AFTER TWO CONSECUTIVE TRANSABDOMINAL CERCLAGES SUCCESSFUL
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SUCCESSFUL PREGNANCIES AFTER TWO CONSECUTIVE TRANSABDOMINAL CERCLAGES IN UTERUS DIDELPHYS Dr.Kanchana Rajan, FRCOG, Senior Consultant-OBGYN/Muscat Private Hospital Introduction This case is presented for 3 reasons- Patient had 6 miscarriages and two successful pregnancies with a)Dual Pathology- Uterus didelphys, systemic lupus erythematosis,positive antiphospholipid antibodies, the leading causes of recurrent miscarriages. b)Transabdominal cerclage of both uteri, on the right hemi uteri in 2006 and on the left in 2009 c)Cesarean section on both uteri in 2006/2009 and bilateral tubal ligation. Didelphys uterus is a Mullerien abnormality classified by AFS as Class III: i.e. failure of lateral fusion involving both the uterus and vagina without any obstruction, results in the formation of a double uterus, double cervix, and double vagina. It is one of the least com- mon anomalies. Case History 25 yrs old Mrs s with recurrent miscarriages presented in her 5th pregnancy in 2006 at 8 weeks gestation.She is known to have uterus didelphys ,systemic lupus erythematosis with positive APL-antibod- ies. MRI showed double uterus with double cervix and no renal anomalies.The SLE was under remission and she was on Pred- nisolone 10mgm, hydroxychloroquine 200 mg bid. Aspirin and Hep- arin were on for Anti Phospholipid antibody Syndrome. There were no signs of vasculitis or synovitis and her renal functions were normal. She had 4 miscarriages in the past, 2 in first trimester in the left horn and 2 in second trimester on the right. In her 4th preg- nancy she had a McDonalds cerclage but miscarried after PROM at 20 weeks. gestation in rt horn Tac seen on ultrasound Tac of rt uterus-2006---C-section of left uterus--2009 An Ultrasound confirmed the pregnancy in the right uterus. An exam- ination under anesthesia at 11+ weeks confirmed the double cervix but deficient medially. Hence a transabdominal cerclage was per- formed. She had a successful outcome in that pregnancy. At 29 weeks she had premature uterine contractions and abruption.Following an emergency lower segment cesarean section on the right hemi uterus a baby girl was delivered in good condition weighing 1.3 kg, with 200 gms of retroplacental clots.The abdominal cerclage was left in place for future pregnancies.Both the mother and baby were discharged home in good condition. she had 2 more miscarriages at 8 and 13 weeks in 2007 both on the left hemi uterus, for which suction evacuation was performed. In 2009 the gestation was viable in left horn of uterus. At 11+ weeks an abdominal cerclage was performed. The non preg- nant right uterus with TAC was seen in the RT iliac fossa; the left uterus was enlarged to 12 weeks At 31 weeks she was admitted with premature uterine contractions.An emergency cesarean section with bilateral tubal lig- ation was performed and a baby boy weighing 1.450 kg with good agar score was delivered. Discussion Trans abdominal cerclage is performed where vaginal cerclage is unsuccessful. First described in 1965 by Benson and Durfee, the in- dications are absent or very short cervix, severely lacerated vaginal portion of cervix,surgery,trauma,developmental uterine abnormality, previous uterine surgery and failed previous cervical cerclage. 18 cases of dual pathology were studied- with 56% risk of preterm labour when compared to cervical weakness alone-in 18%. Trans- abdominal cerclage(Tac) is a last resort treatment for such patients. In an observational study of 101 patients with classic history of cer- vical insufficiency and traumatised cervix that precludes TVc, TAc had successful outcome but with procedure related complications. References Medscape -Anatomic factors in recurrent pregnancy loss-Anne S.Devi Wold, MD, Division of Reproductive Endocrinology and Infertility,Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut. An Observational cohort study of Outcome after TAc, Obstet Gy- necol-Vol-107,No.4,April 2006.
