew was summoned to the scene. History obtained only through a Spanish-speaking interpreter revealed the patient to be approximately 6 months pregnant and without any prenatal care. Physical assessment revealed the patient to be alert and oriented but weak, pale, and diaphoretic. The abdomen examination demonstrated diffuse, severe tenderness and guarding to palpation. There was no evidence of vaginal bleeding or signs of imminent delivery. A repeat blood pressure by the flight crew was 82 mmHg by palpation.

Laparoscopic hemi-hysterectomy in treatment of a didelphic uterus with a hypoplastic cervix and obstructed hemi-vagina

OBJECTIVE

Maldevelopment of the Müllerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix and obstructed hemi-vagina.

CASE REPORT

We report a patient with this anomaly who was treated by laparoscopic hemi-hysterectomy and hysteroscopic resection of hemi-vagina. A 16-year-old patient who had complained of vaginal pus-like discharge on and off for 1 year was diagnosed by MRI to have a double uterus with obstructed right hemi-vagina and ipsilateral renal agenesis. After hysteroscopic identification of hypoplasia of the right uterine cervix, laparoscopic resection of the right uterus and right fallopian tube and hysteroscopic assisted resection of the vaginal septa were performed successfully.

CONCLUSION

We think that combined laparoscopy and hysteroscopy may be an effective alternative in the management and diagnosis of Mullerian anomalies.

"Pseudoseptum" of the uterine cervix on MRI

PURPOSE

To determine the prevalence of a longitudinal "pseudoseptum" on T2-weighted MR images within the cervices of women who do not have a uterine anomaly.

MATERIALS AND METHODS

We reviewed 317 consecutive female pelvic MR examinations performed at a single institution over a four-month period. All examinations included T2-weighted sequences in at least two orthogonal planes. Of the 317 studies, 57 were excluded due to prior radical hysterectomy. Axial and coronal T2-weighted images of the remaining 260 examinations were evaluated for the presence of a longitudinal low T2 signal intensity structure within the endocervical lumen that mimicked the appearance of a septum. Interpretations were performed independently by two MR radiologists and kappa analysis of interobserver agreement was performed.

RESULTS

In 50 (19%) of the 260 women, both readers noted the presence of a pseudoseptum on at least one imaging plane. In 162 (62%), neither reader noted a pseudoseptum. Overall, there was 81% agreement between the readers. Kappa analysis yielded a value of 0.55, indicating a moderate degree of interobserver agreement beyond chance.

CONCLUSION

A pseudoseptum was depicted in 20% to 30% of women's cervices on T2-weighted imaging. We hypothesize that chance long-axis depiction of the endocervical folds can mimic a cervical septum. The presence of a pseudoseptum on MRI should be considered a normal finding and not a feature of a developmental anomaly of the uterus or cervix.

Laparoscopically assisted uterovestibular anastomosis in patients with uterine cervix atresia and vaginal aplasia

OBJECTIVE

To describe the surgical technique and the long-term anatomic and functional results of laparoscopically assisted uterovestibular anastomosis.

DESIGN

Descriptive study.

SETTING

Tertiary referral center.

PATIENT(S)

Twelve consecutive patients with uterine cervix atresia and vaginal aplasia.

INTERVENTION(S)

Laparoscopically assisted uterovestibular anastomosis was performed in all patients. Follow-up assessments at 1, 6, and 12 months included pelvic examination, transvaginal ultrasonography, and, in selected cases, vaginoscopy and hysteroscopy. Subsequent follow up was done by referring physicians or by means of telephone interview. Mean follow-up was 6 years.

MAIN OUTCOME MEASURE(S)

Intra- and postoperative characteristics and anatomic and functional outcome.

RESULT(S)

The surgical procedure was successful in all cases and all of the women have experienced regular menstruation. At 6-month follow-up, mean vaginal length was 6 cm and at least 80% of neovaginal epithelium was iodine-positive in all patients. Six women were sexually active during follow-up without difficulty. None have yet attempted to seek a pregnancy.

