Transcript Surgical management of congenital uterine anomalies

Surgical management of congenital
uterine anomalies
• Surgical repair of congenital uterine anomalies is
primarily directed toward women with uterine
septa, bicornuate uteri, and obstructed hemiuteri.
• Women with unicornuate or arcuate uteri are
generally not candidates for reconstructive
procedures because surgery does not improve
pregnancy outcome
• The most common indications for repair of
congenital uterine anomalies are pelvic pain and
repetitive pregnancy loss.
• Prior to surgical intervention, however, other
causes of these problems should be excluded.
• Dysmenorrhea in women with septate uteri
may be considered an indication for
hysteroscopic metroplasty if medical therapy is
not effective.
• Laparoscopic evaluation for coexistent
endometriosis (common in women with
structural abnormalities of the reproductive
tract) should be undertaken
• Do not believe abdominal repair of the didelphic
uterus to improve pregnancy outcome is
sufficiently supported by existing data.
• Pregnancy outcomes in women with bicornuate
uteri have been reported to be close to those of
the general population.
• However, since some of these women have
recurrent pregnancy loss, surgical treatment
with uterine reunification via laparoscopy or
laparotomy may be indicated after other
possible causes of recurrent pregnancy loss have
been addressed
• Surgical correction is not warranted in
asymptomatic women or those with primary
infertility.
• Uterine abnormalities typically don't prevent
conception and implantation.
• As an example, one series of 228 women with
uterine anomalies noted that 9.1 percent had
primary infertility, and most of these cases could
be explained by other defects
• Most authorities agree that primary infertility in
the presence of uterine anomalies is not an
indication for metroplasty.
• However, metroplasty may be considered after a
complete diagnostic evaluation has been
performed and appropriate therapeutic
interventions have failed.
OBSTRUCTED UTERINE RUDIMENTARY
HORNS
• Women with müllerian aplasia or a unicornuate
uterus and cyclic or chronic abdominal or pelvic
pain may have a noncommunicating uterine horn
with functional endometrium
• MRI or ultrasound are useful in identifying the
noncommunicating uterine horn and determining
whether an endometrial stripe is present.
Right hemiuterus does not communicate with the cervix and
should be removed laparoscopically.
• Patients with an obstructed uterine horn are at
increased risk of endometriosis, but the endometriosis
usually resolves after the removal of the obstructed
hemiuterus.
• Excision of the obstructed rudimentary blind horn will
prevent endometriosis by eliminating reflux, and will
also prevent development of a pregnancy (and
pregnancy complications) in the obstructed uterine
horn
• The obstructed rudimentary noncommunicating
uterine horn should be removed laparoscopically
HYSTEROSCOPIC REPAIR OF THE
SEPTATE UTERUS
• Hysteroscopic metroplasty has become the method of
choice for repair of most uterine septa.
• Benefits to the transcervical approach include less
morbidity, no abdominal or transmyometrial incisions,
and faster return to normal activity.
• As there is no abdominal incision, possible infections
and intra-abdominal adhesions that may cause future
infertility problems or pain are avoided.
• Women may attempt pregnancy sooner after a
vaginal/transcervical approach than after abdominal
procedures.
• Vaginal delivery is not contraindicated.
Smooth broad fundus of septate uterus viewed through a laparoscope
Uterine septum separating uterine
cavity into two horns
• Various techniques and instruments are used
either to incise or remove the septum,
including semirigid or rigid scissors (7
French) or unipolar wire loop (8 mm)
urologic resectoscope (21 to 26 French
sheath); Versapoint bipolar electrode (1.6
mm; 5 mm sheath); or Potassium-titanphosphate (KTP/532), neodynamic:yttrium
aluminum garnet (Nd:YAG), or argon lasers.
Use of any of the above instruments is
associated with good success rates and
infrequent complications.
Use of microscissors or bipolar electrode
may decrease operating time
Postoperative care
• No further treatment is required postoperatively.
• Intrauterine devices, Foley balloons, high-dose
estrogen, and antibiotics are not necessary
• Formation of intrauterine synechiae is rare, as are
postoperative infections.
• Endogenous estrogen is sufficient to promote new
endometrium within two months of hysteroscopic
metroplasty
• An HSG should be performed two months after
surgery to assess success.
• Typically, over 90 percent of the septum is
removed during the procedure.
• Attempts at pregnancy may begin two months
postoperatively if the procedure is deemed
adequate
Outcome
• A meta-analysis of 29 observational studies
that evaluated hysteroscopic metroplasty
in women who were not treated with in
vitro fertilization found a pregnancy rate of
64 percent and a live birth rate of 54
percent after the procedure
LAPAROSCOPIC/ABDOMINAL
TRANSMYOMETRIAL REPAIR OF THE
SEPTATE UTERUS
• Most uterine septums can be successfully
surgically addressed hysteroscopically.
• If however the septum cannot be safely
removed hysteroscopically, then an
abdominal or laparoscopic approach, such as
the Jones or Tompkins metroplasty, can be
used
UTERINE TRANSPLANTATION
• Uterine transplant is a potential option for patients
with Müllerian agenesis and fusion defects (eg,
Mayer-Rokitansky-Küster-Hauser syndrome
[MRKH], congenital absence of the uterus).
• For women with MRKH, approaches to having a
child include adoption, gestational carrier, or
uterine transplant.
• Extensive counseling and discussion should occur
due to the risks and benefits of each option.
• In some parts of the world, gestational carriers are
not legal and thus adoption and transplant are the
only options.
• If a uterine transplant is a possibility, the decision
process includes consideration of the surgical risk to
the donor and recipient, immunosuppressive
medications for the recipient, and the potential
unknown risk to the baby due to in-utero exposure
to the antirejection medications.
• There have been only a few reports of human uterine
transplantation [19-23].
• Donors were deceased [21,24], from mothers to
daughters [20], and from an unrelated friend [23].
• The first live birth after uterine transplantation occurred
in 2014 [23].
• The uterus donor was a 61 year-old unrelated family
friend. The transplant recipient, a 35 year-old woman
with congenital Müllerian agenesis, was delivered via
cesarean at 32 weeks of gestation because of
preeclampsia. The healthy 1775 gram infant was
appropriately grown for gestational age.
• However, in one case, uterine necrosis developed 99 days
after the transplant and required hysterectomy [25].
OUTCOME
• Fetal salvage — Improved fetal survival has been
demonstrated for all of the above described
procedures.
• The successful pregnancy rate after hysteroscopic
metroplasty is 85 to 90 percent, which compares
favorably with preoperative fetal salvage rates of 5
to 10 percent
Reduction in pregnancy complications
• The frequency of malpresentation, retained
placenta, and intrauterine growth restriction
associated with müllerian abnormalities
should return to that of the general
population after repair. It is unclear whether
there is an improvement in preterm birth rate
Reduction in dysmenorrhea
• A prospective study of dysmenorrhea
reported by women who underwent Tompkins
(n = 28) or hysteroscopic (n = 62) metroplasty
for septate uteri found that the frequency of
dysmenorrhea fell from 50 to 32 percent after
the Tompkins procedure and from 55 to 18
percent after hysteroscopic treatment [42].
COMPLICATIONS
• There is an increased risk of uterine rupture with
procedures requiring fundal hysterotomy.
• Most authors recommend cesarean delivery for
these women.
• attempted vaginal delivery is generally
recommended after these procedures in the
absence of other obstetrical indications for
cesarean birth
• In complex uterine anomaly cases, an option of
adoption or gestational carrier should be
addressed with the patient.