Kirbe A. Labarcon

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OB-OB-GynecologyGynecology

ACase Presentation

Angealyn A. GealonDMSF-PGI 2012

Davao Medical School Foundation HospitalMedical Drive, Bajada, Davao City

What is the True essence What is the True essence of Being A Woman?of Being A Woman?

BIRTH

GENERAL GENERAL DATADATAP.B.29 G2P1 (1001)MarriedBajada, Davao

CityDoA: May 28,

2012 9:40 PM

CHIEF CHIEF COMPLAINTCOMPLAINTVaginal Vaginal

SpottingSpottingLMP: September (2nd wk), 2011 5days X 2-3 pads/day

PMP: August 2011 4-5 days X 2-3 pads/day

HISTORY OF PRESENT HISTORY OF PRESENT ILLNESSILLNESS

+Irregular, tolerable uterine +Irregular, tolerable uterine contractions,contractions,

+ associated with fetal + associated with fetal movementmovement

-Vaginal dischargesVaginal discharges

(-)signs & symptoms(-)signs & symptoms

-Consultation-Consultation

In the MorningIn the Morning+persistent uterine +persistent uterine contractioncontraction

-no other associated -no other associated symptomssymptoms

+ Routine PNCU + Routine PNCU IE=1cm dilatationIE=1cm dilatation

+Advised admission+Advised admission x3 daysx3 days

Metronidazole 500mg/tab Metronidazole 500mg/tab BIDBID

Nifedipines 5mg/tab QIDNifedipines 5mg/tab QIDDuvadilan Tab TIDDuvadilan Tab TID

+ Tolerable uterine + Tolerable uterine contraction contraction -Vaginal spottingVaginal spotting+Routine PNCU+Routine PNCU IE= 1cm dilatationIE= 1cm dilatation

-admission for -admission for scheduled CSscheduled CS

Work up

Fig.1 A) Ultrasound image B) Biophysical Score C) Ultrasound Report

Admitting Impression: PU 35 2/7 wks AOG, CILP, G2P1 (1001)ABDOMEN: L1Breech L2Right L3Cephalic FH: 33cm EFW: 3.03kg FHT: 145-150bpm Cephalic presentationINTERAL EXAMINATION:External Genitalia: Grossly normal Cervix: Length: 3 cmVagina: (+) thick whitish vaginal discharge Dilatation: 1 cm

Effacement: Closed % Posterior IBOW Station -3

LABORATORIES: CBC, PC; UA; Gram Stain of Vaginal discharge; BPSFINAL DIAGNOSIS: PU 35-36 wks AOG, IPTL-Controlled, G2P1 (1001) Previous CS (Uterine Didelphys) Bacterial Vaginosis

ABC

ᵜBajada, Davao CityᵜMarried with 1daughterᵜNon-smokers ᵜEmployed:Certified Public AccountantᵜAbove minimumᵜNon-smokerᵜNon-alcoholic beverage drinkerᵜNo food preference or special diet regimen.

INTERNAL[ + ] HPN (Father – unknown maintenance med)[ + ] DM (Father – unknown maintenance med)[ - ] Heart Diseases[ - ] Asthma[ - ] No similar illness to that of the px

SurgicalSurgical

(-) HPN (+) Allergies(-) DM + Meds: NSAIDS(-) Asthma - Foods

Denies previous hospitalizationDenies previous surgical operation

No psychiatric historyPsychiatricPsychiatric

MedicalMedical

Family Size : 4Menarche : 18 yoCoitarche: 21yrs old X 1 sexual partnerOCP: (-) usage Menstrual cycle: 28-35days X 5days X 3soaking pads/day

PregnancyOrder

PregnancyOutcome Year Gestation

Completed Sex Birthweight PresentStatus Complications

G1 LSTCS 2011 FT F 2.85kg Healthy none

G2 -present pregnancy-

OB-Score

Present Pregnancy LMP: September 13, 2011 X 5days X 2-3soaking pads/day DATE OF QUICKENING : December, 2011 (~3mons AOG)EDD: June 20, 2012AOG: 37 6/7 weeksULTRASOUND : >5x (1st: October, 2011; ~8weeks AOG) (last: May 18, 2012; ~35 3/7wks AOG)PRENATAL VISIT: >x5HEALTHCARE PROVIDER: OB-GynecologistIMMUNIZATION: OCP: (-) Tetanus (-) Hep B (-) others