CONCLUSION(S)

The study shows the safety and effectiveness of a laparoscopic approach to uterovestibular anastomosis in women with cervical atresia and vaginal aplasia. In these patients, we believe that conservative surgery should represent the first therapeutic option. A longer follow-up is needed to assess pregnancy rates and outcome.

Clinical significance of the presence of amniotic fluid 'sludge' in asymptomatic patients at high risk for spontaneous preterm delivery

OBJECTIVES

To determine the clinical significance of the presence of amniotic fluid (AF) 'sludge' among asymptomatic patients at high risk for spontaneous preterm delivery.

METHODS

This retrospective case-control study included 281 patients with (n = 66) or without (n = 215) AF 'sludge', who underwent transvaginal ultrasound examination between 13 and 29 completed weeks of gestation. Patients with threatened preterm labor, multiple gestation, fetal anomalies, placenta previa or uterine contractions were excluded.

RESULTS

The prevalence of AF 'sludge' in the study population was 23.5% (66/281). The rates of spontaneous preterm delivery at < 28 weeks, < 32 weeks, < 35 weeks and < 37 weeks of gestation were 14.7% (29/197), 21.3% (46/216), 28.7% (62/216) and 42.1% (91/216), respectively. Patients with 'sludge' had: (1) a higher rate of spontaneous preterm delivery at < 28 weeks (46.5% (20/43) vs. 5.8% (9/154); P < 0.001), < 32 weeks (55.6% (25/45) vs. 12.3% (21/171); P < 0.001) and < 35 weeks (62.2% (28/45) vs. 19.9% (34/171); P < 0.001); (2) a higher frequency of clinical chorioamnionitis (15.2% (10/66) vs. 5.1% (11/215); P = 0.007), histologic chorioamnionitis (61.5% (40/65) vs. 28% (54/193); P < 0.001) and funisitis (32.3% (21/65) vs. 19.2% (37/193); P = 0.03); (3) a higher frequency of preterm prelabor rupture of membranes (PROM) (39.4% (26/66) vs. 13.5% (29/215); P < 0.001), lower gestational age at preterm PROM (median 24.7 (interquartile range (IQR), 22.3-28.1) weeks vs. 32.3 (IQR, 27.7-34.8) weeks; P < 0.001); and (4) shorter median ultrasound-to-delivery interval ('sludge' positive 127 days (95% CI, 120-134 days) vs. 'sludge' negative 161 days (95% CI, 153-169 days); P < 0.001) and ultrasound-to-preterm PROM interval ('sludge' positive 23 days (95% CI, 7-39 days) vs. 'sludge' negative 57 days (95% CI, 38-77 days); P = 0.003) than those without 'sludge'. AF 'sludge' was an independent explanatory variable for the occurrence of spontaneous preterm delivery at < 28 weeks, < 32 weeks and < 35 weeks, preterm PROM, microbial invasion of the amniotic cavity (MIAC) and histologic chorioamnionitis. Moreover, the combination of a cervical length < 25 mm and 'sludge' conferred an odds ratio of 14.8 and 9.9 for spontaneous preterm delivery at < 28 weeks and < 32 weeks, respectively.

CONCLUSIONS

AF 'sludge' is an independent risk factor for spontaneous preterm delivery, preterm PROM, MIAC and histologic chorioamnionitis in asymptomatic patients at high risk for spontaneous preterm delivery. Furthermore, the combination of 'sludge' and a short cervix confers a higher risk for spontaneous preterm delivery at < 28 weeks and < 32 weeks than a short cervix alone.

Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To investigate the efficacy of vaginal progesterone to prevent early preterm birth in women with sonographic evidence of a short cervical length in the midtrimester.

