WELCOME TO ZONAL CME at Guntur Medical College

Transcription

1 WELCOME TO ZONAL CME at Guntur Medical College

2 PRESENTATION ON ANATOMIC UTERINE FACTORS IN RECURRENT PREGNANCY LOSS By Dr. V. MADHU BINDU, Prof. of OBG Dept., Katuri Medical College & Hospital GUNTUR - A.P

3 INTRODUCTION Anatomic Uterine factors are found in 12-15% of women evaluated for RPL. In addition to pregnancy loss, uterine malformations predispose women to other reproductive difficulties like infertility, preterm labour and malpresentations. Anatomic uterine defects are classified as Congenital Acquired.

4 CONGENITAL UTERINE ANOMALIES Incidence 1% in general population 3% in women with RPL Classification of Mullerian anomalies (ASRM) Class I Mullerian agenesis lethal (bil renal agenesis) Hypoplasia MRKS syndrome Class II Unicornuate uterus Class III Didelphys uterus Class IV Bicornuate uterus Class V Septate uterus Class VI Arcuate uterus Class VII DES exposed uterus

5 CLASS I SEGMENTAL MULLERIAN AGENESIS A. Vaginal B. Cervical C. Fundal D. Tubal E. Combined INCOMPLETE..Mayer Rokitansky Kuster Hauser Syndrome. Infertile.

6 CLASS II UNICORNUATE UTERUS Agenesis/ Hypoplasia of one of the Mullerian ducts results in Unicornuate uterus. 20% of uterine anomalies. Variations A. With rudimentary horn 1. with communicating cavity 2. with non-communicating cavity. 3. with no cavity. B. Without rudimentary horn

7 . Unicornuate uterus with rudimentary horn with cavity can present with unilateral cyclic pelvic pain secondary to haematometra. Usually associated with renal anomalies (40%) ipsilateral to the hypoplastic horn. Spontaneous abortion rates -51% Premature birth rates 15% Other c/o ECTOPIC PREGNANCY, rupture of horn, malpresentations, IUGR.

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9 . Cause of pregnancy wastage reduced intra luminal volume, inadequate vascular supply. Associated with cervical incompetence. Management- Expectant.cervical length measurements Rudimentary horn resection to be done to relieve dysmenorrhoea, prevent haematometra, ectopic, uterine rupture.

10 CLASS III UTERUS DIDELPHYS There is failure of lateral fusion involving uterus and vagina. Results in formation of double uterus, double cervix and double vagina. 5-7% of Mullerian defects. Reproductive outcome is better than unicornuate uterus. Spontaneous abortion rate -43% Preterm birth rate 38% Fetal survival rate- 54%

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12 . Septate vagina causes difficulty with sexual intercourse or vaginal delivery. Management- Resection of the septum is necessary in these conditions. Strassmann s utriculoplasty unifies fundus but leaves double cercices intact. Is reserved on a case by case basis for selected patients. Risk of rupture in future pregnancy is high.

13 CLASS IV BICORNUATE UTERUS Result of incomplete fusion of uterine horns at the level of fundus. A. Complete upto the internal os B. Partial Presence of two separate but communicating uterine cavities and a single cervix. 10% of all congenital anomalies. Depth of the cleft affects the reproductive outcome. Spontaneous abortion rate 32% Preterm delivery- 29% in partial Management expectant. 66% in complete form strassmann s metroplasty

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16 CLASS V SEPTATE UTERUS Most common. Poorest outcome Miscarriage rate is 60% Mechanism.avascular septum leads to poor implantation. Septum can be partial or complete

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18 . Treatment- Hysteroscopic Septal Resection by micro scissors Electro surgery Laser excision. Micro scissors better than electro surgery as it minimises endometrial thermal damage. For thick septa electro surgery is preferred as coagulation is simultaneously achieved.

19 . Laser speed, good haemostasis + high cost, difficult to manipulate Laparoscopic guidance is used to reduce the risk of uterine perforation. Jones operation of wedge resection of part of fundus including septum, Tomkin s operation of incising fundus in midline, septal excision and reuniting the halves of uterus in midline of historical importance. Not done now a days.

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21 . PRE REQUISITES to lysis of Septum A GnRH agonist may be given for 2 months to reduce the endometrium growth,to facilitate surgeon s view of the uterine cavity OR Procedure to be done in early proliferative phase to avoid bleeding

22 CLASS VI ARCUATE UTERUS Near complete resorption of uterovaginal septum may leave a mild concave indentation of endometrial cavity at the level of fundus giving it an arcuate configuration. Spontaneous abortion rates 13% Management expectant.

