Clinical approach and management of uterine incarceration according to trimester of pregnancy: Case report and literature review

ObjectiveThe purpose of present report is an effective clinical approach to incarcerated uterus by the trimester of pregnancy, in this case and 54 cases reported previously.Case ReportA woman at 18 + 5 weeks of gestation was referred with abdominal pain and urinary dysfunction. In pelvic examination, the cervix was not seen and huge myoma was located at retroverted anterior uterine wall and the elongated cervix was pulled up above the bladder in ultrasonography. The uterine incarceration was confirmed by magnetic resonance imaging. The manual reduction of uterus was attempted with knee-chest-position repeatedly. However, this was unsuccessful because large fibroid was impacted and immovable. Therefore, laparotomy was conducted for repositioning of uterus. Pregnancy was maintained without any complication and a 4250 g healthy female infant was delivered by cesarean section.ConclusionBy analyzing of several cases, useful diagnostic modalities and effective management should be approached according to trimester of pregnancy.     

Auto-transplantation of the uterus in the domestic pig (Sus scrofa): Surgical technique and early reperfusion events

AIM: To develop a method for auto-transplantation of the uterus in the pig and to evaluate the early reperfusion events after short-term cold ischemia. METHODS: The bicornate uterus, with the cervix but without ovaries, was dissected and isolated with its bilateral feeding and draining vessels. The uterine arteries were cannulated in situ and the uterus was flushed with heparinized Ringer Acetate. It was stored at 4 degrees C for 1-2 h during continuous flushing. The uterus was then placed in its original pelvic position and the uterine arteries and veins were anastomosed end-to-end to their origin. During approximately 100 min of reperfusion, blood samples and tissue biopsies were taken for monitoring of reperfusion events and detection of ischemia-reperfusion injuries. RESULTS: Out of 19 auto-transplanted pigs, seven were considered well flushed and were kept for cold ischemia. Of these seven, four showed satisfactory reperfusion judged by change in gross appearance and presence of appropriate venous blood flow. Analysis of blood-gas and metabolite parameters and histology indicated that at least two of these transplants were well reperfused, with no severe ischemia-reperfusion injuries. CONCLUSION: In this first report ever on auto-transplantation of the pig uterus it is demonstrated that an acceptable reperfusion can be achieved. Furthermore, it is suggested that because of the large total size of the pig uterus with long uterine horns and the small size of the vessels available for re-anastomosis, the pig is a fairly difficult model for further studies on transplantation of the uterus.     

残角子宫的腹腔镜手术

目的:探讨残角子宫腹腔镜手术的临床价值。方法:回顾性分析应用腹腔镜诊断及治疗的13例残角子宫的临床资料。结果:13例患者均在腹腔镜下确诊,其中10例联合宫腔镜进行诊治。11例成功在腹腔镜下手术切除残角子宫,术中出血少,疗效满意;另2例无需处理。结论:腹腔镜技术是诊治残角子宫的理想方法,必要时联合宫腔镜检查。腹腔镜手术切除残角子宫是安全有效的,值得推广。     

Colonoscopy-assisted reposition of the incarcerated uterus in mid-pregnancy: a report of four cases and a literature review

The treatment of mid-gestational uterine incarceration remains a challenge. The success rate of manual reduction decreases with gestational age, and an operative procedure may carry important fetal, next to possible maternal morbidities. We will present four cases of uterine incarceration between the 15th and 25th week of pregnancy of which three colonoscopy-assisted manual repositions proved successful. It illustrates that conservative treatment of uterine incarceration is feasible, even during the late second trimester. That is why a review of the conservative approach of this rare condition is also presented.     

Lymphatic vessels in the uterine endometrium of virgin rats

Uteri from four diestrous rats fixed by perfusion were examined histologically for the presence of lymphatic vessels in the endometrium, using 1 micron epoxy sections stained with toluidine blue. For each animal, multiple random sections were prepared from 3 tissue samples. In all sections, lymphatics were readily apparent in the myometrium, being identified by their irregular shape and contents of stained lymph proteins, which contrasted with the clear, empty blood vessels. While similar lymphatics were not seen in the endometrium of most tissue samples, one sample from each of three females revealed a small lymphatic vessel near the bases of the uterine glands, clearly in the endometrium. One of these was followed in serial alternating light and electron microscopic sections. The vessel maintained its relative position to the endometrial glands for a considerable distance, and also joined with two separate branches that appeared along its course. Ultrastructural observations, including a thin endothelium without a continuous basal lamina, the presence of anchoring filaments, and only mononuclear cells and cellular debris in the lumen, confirmed the vessel's identification as a lymphatic. The vessel's size was normally large enough to be followed by light microscopy; however, at some places along its course, the lumen narrowed to such a degree that it was only identifiable ultramicroscopically . These observations refute claims that there are no lymphatic vessels in rodent uterine endometrium, but indicate that they are small and sparsely distributed.     

