Successful Surgical and Medical Management of Cesarean Scar Pregnancy in 2 Patients

Background: Cesarean scar pregnancy (CSP), once a rare entity, is on the rise due because of an increase in the cesarean section rate worldwide. Currently, there is no standard protocol available for managing CSP. To contribute to the existing literature, this article presents the current authors' experience with 2 cases of CSP that were treated successfully with two different modalities. Cases: Case 1: A 34-year-old, gravida 2, para 1, was diagnosed with a CSP on initial transvaginal ultrasound (TVUS) scan at 6 weeks of gestation. Aspiration of the gestational sac and a local injection of methotrexate was performed. After 2 weeks, the gestational sac increased in size with thinning of the CS scar (1?mm), and plateauing of the ß?human chorionic gonadotropin (ß-hCG) occurred. Laparoscopic excision of the CSP and myometrial repair resulted in resolution. Case 2: A 31-year-old, gravida 3, para 1, achieved pregnancy after a frozen?thawed embryo transfer cycle. A TVUS scan, performed at 6 weeks of gestation showed a CSP. The patient's ß-hCG level was 310 mIU/mL. Systemic methotrexate was administered intramuscularly. The patient's ß-hCG on days 4 and 7 was 260 and 252, respectively. A repeat TVUS on day 7 showed a resolving gestational sac. A second dose of methotrexate resulted in complete resolution of the CSP. Results: The treatments (aspiration, methotrexate, and laparoscopic excision for Case 1, and methotrexate for Case 2) enabled resolution of the CSPs of these 2 patients. Conclusions: Various treatment modalities have been described for managing CSP with varied levels of success. When local injection of methotrexate into the gestational sac of CSP is unsuccessful, laparoscopic removal is safe and effective. Moreover, in the presence of low levels of ?-hCG, treatment with systemic methotrexate is usually successful. (J GYNECOL SURG 30:168)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140096/1/gyn.2013.0131.pd

Herlyn–Werner–Wunderlich Syndrome: Presentation and Surgical Management Options for Five Cases

Background: Herlyn?Werner?Wunderlich syndrome is a rare Müllerian-duct anomaly consisting of uterine didelphys, a unilateral obstructed hemivagina, and ipsilateral renal agenesis. This article presents clinical and laparoscopic findings as well as the surgical management of 5 cases with various clinical scenarios. Cases: Case 1: An 11-year-old premenarchal female presented with chronic vaginal discharge and negative cultures. She had a uterus didelphys, a unilateral partial obstructed hemivagina, and ipsilateral renal agenesis. She underwent excision of the hemivagina. Case 2: A 14-year-old female presented with severe dysmenorrhea. As part of the work-up for a two-vessel cord at birth, an ultrasound revealed an absent left kidney. Magnetic resonance imaging suggested uterine didelphys and a left hematometrocolpos. At surgery, the MRI findings were confirmed. She underwent excision of the left hemivagina. Case 3: A 23-year-old asymptomatic female was referred following an incidental finding of a duplicated uterine horn and hematocolpos on ultrasound. She had a uterus didelphys, a unilateral obstructed hemivagina, and ipsilateral renal agenesis. She underwent excision of the hemivagina. Case 4: A 26-year-old female presented with severe dysmenorrhea and chronic pelvic pain. She had a uterus didelphys and a high right-sided obstructed hemivagina, with no hematocolpos, hematometra, hematosalpinx, endometrioma, and ipsilateral renal agenesis. She underwent a hemihysterectomy, unilateral salpingectomy, and endometrioma excision. Case 5: A 15-year-old female had a history of severe dysmenorrhea. During laparoscopy for an acute abdomen, she was noted to have uterus didelphys. Further evaluation revealed a hypoplastic cervix and a high right-sided obstructed hemivagina, with minimal hematocolpos, hematometra and ipsilateral renal agenesis. She underwent a hemihysterectomy. Results: The patients recovered well and, in most cases, had complete resolution of their symptoms. In Case 4, the patient's symptoms were greatly reduced. Conclusions: In patients with obstructed hemivaginas that are diagnosed early, resection of the vaginal septum is a convenient and effective treatment modality. Hemihysterectomy should be considered in patients with cervical hypoplasia/aplasia and high position of obstructed hemivaginas, and in patients with severe endometriosis, tubal damage, and extensive pelvic adhesions. (J GYNECOL SURG 31:46)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140097/1/gyn.2014.0081.pd