METHODS

This was a planned, but modified, secondary analysis of our multinational, multicenter, randomized, placebo-controlled trial, in which women were randomized between 18 + 0 and 22 + 6 weeks of gestation to receive daily treatment with 90 mg of vaginal progesterone gel or placebo. Cervical length was measured with transvaginal ultrasound at enrollment and at 28 weeks of gestation. Treatment continued until either delivery, 37 weeks of gestation or development of preterm rupture of membranes. Maternal and neonatal outcomes were evaluated for the subset of all randomized women with cervical length < 28 mm at enrollment. The primary outcome was preterm birth at </= 32 weeks.

RESULTS

A cervical length < 28 mm was identified in 46 randomized women: 19 of 313 who received progesterone and 27 of 307 who received the placebo. Baseline characteristics of the two groups were similar. In women with a cervical length < 28 mm, the rate of preterm birth at </= 32 weeks was significantly lower for those receiving progesterone than it was for those receiving the placebo (0% vs. 29.6%, P = 0.014). With progesterone, there were fewer admissions into the neonatal intensive care unit (NICU; 15.8% vs. 51.9%, P = 0.016) and shorter NICU stays (1.1 vs. 16.5 days, P = 0.013). There was also a trend toward a decreased rate of neonatal respiratory distress syndrome (5.3% vs. 29.6%, P = 0.060).

CONCLUSION

Vaginal progesterone may reduce the rate of early preterm birth and improve neonatal outcome in women with a short sonographic cervical length.

Intra-amniotic sludge, short cervix, and risk of preterm delivery

OBJECTIVE

To evaluate the association between intra-amniotic sludge seen at cervical ultrasound and preterm delivery.

METHOD

This retrospective study included women at high risk for preterm delivery who were referred for second trimester cervical length measurement by ultrasound between 18 and 32 weeks' gestation. Patients with multiple gestations, cerclage, or preterm labour were excluded. Ultrasound images were reviewed by two independent observers and divided into three groups: (1) no amniotic sludge, (2) light sludge, and (3) dense sludge in the amniotic fluid. The primary outcome measures were delivery within 14 days of examination and delivery before 34 weeks' gestation. Logistic regression analyses were performed to adjust for confounding factors.

RESULTS

Eighty-nine patients met the inclusion criteria. Mean gestational age at presentation was 25.8 +/- 4.4 weeks, and mean cervical length was 33 +/- 12 mm. The prevalence of light and dense amniotic fluid sludge was 10.1% and 5.6%, respectively. Delivery within 14 days of examination occurred in four (5.3%) women with no sludge, in two (22.2%) women with light sludge, and in three (60.0%) women with dense sludge (P < 0.01). Delivery before 34 weeks occurred in five (6.7%), four (44.4%) and four (80.0%) women, respectively (P < 0.01). Logistic regression analyses demonstrated that light amniotic fluid sludge, dense sludge, and cervical length of less than 25 mm were all significant and independent predictors of delivery within 14 days of examination and delivery prior to 34 weeks.

CONCLUSION

The presence of amniotic fluid sludge is associated with delivery within 14 days and delivery before 34 weeks' gestation.

Leiomyoma on the septum of a septate uterus with double cervix and vaginal septum: a challenge to manage

OBJECTIVE

To describe the first case of a leiomyoma localized in the septum of a septate uterus that had cervical duplication and a longitudinal vaginal septum.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A 43-year-old patient with primary infertility and complaint of menorrhagia.

INTERVENTION(S)

Laparotomy, adhesiolysis, myomectomy, and resection of the vaginal septum in the first operation. Hysteroscopic resection of the complete uterine septum in the second operation.

MAIN OUTCOME MEASURE(S)

Magnetic resonance imaging findings and two-step repair of the anomaly. Cervical length at second trimester.

RESULT(S)

Restoration of normal anatomy was achieved after correct diagnosis and a two-step operation procedure. A normal cervical length was measured at 26 weeks of gestation.

CONCLUSION(S)

Large leiomyoma at rare localizations in the presence of uterine anomalies is a diagnostic challenge, but with available diagnostic technology and appropriate operations, successful results can be obtained.