Laminaria dilatation and evacuation for pregnancies with mid-trimester premature rupture of membranes: a retrospective cohort study

Objective: To assess the efficacy and risk of chorioamnionitis with laminaria tents and uterine evacuation in patients with mid-trimester premature rupture of membrane (MPROM). Study Design: A retrospective cohort study of 34 women, admitted between January 1995 and May 1999 with confirmed mid-trimester (14–23 weeks) PROM and 34 controls matched for gestational age, undergoing elective termination. All women underwent cervical dilatation by the use of laminaria tents followed by uterine evacuation (D∝E). Perioperative complications were retrieved from the medical records and long-term ones by telephone questionnaire. Results: Apart from one case requiring a change in antibiotic, no short- or long-term complications were reported. Although, in 8 out of 19 study cases (42%) endocervix culture was positive. The number of laminaria tents used was similar in both groups. The future pregnancy rate was higher in the study group but included four early spontaneous abortions and one ectopic pregnancy. Conclusion: Evacuation of uterus following cervical dilatation by laminaria tents in patients presenting with MPROM is safe, and probably not associated with future adverse pregnancy outcome.     

妊娠期子宫及宫旁静脉破裂出血6例诊治分析

目的 探讨妊娠期子宫及宫旁静脉破裂出血的诊断,治疗及孕妇、胎儿预后。方法 回顾性分析台州市中心医院2001年1月至2012年8月收治的6例子宫及宫旁静脉破裂出血的诊治过程。结果 6例孕妇均以无明显诱因的剧烈腹痛症状就诊,超声检查腹腔中均见游离液体,其中3例见血肿形成,腹腔穿刺均抽出不凝血,均行开腹探查,1例中孕单胎行缝扎和明胶海绵填塞止血,保守治疗至足月后剖宫分娩,胎儿存活,4例晚孕单胎立即行剖宫产,胎儿存活,1例中孕双胎行剖宫产,胎儿死亡。结论 超声提示腹腔积液,腹穿抽出不凝血并排除其他可能病因,术前可以做出子宫及宫旁静脉破裂出血的诊断,及时治疗能提高围产儿生存率。     

Differentiating Between Septate and Bicornuate Uterus: Bi-dimensional and 3-Dimensional power Doppler Findings

Study ObjectiveTo assess if any difference could be found in uterine vascularization between septate and bicornuate uterus.DesignPilot study (Canadian Task Force classification II-2).SettingUniversity hospital infertility clinic.PatientsOne hundred nine women with complete duplication of the uterine cavity. All had already received the final diagnosis of the type of uterine malformation, either septate uterus or bicornuate uterus, via diagnostic hysteroscopy and laparoscopy. Another group of 10 patients with uterine anomalies and affected by ovarian mass were also evaluated via intravenous contrast medium–enhanced ultrasound examination.InterventionsPatients were evaluated using 2-dimensional and 3-dimensional power Doppler imaging of the uterus.Measurements and Main ResultsSeventy-three patients with septate uterus, with or without cervical and vaginal duplication, and 36 patients with bicornuate uterus were selected for inclusion in the study. Irregular vascular networks were detected between the 2 hemicavities in the patients with septate uterus. All bicornuate uteri showed a peculiar vascular network between the 2 hemicavities: the main recognizable vessels formed a network depicting the Greek letter γ at the level of the uterine midline. Detection of the γ sign can be used to differentiate septate from bicornuate uterus. This finding was also confirmed in patients who underwent intravenous contrast medium–enhanced ultrasound examination.Conclusionspower Doppler provides a new and uninvasive tool for differentiation of septate from bicornuate uterus.     