Pregnancy Outcomes After Endometrioma Excision in Patients Undergoing In Vitro Fertilization and Embryo Transfer: A Historical Cohort Study

Objective: The objective of the study was to examine the effect of endometrioma excision on pregnancy outcomes in women with advanced-stage endometriosis who underwent in vitro fertilization and embryo transfer (IVF-ET). Design: This is a historical cohort study. Materials and Methods: We compared the pregnancy outcomes of 141 women undergoing IVF-ET. The study group consisted of 25 patients who had stage III/IV endometriosis and endometrioma excision (group 1). The control groups included 40 patients who had stage III/IV endometriosis, but no endometrioma and who underwent ovariolysis (group 2) and 76 patients with tubal factors infertility who underwent tubal surgery (group 3). After surgery up to two IVF-ET cycles in each group were analyzed. Results: Our study showed that the mean total dose of gonadotropin administered in IVF-ET cycle I was higher in group 1 compared with groups 2 and 3 (p=0.03). Otherwise, there was no significant difference in the ovarian responses among the three groups. There was a statistically significant increase in clinical pregnancy rate per cycle in the endometrioma group (69.7%) versus the ovariolysis group (48.1%) and tubal factor group (48.0%). However, there was no significant difference in delivery rate per cycle among the three groups. There was a statistically significant higher miscarriage rate in the endometrioma group (39.1%) compared with the ovariolysis group (11.5%) and tubal factor group (14.3%). Conclusion: In conclusion, our study suggests that endometrioma excision surgery does not compromise the overall ovarian reserve or pregnancy outcomes after IVF-ET. (J GYNECOL SURG 31:214)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140100/1/gyn.2015.0013.pd

Laparoscopic Myomectomy Followed by Minilaparotomy for Management of a Large Submucous Fibroid

Background: We describe a patient with a single large type II submucous fibroid distorting and occupying the entire endometrial cavity, which was managed successfully with an approach less invasive than laparotomy. Case: The patient was a 36-year-old woman who presented with primary infertility of 2 years duration. Her associated complaints were menorrhagia and known uterine fibroids. She had undergone hysteroscopic myomectomy in the past without any improvement. An hysterosalpingogram revealed that the uterine cavity was occupied by a single large submucosal fibroid. Transvaginal ultrasound and saline infusion hysterosonogram showed a large anterior type II submucous, intramural, subserous fibroid. Diagnostic hysteroscopy and laparoscopy revealed a type II submucous fibroid occupying the entire anterior wall of the uterus. Laparoscopic myomectomy was performed and a fibroid measuring 8?cm was dissected. During the process, the endometrial cavity was entered and a minilaparotomy via a 5-cm transverse skin incision was performed to repair the endometrial cavity and overlying myometrium adequately and to remove the myoma. Results: Her postoperative course was uneventful. Six weeks later, saline infusion hysterosonogram revealed a uniform endometrial cavity with no filling defects or synechiae. Conclusions: Laparoscopic myomectomy with minilaparotomy is a safe, cost-effective, and less invasive approach for the treatment of patients with large type II submucous fibroids who want to preserve their reproductive potential. (J GYNECOL SURG 29:161)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140091/1/gyn.2012.0027.pd

Management Dilemma of an Infertile Patient with More Than 20 Submucous Fibroids

Background: Submucous fibroids can lead to menorrhgia, infertility, recurrent pregnancy loss, and obstetric complications. The management of multiple submucous fibroids in patients who would like to preserve their reproductive function can be a challenge. The aim of this report is to discuss the management dilemma of a patient who presented with multiple (more than 20) submucous fibroids. Case: The patient was a 33-year-old Caucasian woman who had an initial complaint of menometrorrhagia and secondary infertility, which led to a diagnostic hysteroscopy. Multiple submucosal fibroids were noted; no other etiology for infertility was identified. She subsequently underwent hysteroscopic resection of several fibroids. Postoperative hyterosalpingogram demonstrated intrauterine scarring, unilateral tubal blockage, and several remaining fibroids. She did, however, conceive with intrauterine insemination. Unfortunately, this pregnancy ended in an early spontaneous abortion of twins. After being counseled on her options, including the possibility of needing a surrogate uterus, she elected to have an abdominal resection of the remaining fibroids. During this procedure, several steps were taken to restore the uterine cavity to a normal shape. After allowing her uterus to heal, she achieved pregnancy through in vitro fertilization. At 29 weeks of gestation, she had preterm premature rupture of membranes and, subsequently, had a cesarean section at 34 weeks of gestation. She had a viable 6 pound 1 ounce baby boy. At the time of her cesarean section, only one submucosal fibroid was identified. Conclusion: We present a unique case of multiple sub-mucous fibroids that failed hysteroscopic management and were subsequently treated successfully with hysterotomy, myomectomy, and uterine reconstructive surgery. Based on our experience with this case, we recommend hysterotomy and myomectomy for management of multiple sub-mucous fibroids from the outset. (J GYNECOL SURG 31:274)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140098/1/gyn.2014.0123.pd

