MFD.
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Transcript of MFD.
Mounir M. Fawzy El-HaoProf. in Ob/Gyn
Ain Shams UniversityCairo - Egypt
Incidence of Mullerian Abnormalities
General population Unknown0.1 1.5% (Rudigozand Dorgent, 1985)
HSG in infertility 1-3% (Ludmir et al., 1990)
Women with reproductive difficulties1-12% (Rock and Schlaff, 1985)
Incidence:
15 – 25% of spontaneous abortions are
caused by Mullerian fusion defects
(Portuonodo et al., 1986)
Simple classification of Mullerian anomalies:
1. Agenesis (R-K.H-Syndrome)
2. Problems of vertical fusion Obstructive Non-obstructive
3. Problems of lateral fusion Obstructive Non-obstructive
Agenesis (RKH syndrome)
Surgically corrected for sexual function
Mc indoe’s
William’s
Modified vicchietti
Remember …
Problems with vertical fusion represent a fault in the function between the down-growing Mullerian ducts (tubercle) and the up-growing derivative from the urogenital sinus
Remember …
Problems of lateral fusion of the two Mullerian ducts are especially note worthy in that obstructive lesions seem to have been observed clinically only when the obstruction was unilateral (absent kidney) i.e. (if bilateral = nonviable)
Remember …
Attention to obstructive lesions is often urgently necessary to prevent deterioration of reproductive capacity from retained mucous or menstrual blood
Classification of LFD.
Septum Resction
Pregnancy rate
Topkins laparotomy procedure is 71.4%
Hysteroscopic resection of septum is 84%
(Fayez, 1986)
Vaginal delivery
Topkins laparotomy 80%
Hysteroscopic metroplasty
76%(Fayez, 1986)
Hysteroscopic resection of the
uterine septum was first
described by Edstrom in 1974
DIAGNOSIS.HSG.LAPAROSCOPY.HYSTEROSCOPY.MRI.3DIMENSION US.
Diagnosis:Difference between the data obtained by HSG and those by hysteroscopy as regards the length of the septum, was due to dispersion of the dye around the septum on both sides, which faded the septum that disappears especially in the lower part
(Kesler and Lancet, 1986)
LAPAROSCOPY.
VISUALISES THE OUTSIDE OF THE UTERUS.
HYSTEROSCOPY
VISUALISES THE INSIDE OF THE UTERUS.
THREE DIMENSION US VISUALISES THE INSIDE OF THE UTERUS,THE CAVITY AND THE OUUTSIDE..
Septate uterus.
MRI septate uterus ?
Laparoscopy broad fundus.
SEPTATE BY 3D.
LARGE BASE SEPTUM
DISTORTED SEPTATE ? TB.
Septate with two cervicies.
Told unicornuate.
Told unicornuate.
WRONG DIAGNOSIS BY HSG(end on x ray)
(Portuonod(Portuonodo (Portuonod(Portuonodo
et al., 1986)et al., 1986)
o et al., 1986)o et al., 1986)
Unicornuate uterus by HSG.
Laparoscopy unicornuate uterus.
Unicornuate uterus.
URINARY BLADDER.
HAEMATOMETREIA
Abnormal uterus by three D US.
Endometrium of each uterus shows triangular cavity.
Unequal double uterus.
Remember …
Primary infertility in a patient with a symmetrical double uterus (bicornuate or septate) is sometimes observed, but the etiological relationship between the infertility and the anomaly is an unresolved problem
(Howard Jones, 1983)
Remember …
It is seldom that a bicornuate uterus needs surgical reconstruction. It follows that almost invariably if a double uterus gives reproductive problems which require surgical correction, it is the septate uterus which will be involved
(Howard Jones, 1983)
Recurrent pregnancy loss in septate uterus
Poor blood supply
Poorly developed endometrium
Inability to expand
Abnormal uterine contraction
(De Cherney et al., 1986)
Timing
Follicular phase, when
pregnancy is unlikely and the
endometrium is thin, tubal
ostea are well apparent
Technique
Down up or side to side?
Knife or loop?
Diathermy or scissor
One or two sittings?
Technique Medium used:
Gas: smoke and bubbles and thermal effectGlycine: no electric conduction, cooling effect
of electric current
Technique Because the resectoscopic electrode also provides coagulation while the septum is incised, vessels at the fundal region may not bleed upon division, depriving the hysteroscopist of their landmark when the myometrium is reached
SEPTUM RESECTION.
Complications PerforationPerforation33 casescases
HemorrhageHemorrhageNoneNone InfectionInfectionNoneNone
IUSIUSMinor (7 cases)Minor (7 cases)
Major (None)Major (None)
Complications Cervical laceration and uterine perforation
during introduction of the scope
Distention media complications
Deep dissection problems (bleeding, IUS)
Incidence of different complaints in patients with uterine septum
Main ComplaintMain ComplaintNo of No of patientspatients%%
Repeated abortions*Repeated abortions*636366.366.3
Unexplained infertilityUnexplained infertility242425.225.2
DysmenorrheaDysmenorrhea555.35.3
Irregular uterine bleedingIrregular uterine bleeding333.23.2
TotalTotal*repeated abortions=2 or *repeated abortions=2 or more spontaneous more spontaneous miscarriages.miscarriages.
9595100100
Correlation between hysteroscopy and HSG in women with uterine septae
Degree of the septumDegree of the septumHSGHSGHysteroscopyHysteroscopy
CompleteComplete36364141
2/32/3 40403838
1/31/319191616
TotalTotal95959595
Correlation of number of repeated abortions and number of patients (63 cases)
No of abortionsNo of abortionsNo of patientsNo of patients%%
22383860.360.3
33191930.230.2
> >44669.59.5
TotalTotal6363100100
Operative details of 95 cases of uterine septae resection with resectoscope
Operative detailsOperative detailsMean dataMean data Operating timeOperating time1515 ± ±44( ( minmin)) Average amount of distention Average amount of distention mediamedia12751275 ± ±5656( ( mlml))
Deficit of mediumDeficit of medium210210 ± ±550550( ( mlml)) Intra-uterine FoleyIntra-uterine Foley’’s catheters catheter1919 casescases None intra-uterine None intra-uterine 7676 casescases Postoperative antibioticsPostoperative antibiotics 87cases87cases
Obstetric performance (follow up 24 months)
DefaultersDefaulters2323 casescases24.2%24.2% Spontaneous Spontaneous abortionabortion66 casescases6.3%6.3%
Preterm laborPreterm labor77 casescases7.4%7.4% Term laborTerm labor4848 casescases50.5%50.5%
No pregnancyNo pregnancy1111 casescases11.6%11.6%
TotalTotal9595 casescases100%100%
Remember …
The main reason for performing hysteroscopic metroplasty is for poor pregnancy outcome, recurrent pregnancy loss and infertility
Why hysteroscopic?Outpatient basis
No abdominal or uterine scar
Minimal postoperative morbidity
No reduction in uterine volume
Pregnancy attempted soon after the operation
(Fayez, 1986 – Daly, 1983)
THANK YOU FOR YOUR ATTENTION..