Total Weight Gain: 65 -52 = 13klg BP: 120/80mmHg Hgb: 119 g/dL Urine Lab: Normal Sugar: Normal

REVIEW OF REVIEW OF SYSTEMSYSTEM(-) MB(-) Infection LG Tract(-) HPN(-) Cardiac(-) Renal(-) DM/Metabolic(-) Respiratory(-) Fetal wastage

(-) IUGR(-) Infertitlity(+) Uterine contraction x 1mon(+) UTI 3mons AOG Cefalexin 500mg/cap 1cap TID x 7days(+)

(+) Premature Labor 12days PTA(+) Genitourinary 12days PTA Bacterial Vaginosis(+) Previous CS 2011

PHYSICAL EXAMPHYSICAL EXAMGeneral:

Patient came in per wheelchair. The patient was examined in lying position. She was awake, well-groomed, cooperative and not in respiratory distress

BMI was 21.6, weighing 52kg and 5’1 standing

PHYSICAL EXAMPHYSICAL EXAMA. Vital Signs Temperature: 36.30C (Afebrile)Blood Pressure: 120/70 mm Hg (Normotensive)Respiratory Rate: 22 breaths/min (Tachypneic).Cardiac Rate: 85bpm (Non-tachycardic). 

AS, PPC, -CLAD

[-] Remarkable lesionECE, Resonant, CBS

AP, -murmur

-Gross deformitiesFull range of Motion

No Neurologic deficit

PHYSICAL EXAMPHYSICAL EXAMAbdomenAbdomen

I :I : Globular, [+] Striae gravidarum [+] Previous CS scar

A:A: Normal active bowel sound

P: P: Tympanitic all over

PHYSICAL EXAMPHYSICAL EXAMAbdomenAbdomen

P :P : LEOPOLD’s MANUEVER L1= Breech L2= Right L3= Cephalic

FH= 29cmEFW = 2.47klgFHT= 130-140bpm

29 cm

PHYSICAL EXAMPHYSICAL EXAMInternal ExaminationInternal Examination

Grossly Normal PELVIMETRY? (I) (I) : Admits 2 fingers with ease(C):(C): 1-2cm dilatation Beginning effacement Intact bag of water Station -3(U) (U) : Enlarged to 8-9 months AOG(A)(A) ::Non-palpable(D) (D) : No vaginal discharges

SALIENT FEATURES*29 G2P1(1001)

*Vaginal spotting *Amenorrhea*Hx of Preterm LaborPE:*Gravid abdomenGenitoUrinary & IE

ADMITTING IMPRESSION

G2P1 (1001),Pregnancy Uterine 37 6/7 weeks Age of Gestation, Breech in latent phase of Labor

S/P CS (Non-Reassuring Fetal Heart Rate Pattern)

Course in the WARD

On admission

Please admitNPO post midnightMonitor VS q4o

Monitor FHT & POL q4o and recordSchedule for repeat CS tomorrow at 8AMBaseline EFMLABS: CBC, PC BT UAIVF: D5LR 1L at 120cc/hrMed: Cefazolin 1grm IVTT (-)ANST Ranitidine 50grm/amp, 1amp IVTT 1hr Prior to OR Metoclopramide 10grm/amp, 1amp IVTT

Course in the WARDSURGERY: May 28 (1st HD)

VS: 110/70mmHg 36.2oC 78bmp 19cpm

Blood loss: <1000cc

Preoperative Diagnosis: G2P1 (1001),Pregnancy Uterine 37 6/7 weeks Age of Gestation, Breech in latent phase of Labor

S/P CS for NRFHRP

Operation Done 10 LSTCS (Right Hemi-Uterus) secondary to Franck breech presentation

Course in the WARD

Figure 2 . Didelphic uterus after fetal delivery.