Double vagina and cervix communicating bilaterally with a single uterine cavity: report of a case with an unusual congenital uterine malformation

BACKGROUND

The existence of a longitudinal vaginal septum with double cervix communicating bilaterally with a nonseptate uterine body and normal adnexa is an unusual müllerian anomaly.

CASE

A 43-year-old woman presented with menorrhagia and duplication of the cervix and vagina. Afibromatous uterus was suggested by clinical examination and confirmed by ultrasonography. The patient underwent total abdominal hysterectomy with bilateral salpingooophorectomy. The surgical specimen revealed a fibromatous uterus with double cervix communicating bilaterally with a nonseptate uterine body; both adnexa were normal.

CONCLUSION

This rare müllerian anomaly is inconsistent with the classical embryologic theory of caudal to cranial müllerian development but supports the alternative embryologic hypothesis suggested by Müller et al, according to which fusion and absorption begin at the isthmus and proceed simultaneously in both the cranial and caudal directions.

A case of blind vagina in a crossbred Lusitano mare

This report describes a case of blind vagina diagnosed during a pre-breeding evaluation of a 5-year-old crossbred Lusitano mare. This mare was mated twice during the previous breeding season but remained open. Clinical evaluation revealed the existence of follicles in the ovaries and an enlarged uterus. An ultrasound examination showed that a granular free-floating fluid distended the uterus. No connection was detected between the uterus and the vagina and a presumptive diagnosis of congenital vaginal obstruction was raised. On vaginal examination it was noticed that the vagina was short in depth and ended as a blind pouch. The typical cervical morphology was not observed. Careful evaluation of the clinical situation, both during the follicular and the luteal phases of the mare's oestrous cycle, lead to a diagnosis of segmental aplasia of the cranial vagina. The mare had a normal karyotype on cytogenetic examination [64XX].

Targeted therapy for threatened preterm labor based on sonographic measurement of the cervical length: a randomized controlled trial

OBJECTIVE

False positive diagnosis of preterm labor is common. As a consequence, medications including corticosteroids to promote fetal lung maturity and tocolysis are prescribed unnecessarily. We tested the hypothesis that management of threatened preterm labor based on measurement of cervical length by ultrasonography can reduce the number of women who receive inappropriate treatment.

METHODS

Forty-one women with threatened preterm labor for whom a clinical decision was made to prescribe antenatal corticosteroids and tocolysis were randomized to have their cervical length measured by transvaginal ultrasound (n=21) or to receive therapy as planned (n=20). Fourteen women in the ultrasound group had a cervix longer than 15 mm and the therapy was withheld, while the other seven with a short cervix were managed in the same way as the control group.

RESULTS

Three women (14%) in the ultrasound group were treated inappropriately with antenatal corticosteroids because they remained undelivered for more than a week. This compared favorably with the control group where 18 out of 20 (90%) received corticosteroids unnecessarily (relative risk (RR) 0.16; 95% confidence interval (CI), 0.05-0.39). Tocolysis was given to only seven women (33.3%) in the ultrasound group compared with 20 (100%) in the control group (RR 0.3; 95% CI, 0.15-0.54). There were no babies in either group who were born prematurely without being given a full course of antenatal corticosteroid therapy.

CONCLUSION

Women with threatened preterm labor and cervical length more than 15 mm should not receive tocolysis. The issue of the safety of withholding corticosteroid therapy in this clinical scenario warrants further study.

Short cervix: is a follow-up measurement useful?

OBJECTIVE

To study if a repeat cervical length (CL) measurement in the patient already diagnosed with a short cervix has any additional value in the prediction of preterm delivery.

STUDY DESIGN

This was a retrospective study of singleton pregnancies with cervical lengths 1-25 mm at a gestational age of 16-28 weeks seen in our institution between 2002 and 2005. Patients who were managed expectantly and had a follow-up CL measurement within 3 weeks were included. Delivery data were obtained from the patients' computerized medical records.