Transcript of AFTER TWO CONSECUTIVE TRANSABDOMINAL CERCLAGES SUCCESSFUL
SUCCESSFUL PREGNANCIES AFTER TWO CONSECUTIVE TRANSABDOMINAL CERCLAGES
IN UTERUS DIDELPHYSDr.Kanchana Rajan, FRCOG,
Senior Consultant-OBGYN/Muscat Private Hospital
IntroductionThis case is presented for 3 reasons- Patient had 6 miscarriagesand two successful pregnancies with
a)Dual Pathology- Uterus didelphys, systemic lupuserythematosis,positive antiphospholipid antibodies, the leadingcauses of recurrent miscarriages.
b)Transabdominal cerclage of both uteri, on the right hemi uteriin 2006 and on the left in 2009
c)Cesarean section on both uteri in 2006/2009 and bilateral tuballigation.
Didelphys uterus is a Mullerien abnormality classified by AFS asClass III: i.e. failure of lateral fusion involving both the uterus andvagina without any obstruction, results in the formation of a doubleuterus, double cervix, and double vagina. It is one of the least com-mon anomalies.
Case History25 yrs old Mrs s with recurrent miscarriages presented in her 5thpregnancy in 2006 at 8 weeks gestation.She is known to have uterusdidelphys ,systemic lupus erythematosis with positive APL-antibod-ies.
MRI showed double uterus with double cervix and no renalanomalies.The SLE was under remission and she was on Pred-nisolone 10mgm, hydroxychloroquine 200 mg bid. Aspirin and Hep-arin were on for Anti Phospholipid antibody Syndrome.
There were no signs of vasculitis or synovitis and her renal functionswere normal. She had 4 miscarriages in the past, 2 in first trimesterin the left horn and 2 in second trimester on the right. In her 4th preg-nancy she had a McDonalds cerclage but miscarried after PROMat 20 weeks.
gestation in rt horn Tac seen on ultrasound
Tac of rt uterus-2006---C-section of left uterus--2009
An Ultrasound confirmed the pregnancy in the right uterus. An exam-ination under anesthesia at 11+ weeks confirmed the double cervixbut deficient medially. Hence a transabdominal cerclage was per-formed. She had a successful outcome in that pregnancy.
At 29 weeks she had premature uterine contractions andabruption.Following an emergency lower segment cesarean sectionon the right hemi uterus a baby girl was delivered in good conditionweighing 1.3 kg, with 200 gms of retroplacental clots.The abdominalcerclage was left in place for future pregnancies.Both the motherand baby were discharged home in good condition.
she had 2 more miscarriages at 8 and 13 weeks in 2007 both on theleft hemi uterus, for which suction evacuation was performed.
In 2009 the gestation was viable in left horn of uterus.
At 11+ weeks an abdominal cerclage was performed. The non preg-nant right uterus with TAC was seen in the RT iliac fossa; the leftuterus was enlarged to 12 weeks
At 31 weeks she was admitted with premature uterinecontractions.An emergency cesarean section with bilateral tubal lig-ation was performed and a baby boy weighing 1.450 kg with goodagar score was delivered.
DiscussionTrans abdominal cerclage is performed where vaginal cerclage isunsuccessful. First described in 1965 by Benson and Durfee, the in-dications are absent or very short cervix, severely lacerated vaginalportion of cervix,surgery,trauma,developmental uterine abnormality,previous uterine surgery and failed previous cervical cerclage.
18 cases of dual pathology were studied- with 56% risk of pretermlabour when compared to cervical weakness alone-in 18%. Trans-abdominal cerclage(Tac) is a last resort treatment for such patients.
In an observational study of 101 patients with classic history of cer-vical insufficiency and traumatised cervix that precludes TVc, TAchad successful outcome but with procedure related complications.
ReferencesMedscape -Anatomic factors in recurrent pregnancy loss-AnneS.Devi Wold, MD, Division of Reproductive Endocrinology andInfertility,Department of Obstetrics and Gynecology, Yale UniversitySchool of Medicine, New Haven, Connecticut.
An Observational cohort study of Outcome after TAc, Obstet Gy-necol-Vol-107,No.4,April 2006.