Pre-operative ultrasonographic evaluation of nongravid, enlarged uteri - correlation with bimanual examination

Objective: To correlate the size of the nongravid uterus measured by ultrasound and bimanual examination before hysterectomy, with the actual size of the specimens. Patients and Methods: Uterine size of 49 consecutive patients, who underwent elective hysterectomy, was assessed by bimanual pelvic examination, preoperative ultrasonographic evaluation and actual postoperative size. Results: All preoperative ultrasonographic uterine dimensions significantly correlated with the corresponding actual dimensions of the uterine specimens. Furthermore, ultrasonographic uterine length had the best correlation with uterine size estimation by bimanual examination. A formula was established in an attempt to calculate clinical uterine size by gestational week, using preoperative ultrasonographic dimensions. Conclusions: By using the aforementioned formula, ultrasonographic uterine dimensions can be extrapolated to uterine size in terms of gestational week, and therefore, be applicable to traditional clinical practice.     

双子宫和纵隔子宫与复发性流产的关系及处理

Abstract:Uterus didelphys and septate uterus is the most common uterine malformation,and is one of the causes of recurrent spontaneous abortion.Septate uterus has the highest abortion rate.The two-dimensional ultrasound can be used as a uterine malformation screening method.Color Doppler can be used to detect a higher incidence of mediastinal blood flow by abortion,to help prediction of mediastinal uterine abortion.3D ultrasound is the preferred method for the diagnosis of uterine malformations.Mediastinal resection can significantly improve the reproductive prognosis of septate uterus.Double uterus generally does not need orthopedics surgery. Orthopedics of the other types of uterine malformations is perhaps helpful for the prevention of miscarriages. Patients with uterine malformations are easily combined cervical incompetence,uterine malformations,but unconfirmed merger cervical insufficiency,lack evidence of prophylactic cervical cerclage.     

不锈钢O型宫内节育器的脱落与宫腔形态及收缩压力关系的研究

本文用国产GCH—Ⅰ型宫腔测量器对143例育龄妇女进行宫腔测量,模拟出宫腔形态,探讨不锈钢O 型宫内节育器(IUD)脱落原因。通过测量,80%左右的宫腔近似等腰或等边三角形;14～20%的妇女宫腔下段过窄或过宽。从13例数次脱环者中看出,这些不规则的宫腔形态是IUD 脱落的主要原因之一。对23例妇女置器前后子宫收缩压力测定表明,宫腔内有器时,其子宫收缩压力比无器时大,t 检验结果(P<0.05)有显著性差异。但置器后一周宫缩的振幅又恢复正常,说明单纯置器后在正常范围内的宫缩并不致引起脱落。不锈钢O 型宫内节育器的脱落与不规则的宫腔形态有一定关系。     

Staircase sign: a newly described uterine contraction pattern seen in rupture of unscarred gravid uterus

Although extremely rare, rupture of an unscarred gravid uterus poses significant morbidity and mortality to both fetus and mother. In the past, loss of uterine contraction was thought to be characteristic of uterine rupture, while recent evidence shows that uterine contraction pattern is not associated with uterine rupture. We report two cases of rupture in the unscarred term uterus. Both patients were multiparous and denied any past medical complications, previous cesarean delivery or myomectomy. Uterine rupture occurred in the latent phase of labor at 1 cm dilation (Case 1) and during an intravenous oxytocin infusion after three doses of intravaginal misoprostol (Case 2). Case 2 required cesarean hysterectomy and blood transfusion. Case 1 was monitored with an external tocodynamometer, while Case 2 was monitored with an internal pressure transducer. External monitoring demonstrated the classic sign of complete loss of uterine tone. In contrast, internal monitoring demonstrated an increase in uterine resting tone. Both techniques revealed a stepwise gradual decrease in contraction amplitude followed by sudden onset of profound and prolonged fetal bradycardia (staircase sign). In cases of uterine rupture, differing baseline characteristics between contraction patterns were dependent on uterine monitoring technique. In both techniques a stepwise gradual decrease in contraction amplitude was followed by prolonged fetal bradycardia.     

