UTERINE SEPTUM. September 2016 GKS Pauliina Aukee. septum, septa (pl)

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1 UTERINE SEPTUM September 2016 GKS Pauliina Aukee septum, septa (pl)

2 Pauliina Aukee PhD, Speciality in obstetrics and gynaecology Special competence in urogynaecology Special competence in medical education Current position: Head of gynaecological outpatient clinic, Central Finland Central Hospital Consultant, Pelvic Floor Research and Therapy Unit, Central Finland Central Hospital Private practice: Suomen Terveystalo, Jyväskylä Membership: Finnish Medical Association Duodecim, GKS IUGA, ICS Educational reward from: Allergan Oy, Astellas Oy

3 Case Spring, 25 years Referral to gynaecological outpatient clinic Anamnesis: Ceasarean section 2015, healthy baby at term Obstetrician noticed a septum inside the uterus. Futher investigations? Question: Is there need for further examination?

4 What do we know about septum uterine? There is a fair evidence that uterine septum contributes to miscarriage and pretem birth A uterine septum may increase the risk of adverse pregnancy outcomes such as malpresentation, plasental abruption and perinatal mortality The size or lenght of septum does not correlate to pregnancy outcome In a patient with infertility, prior pregnancy loss, or poor obstetrical outcome it is reasonable to consider septum incision 3D ultrasound, sonohysterosgraphy, and MRI are good diagnostic test for distinguishin a septate and bicornuate Data do not exist to suggest an association between septate uterus and renal anomalies Grade B B C B

5 How uterine septum becomes? As a result of failure of resorption of the tissue connecting the two paramesonephric (Mullerian) ducts prior to the 20th embryonic week Imcomplete/partial complete septate uterus Asymptomatic infertility, adverse pregnancy outcome Fibroelastic tissue, poor vascularity

6

7 Kohtuanomalioiden luokittelu

8 3D sonohysterosgraphy of septate uterus dept > 1,5 cm, angle < 90º and fundal indentation

9 Case Autum 30 years 2009 Aap 5/2016 PROM H H19 decision of AAP, MBA 40 medical abortion bleeding, endometrium 15 mm. MBA 05 MVA- vacuum aspiration. US: Endometrium is thinn Control. No explanation for the miscarriage, US: Septum? Hydrosonografia nihil Control. US: suspicion of uterine septum resectoscopia

10 Bipolar needle electrode Resectoscope Wolf NaCl

11 Hysteroscopy to treat a uterine septum Early in the menstrual cycle or endometrial supression with contraception pills Resectoscope with a mo/bipolar knife/hysteroscope 5 mm+versapoint device/cold scissors (ND*) Resection of the avascular septum until both tubal ostium can be seen. If bleeding occurs, it is from myometrium and stop resection! Postoperatively no evidence to use IUD, Foley balloon or estrogen to prevent adhesions The uterine cavity is healed in 2 months, no need for wait a longer period for a new pregnancy

12 3D- SIS versus hysteroscopy after monopolar resection N = 141 Indication: >1 miscarriage or infertility 3D-SIS and second look hysteroscopy after 6-8 weeks 3D-SIS as diagnostic as hysteroscopy Second look hysteroscopy necessary only for re-operation Ludwin A 2014

13 Kohdun rakennekuvat Ludwin ja loppuun tulostaulukko Various uterine cavity shapes after hysteroscopy metroplasty. In 132/141 (93, 6 %) cases cavity was normal

14 Uterine septum resection Infertility problem and new investigations. Male factor. No evidence of adhesions in ultrasound or in hysteroscopy

15 Expert s opinion 2014 Dilatation Neovagina operatio Septum resection TAYS + Vecchietti ( 13 kpl/ ) 1-2/month. Spesialist HUS + No need Ambulatory/Day surgery Difficult cases to specialist KYS + No 1-3/yr Specialist OYS + No 1-3/yr Ambulatory Specialist TYKS + Davidov Few Specialist Päivi Härkki (HUS), Kaisa Raatikainen (KYS), Eila Suvanto ja Sari Koivurova (OYS), Seija Ala- Nissilä ja Riikka Aaltonen (TYKS), Pentti Heinonen (TAYS)

16 Case S. 2 preterm pregnancies, on live baby, wants to have a new pregnancy

17 Take home message If you find a septum inside a uterus, describe it thoroughly Use 3D ultrasound and SIS Most cases are asymptomatic If resection is done, use monopolar needle electorode

18 References Uterine septum: a guideline. ASRM pages. Fertility and Sterility 2016 Ludwin A, Ludwin I etc Diagnostic accuracy of three- dimensional sonography compared with office hysteroscopy and its interater/intrarater agreement in uterine cavity assesment after hysteroscopy metroplastu. Fer Ster 2014, 5: Paradisi R, Barzanti R, Fabbri R. The techniques and outcomes of hysteroscopic metroplasty. Curr Opin Obstet Gynecol 2014, 26:

19 Special thanks to: Tuomo Kalliola Kirsi Tiainen Kirsi Väyrynen Synnove Staff, TAYS LOS 3, K- SKS

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