Uterus reconstruction

[s42brown]

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I was involved in a c-section in which the patient had a bicornuate uterus. The patient was G3 P1102 with her first child born at 35wks in the right horn of her uterus. Her second child was born at 38 wks again in the right horn. Her third child was born premature at 35 wks in the left horn of her uterus. I wrote the case up and noticed that the patient was a candidate for uterine metroplasty. As a MSIII I have only complete one ob/gyn rotation and never saw any prodecure like this. My question is who would do this, would a general ob/gyn perform such a procedure or does this fall into the realm of Urogyn/pelvic reconstruction? Mullerian system malformations are very interesting to me and as a future ob/gyn would this be something that I may perform someday on one of my patients, or turf it to one of the specialist? 🙄 😎

 

[starayamoskva]

I was involved in a c-section in which the patient had a bicornuate uterus. The patient was G3 P1102 with her first child born at 35wks in the right horn of her uterus. Her second child was born at 38 wks again in the right horn. Her third child was born premature at 35 wks in the left horn of her uterus. I wrote the case up and noticed that the patient was a candidate for uterine metroplasty. As a MSIII I have only complete one ob/gyn rotation and never saw any prodecure like this. My question is who would do this, would a general ob/gyn perform such a procedure or does this fall into the realm of Urogyn/pelvic reconstruction? Mullerian system malformations are very interesting to me and as a future ob/gyn would this be something that I may perform someday on one of my patients, or turf it to one of the specialist? 🙄 😎

I am not sure that the patient you describe would be a candidate for uterine metroplasty. She has had three successful pregnancies and a metroplasty is not a benign procedure and she has proven her ability to carry a pregnancy to near term/term. The surgery would put her at high risk of uterine rupture if she chose to get pregnant again possibly leading to the death of herself and the unborn child.
This one falls under the realm of just because we can do it doesn't mean we should do it.

 

[s42brown]

Thank you for the response.

That is the impression I got from the case. However, with her first pregnacy ending in a premature birth and her wish of future pregnancies it seems like a metroplasty would be a good option. From what I found in the most recent literature the risk of uterine rupture is very slim, in fact one article stated that many of the women went on to have vaginal deliveries. I think we can agree this is not the typical outcome of a complete bicornuate uterus producing three healthy kids. I didn't mention that on delivery we found remnants of an incomplete SAB in her right horn. Who knows if she could have had twins with the procedure.

I still would like to know were this procedure falls under the ob/gyn umbrella.

 

[community]

I saw cases like this quite a bit in the past month where I worked at a reproductive endocrinology and infertility (REI) clinic. The doc that I worked with said the the best prognosis was a bicornate uterus, rather than a septate uterus. In the case of the bicornate uterus, the embryo implants in either horn, and a baby can be carried to term. With a septate uterus, surgical ablation (via laser) may be recommended depending on the depth of the septum. Even after surgery, the embryo can implant on the scar and the miscarriage rate is high. The long of the short is that an REI specialist may be the best person to hand this case over to, unless this is something that you see a lot and have experience with.

community

 

[Diane L. Evans]

one of the risk factors for prematurity is uterine anomaly also these infants often will have IUGR.

Metroplasty is not typically done these days as there is a very high risk of uterine rupture (maternal and fetal death) requring amnio and c section at 35-37 weeks. Also the patient you decribed had a late preterm delivery and thus would not be candidate for metroplasty.

I think there is a crucial piece of information you need here. To enhance your leaning stop by the NICU and ask the peds residents what the complications are at 24-28 weeks 29-32 weeks, 32-34 weeks, and 35-37 weeks. At 35 weeks at worst case infants are on cpap with minimal feeding difficulties which may require a feeding tube-- time in hopsital varies usually wt dependent 1-2 weeks

 

[s42brown]

😀 Thanks for the info. I figured this procedure must be pretty rare, we never learned about it in our womens health class in second year. Either way I thought it was a good case to write up for one of my required presentations. 😀