RESULTS

Sixty-eight patients met the inclusion criteria. 37% of the patients had a shorter CL on the second measurement. These patients delivered at an earlier gestational age (36+4 vs. 38+2 weeks, P=0.031) and were more likely to deliver at <37 weeks (60% vs. 26%, P=0.009). The change in the CL correlated with earlier gestational age at delivery and delivery at <37 weeks.

CONCLUSION

In patients diagnosed with a short cervix, follow-up CL measurement is a strong predictor of preterm delivery. Greater change in the CL correlates with an earlier gestational age at delivery. In the patient diagnosed with a short cervix, a repeat measurement of CL gives additional predictive value.

Prise en charge chirurgicale des patientes présentant un utérus cloisonné total

INTRODUCTION

Septate uterus is the principal müllerian anomaly, but complete septate uterus is uncommon and often associated with frequent obstetrical complications. Surgical section of the septum is however possible.

MATERIAL AND METHOD

We report patients with a complete septum uterus operated in our department between 2002 and 2006. We performed a hysteroscopic section of the cervical, uterine and vaginal septum at discovery of the anomaly. The accuracy of imaging exams, frequency of associated malformations, past obstetrical events and reproductive outcome post surgery were analyzed.

RESULTS

The surgical technique was based on section of the cervical part with scissors and hysteroscopic section of the uterine septum; no perforation was noted. Four patients required a second procedure to achieve complete uterine section. Five patients became pregnant after surgery, 8 pregnancies are reported: 2 term delivery, 1 preterm delivery, 4 miscarriages and 1 ectopic pregnancy.

CONCLUSION

Complete surgical section of the cervical and uterine septum in case of complete septum uterus is safe. However, we cannot conclude about the obstetrical benefit of this surgical technique. A longer follow-up is needed.

Amniotic membrane for cervical reconstruction

OBJECTIVE

To evaluate the use of amniotic membrane grafts in cases of vaginal and cervical agenesis.

METHODS

Five girls with complete cervical and vaginal agenesis underwent cervicoplasty and vaginoplasty using amniotic membrane grafts.

RESULT

Excellent epithelization and patency of cervix and vagina was achieved in all cases.

CONCLUSION

Amniotic membrane may be used as an allograft in cervical reconstruction. It is inexpensive, readily available, of low antigenicity and does not necessitate repeated cervical dilatation. The performance of the reconstructed cervix during labor is yet to be observed. To the author's knowledge, this is the first series reported in the literature in which amniotic membrane was used for cervical reconstruction.

Bicornuate rudimentary uterine horns with functioning endometrium and complete cervical-vaginal agenesis coexisting with ovarian endometriosis: a case report

OBJECTIVE

To report a patient with bicornuate rudimentary uterine horns with functioning endometrium and complete cervical-vaginal agenesis coexisting with ovarian endometriosis.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 37-year-old woman with an extremely rare müllerian anomaly of the uterus and vagina coexisting with ovarian endometriosis.

INTERVENTION(S)

Resection of the rudimentary uterine horns with bilateral salpingo-oophorectomy.

MAIN OUTCOME MEASURE(S)

Relief from pelvic pain after the operative procedure.

RESULT(S)

The definite diagnosis and removal of the müllerian anomaly and endometriosis foci.

CONCLUSION(S)

Cyclic pelvic pain since the age of 14 was due to cryptomenorrhoea in the presence of the bicornuate rudimentary uterine horns with functioning endometrium and cervical-vaginal agenesis. Ovarian endometriosis developed as a result. In such cases, invasive procedures, such as laparoscopy or laparotomy, should be considered to establish the diagnosis. Removing the functioning rudimentary uterine horns just after menarche should prevent the development of endometriosis and hematometra.

Unilateral cervical cancer in a patient with cervix duplex

BACKGROUND

Although uterine anomalies are uncommon, gynecologists must be aware of the anatomical challenges that may be encountered from these anomalies. Cervical cancer in the context of a mullerian lateral fusion defect is rare.

CASE

A case of a unilateral IB1 squamous cell carcinoma of the cervix in the setting of a complete uterovaginal septum and cervix duplex is described.