Basilio, 2012

Course in the WARD

1st PostOPS/O > + minimal vaginal bleeding P > + well contracted uterus + adequate urine output + stable VS + Flattus

2nd POSTOP, 19HD

S/O > + minimal vaginal bleeding P > + well contracted uterus + adequate urine output + stable VS + Flattus

FINAL DIAGNOSIS1)G2P2 (2002), PUFT Franck Breech presentation,

delivered by 10 LSTCS (Right Hemi-Uterus) to a live birth Baby boy with AS 9,10; BS 38wks; BW 2.85; BL 51cm

2)S/P Cesarean Section (Left Hemi Uterus) secondary to NRFHRP

3)Uterine didelphys

4)Paratubal cyst, Right

UTERUSUTERUS

7.5 cm

5 cm

2.5 cm

Wt: 30 - 40 gm

Facies vesicalis

Facies intestinalis

Fundus uteri

Margo lateralis

8 LIGAMENTS

1 anterior vesicouterine1 posterior rectovaginal2 broad/lateral (ligamentu latum uteri)2 uterosacral2 round ligaments

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Columbo reported the first documented case300 300

BCBC

0.1 -3.5 %StrassStrassmanman et al et al 19611961 4.3 %GrimGrim

bizi bizi 20012001

Class III- Uterine DidelphysClass III- Uterine Didelphys

• Midline fusion of the müllerian ducts is arrested,

• ~ 5% of mullerian duct anomalies ( )

• ~11% are didelphys uterus ( )• Characterized by 2 hemiuteri, 2

endocervical canals with cervices fused at the lower uterine segment.

75% ( )

Reported Association with Other AnomaliesReported Association with Other Anomalies

• ~20% Renal agenesis most commonly ( )• Obstructed unilateral vagina (Wunderlich-

Herlyn-Werner syndrome) ( )• Bladder exstrophy with or without vaginal

hypoplasia• Congenital vesicovaginal fistula with

hypoplastic kidney ( )• Cervical agenesis ( )• Malignancies ( )• .

Reported Association with Other AnomaliesReported Association with Other Anomalies

• According to Zhang et al. 2010 Infertility treatment & reproductive

performance is poor• Study of 59 (68.6%) live births

21 (24.4%) preterm deliveries 18 (20.9%) spontaneous abortions 2 (2.3%) ectopics,

Diagnosis of Uterine Didelphys

• The most frequent complaint ( ).

Failure of tampons to obstruct menstrual flow. T

Initial pelvic examination Second-trimester

spontaneous abortion

Figure 1: Speculum examination reveals a double vagina with two cervices (the right cervix is partly visible) Bhattacharya et al. 2011

Diagnosis of Uterine Didelphys

• Hemivaginal obstruction: Onset of dysmenorrhea (

) Progressive pelvic pain (

) Unilateral pelvic mass ( ) Marked rectal pain and

constipation ( )

Diagnostic Modalities

Fig .HSG images show catheterization of two separate cervices with opacification of two widely divergent noncommunicating endometrial cavities (arrow).

1) HSG2) MRI

Fig Uterus didelphysTransverse fast spin-echo T2-weighted MR images show complete duplication of uterine horns (short arrows), with partial degree of fusion of adjacent cervices (long arrows).

3) Ultrasound

Fig Uterus didelphys in Ultrasound

4) IVP

Surgical Procedures

•obstructed unilateral vagina Full excision and marsupialization of the vaginal septum ( )

•Hemihysterectomy with or without salpingo-oophorectomy ( )

•Strassmann metroplasty ( )

PostOperative Management

Vaginal adenosis is a risk after the septum is removed.

Definitive guidelines that monitor for this condition

have not been established, though some experts recommend serial pap

smears and colposcopy.

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D-SURGICAL MEASURES

• Musich JR, Behrman SJ. Obsteric outcome before and after metroplasty in women with uterine anomalies. Obstet Gynecol.1978;52:63.

• Management and outcome of patients with combined vaginal septum, bifid uterus, and ipsilateral renal agenesis (Herlyn-Werner-Wunderlich syndrome). Gholoum S, Puligandla PS, Hui T, Su W, Quiros E, Laberge JM. J Pediatr Surg. 2006 May;41(5):987-92.

• Heinohen PK, Saarikoski S, Pystynen P. Reproductive performance of women with uterine anomalies. Acta Obstet gynecol Scand 1982;61:157.