Myometrial Abscess: A Complication of Myomectomy of a Large Lower-Uterine Segment Myoma

Background: This article describes a patient with a history of two early miscarriages. She presented with menorrhagia and a recurrence of multiple fibroids. Laparotomy and myomectomy were performed and were complicated by a myometrial abscess. The diagnosis and management of such a rare complication are described. Case: A 39-year-old African American female (gravida 3, para 1) presented with a history of two early miscarriages, menorrhagia, and a recurrence of multiple fibroids. An ultrasound (US) scan revealed an enlarged uterus with at least six uterine fibroids. Laparotomy and myomectomy were performed. Four weeks later, this patient presented with complaints of pelvic pain, nausea, vomiting, constipation, and a fever of 1 day's duration. A US scan revealed a slightly enlarged uterus caused by a possible infected hematoma. The patient was admitted to the hospital and she was started on intravenous antibiotics after a blood culture was obtained. A computed tomography (CT) scan of her abdomen and pelvis confirmed the diagnosis of a myometrial abscess. This patient underwent CT scan?guided placement of a ?pigtail? catheter in the myometrial abscess for continuous drainage. The result of the culture of the pus obtained from the abscess revealed the presence of multiple bacteria. The pigtail catheter was removed once there was no drainage 2 weeks after its initial insertion. Results: Two months after her discharge, a transvaginal US scan revealed that this patient's condition was essentially normal. Conclusions: This case report describes how a minimally invasive technique was used to manage a myometrial abscess, which is a complication of myomectomy. This report also illustrates the value of transvaginal US scanning for diagnosing such a pathology, and the roles US plays during management and follow-up. (J GYNECOL SURG 30:240)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140095/1/gyn.2013.0130.pd

Gestational Sac Aspiration of Heterotopic Ectopic Pregnancy in a Cesarean Section Scar

Background: This article describes a case of heterotopic pregnancy that included a normal twin intrauterine pregnancy and one cesarean section (CS) scar pregnancy diagnosed at 6 weeks of gestation. Ultrasound-guided aspiration of the ectopic gestational sac was performed, and the concurrent twin intrauterine pregnancy (IUP) was preserved successfully. The patient was a 50-year-old woman with secondary infertility. Case: The patient underwent in vitro fertilization and embryo transfer using a donor-egg program to achieve pregnancy with her current partner. At 6-weeks' gestation, she underwent a transvaginal ultrasound scan (US) examination showing a viable twin IUP with a third gestational sac with viable embryo located low within the anterior wall of the uterus. The appearance was consistent with a cesarean scar ectopic pregnancy. This was confirmed on a subsequent US 1 week later. She desired to continue the intrauterine pregnancy. US-guided aspiration of the cesarean scar ectopic pregnancy was attempted. The treatment was successful. Results: The twin pregnancy progressed without further complications. Conclusions: Heterotopic CS ectopic pregnancy can be successfully treated with transvaginal US-guided aspiration. (J GYNECOL SURG 29:317)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140090/1/gyn.2012.0026.pd

Myometrial Abscess: A Complication of Myomectomy of a Large Lower-Uterine Segment Myoma