CONCLUSION

Uterine anomalies compound diagnostic difficulty of routine pathology. Thorough examination and evaluation are crucial for timely diagnosis and treatment. Genital tract duplication, although rare, should always be considered.

Uterus didelphys with fibroid uterus and ovarian cyst--rare Muellerian malformation

Persistent Muellerian duct syndrome is a very rare anomaly. A woman of 46-year-old was admitted with the history of lower abdominal pain, bleeding per vaginum and irregular menstrual cycles for last 6 months. An irregular non-tender mass of 16 x 10cm in size was palpable in suprapubic region. Per vaginal examination revealed two cervices and an incomplete vaginal septum. Ultrasound abdomen showed one uterus with endometrial cavity clearly delineated with a fibroid and an ovarian cyst in the left lumbar region. On laparotomy, 2 uterii along with a fibroid from the anterior wall of left uterus and a left ovarian cyst was seen. Patient had undergone total abdominal hysterectomy and adnexa removal. The specimen showed florid adenomyosis with leiomyoma of fibroid.

Perspectives on the management of the short cervix identified by transvaginal ultrasound during pregnancy: an update for Canadian obstetrical caregivers

A shortened cervix is often considered to be equivalent to cervical insufficiency, and a cerclage may be offered as an intervention to prolong pregnancy; however, we may not be differentiating between true cervical insufficiency and intrauterine causes of cervical shortening. A recent meta-analysis found no significant reduction in preterm birth < 35 weeks' gestation in women with cerclage compared with no cerclage in the total population of women studied. However, there was a potentially significant reduction in preterm birth < 35 weeks among women with a singleton pregnancy (relative risk [RR] 0.74; 95% confidence intervals [CI] 0.57-0.96), with a singleton pregnancy and a previous preterm birth (RR 0.61; 95% CI 0.40-0.92), and with a singleton pregnancy with a previous mid-trimester loss (RR 0.57; 95% CI 0.33-0.99). An increase was found in preterm birth among twin gestations with cerclage placed for a shortened cervix on transvaginal ultrasound (RR 2.15; 95% CI 1.15-4.01). This unexpected finding underscores the possibility of harm with this intervention. This intervention deserves further study. A national registry or database would allow us to identify women who may benefit more significantly from cerclage by collecting data on possible confounding effects such as concomitant intrauterine infection or placental disease.

Hysteroscopic metroplasty of the complete uterine septum, duplicate cervix, and vaginal septum

OBJECTIVE

To determine if sectioning of the cervical septum in hysteroscopic metroplasty of the complete uterine septum is associated with intraoperative bleeding, cervical incompetence, and secondary infertility.

DESIGN

Multicenter, randomized, controlled clinical trial.

SETTING

University hospitals.

PATIENT(S)

Twenty-eight women with a diagnosis of complete uterine septum who had a history of pregnancy wastage or infertility. They were randomized into two groups: group A underwent metroplasty including section of the cervical septum; group B underwent the same procedure with preservation of the cervical septum.

INTERVENTION(S)

Hysteroscopic metroplasty was performed for all patients in the two groups.

MAIN OUTCOME MEASURE(S)

Operating time, distending media deficit, total distending media used, intraoperative bleeding, complications, and reproductive outcome.

RESULT(S)

Operating times were 36.40 +/- 10.67 minutes and 73 +/- 14.40 minutes in group A and group B, respectively. Distending media deficit was 456.66 +/- 165.68 mL in group A, while in group B it was 673.84 +/- 220.36. Two cases of pulmonary edema and three cases of significant bleeding (> 150 mL) were seen in group B. The cesarean section rate was significantly higher in group B. There were no significant differences in the reproductive outcome in the two groups.

CONCLUSION(S)

Resection of the cervical septum during hysteroscopic metroplasty of complete uterine septum makes the procedure safer, easier, and less complicated than the procedure with preservation of the cervical septum. This procedure is recommended for all cases of complete uterine septum.