Download 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 hemi-uteri.
• 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-titan-phosphate (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.