Uterine rupture: differences between a scarred and an unscarred uterus

OBJECTIVES: This study aimed to compare risk factors, site of rupture, and outcome of uterine rupture among patients with a scarred versus an unscarred uterus.Study design We conducted a comparison between all cases of uterine rupture (n=53) in women with a scarred versus an unscarred uterus, occurring between January 1988 and July 2002. RESULTS: During the study period, there were ruptures among 26 patients with a scarred uterus and 27 patients without a uterine scar. No significant differences were noted between the scarred and unscarred groups while comparing risk factors such as birth order, birth weight, hydramnios, oxytocin induction, diabetes, and malpresentation. The main site of involvement in both groups was the lower uterine segment representing 92.6% of the ruptures in the unscarred group and 92.3% of the ruptures in the scarred uterus group. Cervical involvement was significantly more common among patients without a previous uterine scar (33.3% vs 7.7%; odds ratio [OR]=6.0, 95% CI, 1.16-31.23, P=.04). Conversely, uterus corpus involvement did not differ between the groups. Perinatal mortality did not differ between the groups. In addition, no significant differences were noted regarding maternal morbidity such as the need for hysterectomy, blood transfusion, or length of hospitalization. CONCLUSION: Although cervical involvement was significantly more prevalent in the rupture of an unscarred uterus, no significant differences in maternal or perinatal morbidity were noted between rupture of a scarred versus an unscarred uterus.     

Endometrial carcinoma arising in one horn of a didelphys uterus

ObjectiveEndometrial cancer in uterine anomalies is very rare. Currently, few cases with endometrial cancer coexistent with didelphys uterus are described. We present a case of a patient with carcinoma in one only horn of a didelphys uterus.Case reportA 50-year-old woman presented with abnormal uterine bleeding. Uterine anomaly was uncertain on initial clinical examination and pelvic ultrasonography. The MRI study showed double uterus and cervixes, a uterine didelphys was suspected. Preoperative histology from curettage described endometrioid adenocarcinoma. The patient underwent laparoscopic hysterectomy with surgical staging. Macroscopic examination revealed a didelphys uterus, and the final histology confirmed the diagnosis of uterine cancer.ConclusionThe coincidence of uterine malignancies and uterine anomalies is rare; however, it should be aware of uncertain diagnosis and delaying of treatment.     

Ultrasonographic assessment of weight of the myomatous uterus: a pilot study using a new combined geometrical formula

OBJECTIVE: To evaluate the accuracy of a formula combining the prolate ellipsoid (uterine corpus) and cylinder (uterine cervix) formulas in estimating the preoperative weight of the total uterus using a transvaginal ultrasound probe to obtain the uterine dimensions for the formulas. STUDY DESIGN: Three dimensions of the uterine corpus (length, width and anteroposterior diameter) and cervical length and cervical anteroposterior diameter were preoperatively determined using a transvaginal ultrasound probe in 12 women with symptomatic leiomyomas scheduled to undergo hysterectomy. In two patients whose uteruses were the largest, part of the measurements had to be taken with a transabdominal ultrasound. Three investigators repeated all the rounds of measurements three times, producing in total 108 of findings (12 subjects x 3 investigators x 3 rounds of measurements). The geometric formula of prolate ellipsoid was compared to a formula combining the ellipsoid and cylinder formulas for accuracy in predicting overall uterine size (corpus and cervix) through correlation with hysterectomy specimens. The weight of the uterus in grams was directly derived from the volume of the uterus. RESULTS: All measurements of the uterine corpus and cervix could be obtained preoperatively with a transvaginal ultrasound probe except in two patients who had the largest uteruses. The plain, traditional formula for the prolate ellipsoid overestimated the weight of the uterus and differences between the estimated and the true weight were statistically significant. The difference was not significant when the formula combining the formulas of the prolate ellipsoid and cylinder was used. CONCLUSION: The new formula combining the prolate ellipsoid and cylinder formulas is more accurate in predicting the true total weight of the uterus than the plain prolate ellipsoid formula. The transvaginal ultrasound probe proved useful in evaluating the dimensions of the uterine corpus and cervix.     

Nondescent vaginal hysterectomy: a constantly improving surgical art

Objective

This study was undertaken to check the feasibility of the vaginal route as the primary route for all hysterectomies, in the absence of uterine prolapse, for benign conditions.

Methods

During 2005 to 2007 an effort was made to perform as many hysterectomies vaginally with or without oophorectomy in women with benign or premalignant conditions in the absence of prolapse. Severe endometriosis, immobility of the uterus, uterine size more than 18 weeks and malignancy were excluded. Patients were classified into two groups — Group I — uterine size up to 12 weeks, with no risk factors and Group II — uterine size 12–18 weeks or with confounding factors like, mild to moderate endometriosis, nulliparity or LSCS in the past. The outcome was compared between the two groups and abdominal hysterectomies done for benign conditions. Statistical analysis was done by SE(d) between mean and proportion.