Background: This article describes a patient with a history of two early miscarriages. She presented with menorrhagia and a recurrence of multiple fibroids. Laparotomy and myomectomy were performed and were complicated by a myometrial abscess. The diagnosis and management of such a rare complication are described. Case: A 39-year-old African American female (gravida 3, para 1) presented with a history of two early miscarriages, menorrhagia, and a recurrence of multiple fibroids. An ultrasound (US) scan revealed an enlarged uterus with at least six uterine fibroids. Laparotomy and myomectomy were performed. Four weeks later, this patient presented with complaints of pelvic pain, nausea, vomiting, constipation, and a fever of 1 day's duration. A US scan revealed a slightly enlarged uterus caused by a possible infected hematoma. The patient was admitted to the hospital and she was started on intravenous antibiotics after a blood culture was obtained. A computed tomography (CT) scan of her abdomen and pelvis confirmed the diagnosis of a myometrial abscess. This patient underwent CT scan?guided placement of a ?pigtail? catheter in the myometrial abscess for continuous drainage. The result of the culture of the pus obtained from the abscess revealed the presence of multiple bacteria. The pigtail catheter was removed once there was no drainage 2 weeks after its initial insertion. Results: Two months after her discharge, a transvaginal US scan revealed that this patient's condition was essentially normal. Conclusions: This case report describes how a minimally invasive technique was used to manage a myometrial abscess, which is a complication of myomectomy. This report also illustrates the value of transvaginal US scanning for diagnosing such a pathology, and the roles US plays during management and follow-up. (J GYNECOL SURG 30:240)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140095/1/gyn.2013.0130.pd

Broad ligament uterine fibroid: Management with Davinci robotic myomectomy

Background: We describe a patient with two fibroids; the largest was a broad ligament fibroid, which was managed successfully with robotic assisted laparoscopic myomectomy. It is well known that myomectomy of a large broad ligament fibroid presents a challenge to the surgeon with intraoperative complications such as excessive bleeding and ureteric injury or later complications such as pelvic hematoma and infection. Case report: A 40-year-old nulliparous white female presented with dysmenorrhea, menorrhagia and pelvi-abdominal mass and primary infertility. Trans-vaginal 2D ultrasound (US) revealed an enlarged uterus 9.6/6.1/7.9 cm in dimension. Two uterine fibroids, intramural sub-serous in nature were seen on trans-vaginal 2D US. Trans-vaginal US with Doppler flow study suggested that the larger fibroid is broad ligament in nature with minimal vascularity between the broad ligament fibroid and the uterus. The patient underwent robotic assisted laparoscopic myomectomy. First an intramural sub-serous fibroid was removed, then a large broad ligament fibroid was dissected from the uterus and the anterior leaf of the broad ligament was sutured. A diagnostic hysteroscopy was performed at the end of the procedure and revealed a normal endometrial cavity. Post-operative course was uneventful. Conclusion: The aim of presenting this case was to demonstrate that in patients with a large broad ligament fibroid, who want to preserve their reproductive potential, robotic assisted laparoscopic myomectomy is feasible and safe. Trans-vaginal US plays an important role in determining the degree of attachment, location and vascularity between the uterus and the broad ligament fibroid, which in turn helps in the choice of surgical procedure and technique

Robotic surgery in the management of benign complex adnexal masses with a frozen pelvis in women desiring to preserve fertility

Background: A “frozen pelvis” is a term often used to describe extensive pelvic adhesions. It is considered as one of the most challenging situations that a gynecologic surgeon can face. It commonly is caused by extensive endometriosis and pelvic inflammatory disease. We present two cases with extensive pelvic adhesive disease with the aim to illustrate the value of robotic assisted laparoscopy in the management of benign complex adnexal masses with severe pelvic adhesive disease in women desiring to preserve the fertility. Case 1: A 27 year old female referred to our clinic for evaluation of a complex left adnexal mass. Trans-vaginal ultrasound scan and an MRI suggested bilateral endometriomas. She was noted to have stage IV endometriosis. Da Vinci robot assisted left salpingo-oophorectomy was performed. Case 2: A 43 year old female presented with recurrent episodes of pelvic inflammatory disease following an unsuccessful in vitro fertilization procedure. A trans-vaginal ultrasound scan showed a complex left adnexal mass. She was noted to have extensive pelvic adhesions secondary to chronic pelvic inflammatory disease. Da Vinci robotic assisted left salpingectomy was performed, while preserving the left ovary. Conclusion: Our experience and review of literature suggest that in hands of an experienced surgeon, the inherent advantages of robotic assisted operative laparoscopy makes it a safe and attractive alternative to conventional operative laparoscopy and laparotomy for managing benign complex adnexal masses with concomitant severe pelvic adhesive disease in women desiring to preserve their fertility