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24 CLASS VII DES Orally active synthetic oestrogen 1940 Incidence of uterine anomalies 69%. T shaped uterine cavity is seen in 70%, small uterus, constriction rings, intra uterine filling defects are also seen. 44% showed structural changes in cervix like anterior cervical ridge, cervical collar, cervical hypoplasia and pseudo polyps. 2 fold increase in spontaneous abortion rate 4 fold increase in ectopic pregnancy risk. Predisposed to cervical incompetence. Prophylactic cerclage in women prone for II trimester abortions/ preterm births.

25 ACQUIRED UTERINE DEFECTS -- Cervical Incompetence -- Synechiae ( intra uterine adhesions) -- Leiomyomas, Polyps -- Adenomyosis

26 A. CERVICAL INCOMPETENCE Diagnosed on the basis of history of painless abortions. Usually causes II trimester pregnancy loss. May be associated with congenital uterine anomalies like Septate or Bicornuate uterus. Rarely due to in utero exposure to DES. Acquired as a result of surgical trauma to cervix such as, after Conization, LEEP, over dilatation of cervix during D& C, obstetric cervical lacerations. Diagnosis. Passing no 8 hegar dilator without resistance in non pregnant state.

27 . Management -serial assessment of cervical measurements by TVS 35-40mm (14-22 wks) 35mm (24-28 wks) 30mm >32 wks Cervical encirclage.vaginal procedures Mc Donald s Shirodkar s Wurm s.abdominal cerclage.

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29 CERVICAL ENCIRCLAGE. Prophylactic Emergency. Emperical Re cerclage Care Removal

30 B. SYNECHIAE / INTRA UTERINE ADHESIONS Result from vigorous endometrial curettage or from post abortal/partum endometritis. Severity of adhesions may range from minimal to complete obliteration of the endometrial cavity. 40% - spontaneous abortion 23% - preterm labour. Reduced uterine cavity volume interferes with normal placentation leading to pregnany loss. Reproductive outcome is poor. Management hysteroscopic surgical excision of adhesions.

31 CLASSIFICATION VALLE & SCIARRA S 1988 MILD Filmy adhesions, composed of basal endometrium, producing partial/ complete uterine cavity occlusion. MODERATE Fibromuscular adhesions, thick, covered by endometrium, bleed on division, partially or totally occlude uterine cavity. SEVERE composed of connective tissue with endometrial lining, bleed upon division, partially / totally occlude uterine cavity.

32 SOCIETY FOR HYSTEROSCOPY I Thin or filmy adhesions easily ruptured by Hysteroscopy sheath alone. Cornual areas normal. II Singular, firm adhesions connecting separate parts of uterine cavity. Visualisation of both tubal ostia possible. IIa Occluding adhesions only in the region of internal cervival os. Upper uterine cavity is normal. III Multiple firm adhesions connecting separate parts of uterine cavity, unilateral obliteration of ostial areas of tubes.

33 . Amenorrhoea may be present. IV Extensive firm adhesions with agglutination of uterine walls. Both tubal ostial areas are occluded. BEFORE LYSIS GnRH agonist may be given for 2 months to reduce the amount of endometrium that can obscure surgeon s view during the procedure. OR to be done in early proliferative phase of the cycle to avoid bleeding.

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35 C. INTRA UTERINE CAVITY ABNORMALITIES Common causes are Leiomyomas and Polyps and Adenomyosis. Incidence %. Mechanism of poor pregnancy outcome cavity. Partially obliterate or alter the contour of endometrial provide poorly vascularised endometrium for implantation or compromise placental development. may act as intra uterine device causing subacute endometritis which may impair migration of sperm, ovum or embryo. 60% incidence of pregnancy loss

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37 . Treatment conservative HIFU, Laser ablation,myolysis Polypectomy Myomectomy..hysteroscopy guided/ abdominal..laparoscopically/ laparotomy Uterine artery embolisation Results after myomectomy are better than UAE.

38 EVALUATION OF UTERINE FACTOR USG - TV 3D HSG SONO HYSTEROGRAPHY HYSTEROSCOPY LAPAROSCOPY MRI USG 3D imaging is - non invasive and provides complete assessment of uterine morphology

39 . HSG.uterine malformations, intra uterine adhesions, Tubal patency assessment. Can t differentiate between Septate and Bicornuate uterus. Saline infusion Sono Hysterography involves trans cervical instillation of fluid into uterine cavity during TVS evaluation. This technique dilineates internal uterine contours provides concomitant visualisation of outer surface of the uterus. Better than HSG or Hysteroscopy. To be done in early follicular phase.

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42 By USG differentiate septate from bicornuate uterus.

43 Hysteroscopy allows diagnosis and simultaneous treatment. Simultaneous Laparoscopy is often necessary to visualise uterine fundus and reliably differentiate between Septate and Bicornuate uterus. MRI is less invasive but expensive imaging modality Successful pregnancy outcome is reported in 60% of cases of surgically corrected anatomic uterine anomalies..

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46 By Dr. V. Madhu Bindu, Prof. of OBG Dept., Katuri Medical College & Hospitals, GUNTUR - A.P