Results

A total of 164 cases nondescent vaginal hysterectomies were done. Of these, 92 (56.1%) were in group I and 72 (43.9%) in group II. The operation time in Group II was significantly more than in group I (81.3 minutes with SD of 31.4 s. 62.6 minutes SE(d) between 2 means-7.49). Debulking techniques were required in 58.7% of the cases in group II compared to 2.1% in group I. Both the groups had one conversion each. The peroperative blood loss, pain score, hospital stay and return to normal activity, was comparable in both the groups of vaginal hysterectomy (VH) and significantly superior to those undergoing abdominal hysterectomies for benign conditions.

Conclusion

The vaginal approach is possible in most benign conditions requiring hysterectomy and is superior to the abdominal route with respect to recovery and complication rates.     

Tubal and uterine motility in vivo in the rhesus monkey

Previous data indicate that there are definite qualitative and quantitative patterns of tubal activity during the various phases of the menstrual cycle. In the present investigation, the simultaneous activity of the uterus and Fallopian tube was recorded in vivo in mature rhesus monkeys throughout the menstrual cycle. The observations indicate that there are characteristic patterns of both tubal and uterine activity, depending on the various phases of the menstrual cycle. The simultaneous recordings of tubal and uterine activity show that the tubal and uterine contractions are not synchronous or even have a similar pattern. The presence of a transmetrial catheter for recording of uterine activity seems to modify the patterns of tubal activity, particularly during the ovulatory phase. It seems possible that the transmetrial catheter has a similar effect as an intrauterine contraceptive device in this species.     

Some features of the developmental uterus in human fetuses

Abstract

Proper development of each component of the reproductive tract is imperative for successful natural reproduction. The aim was to investigate some morphological features of the fetal uterus in early phases of its development. The uteruses of 65 fetuses of different gestational age were included and each of them was measured in three dimensions: uterine length (UL), uterine width (BC) and the antero-posterior (sagittal) thickness of the uterine fundus (FT) using ImageJ computer program. It was observed that the most intense fetal uterus growth occurred between seventh and eighth month of gestational age (between week 25 and 31). The most intense rate of uterine growth had UL and it showed steeper growth curve from the fourth month of gestational age. The values of UL, BC, FT showed statistically highly positive Pearson’s linear correlation with values of CRL, and GA, and among themselves. The strongest correlation was between UL and gestational age. Contrary to proved rising linear trends of UL/FT and UL/BC, BC/FT performed linear trend of decline. However, two divergent linear trends, one ascending (UL/FT), and other declining (BC/FT) have similar descent in values during the early gestational age, from week 12 to 15. Fetal uteruses did not grow at the same rate by all three measured dimensions, and each of measured dimensions has noticeable standard deviations during gestational periods, even with a resolution of a week, suggesting individuality of each human development/growth even during prenatal life.     

疤痕子宫短期内妊娠的安全性分析

目的:了解子宫手术疤痕形成后两年内妊娠的结局,并评估疤痕子宫再次妊娠的安全性和可行性。方法:收集我院2003年1月1日至2009年4月30日101例子宫疤痕形成后两年内妊娠的中晚期孕妇,前次手术系子宫肌瘤剔除术43例(42.6%),前次手术系剖宫产58例(57.4%)。分析再次妊娠原因、再次妊娠距离前次手术的时间、再次妊娠的结局。结果:不同部位、不同大小肌瘤、不同手术途径、肌瘤剔除术后不同阶段的妊娠结局,差异均无统计学意义(P>0.05)。结论:有妊娠要求的疤痕子宫患者可考虑手术6个月后开始妊娠,但应密切注意子宫收缩情况和予以适当的产科处理。     

Uterine lipoma and coincidental cervical cancer: a case report

Pure lipoma of the uterus is a rare clinical event, and only a few cases have been reported in the literature. Clinical symptoms and physical signs are similar to those found in leiomyomas. The histogenesis of these lesions is still unclear. However, adipose metaplasia of stromal cells or smooth muscle cells of leiomyoma were accepted hypothesis that explain histogenesis of lipomas of uterus. We report the case of a 55-year-old woman with pure uterine lipoma and coincidental cancer of uterine cervix.