Saturday, March 29, 2008

Surgeries associated with MA's (preconception and in pregnancy)

Hysteroscopic metroplasty, abdominal metroplasty, hemihysterectomy, vaginoplasty
The quick, reflexive party line here is that if you have a septate uterus, yes, you should have it fixed. Studies tend to show a poor pregnancy outcome in the uncorrected SU, but a near-normal pregnancy outcome in the surgically corrected SU. Of course there are exceptions, and we should not forget that most women with a septate uterus are never diagnosed, and may indeed have no trouble with reproduction.

In deciding whether or not to have it repaired, take into account your own pregnancy history, your complications, your age, and, possibly, your investment. Are you spending thousands per cycle on IVF treatments? Then you may want to get the septum out of the way. If you have no trouble getting pregnant and have had only one miscarriage, some doctors recommend a more conservative approach, treating with surgery only if another miscarriage happens. Resecting a septum, although not without risks, is a relatively minor surgery compared to the open, abdominal metroplasty once performed.

If you have a septate uterus and suffer from painful menstrual periods, there is a good chance that having your septum resected will cure the painful periods.

Bicornuate, arcuate and didelphic uteri are generally thought to do well in pregnancy, but some studies show correlation to miscarriage and other problems. Again, take your history into account, first and foremost, and weigh the benefits versus the risks. Surgical correction of a bicornuate uterus involves an open (laparotomy) procedure in which the surgeon cuts through the uterine wall of each horn and then sews them together. Unlike most septum surgeries, abdominal metroplasty is a major procedure and carries greater risks of bleeding, infection, adhesions, infertility and rupture during pregnancy. Recuperation takes at least twice as long, and greater pain control is required.

Sometimes a well developed unicornuate uterus has a rudimentary bud (anlage) that is capable of supporting a pregnancy for time, but then ruptures, because of its tiny size. This tiny half-uterus may need to be removed in what is known as a “hemihysterectomy.” The surgery eliminates the possibily of an ectopic pregnancy in the rudimenary horn, lessens pain during menses and reduces the possiility of endometroisis caused by retrograde menstruation. The surgery is not common, but a few members have had it done.

Women with UD or with a completely septate uterus may also have a vaginal septum, sometimes expending to the perineum, creating two vaginal openings. This may make intercourse difficult or painful, or using tampons impractical, and surgery to lyse the vaginal septum is fairly simple. There is some controversy about severing the septum within a septate cervix, since there is a possibility of creating an incompetent cervix. Some surgeons prefer to spare the cervical segment of a septum.

How long to wait to TTC following surgery?
The standard advice is to wait either two cycles or 8–10 weeks following hysteroscopic metroplasty surgery, to allow time for the inflammatory response at the wound site to go away. Local inflammation is a normal response to an injury, but may increase miscarriage or hinder conception—opinions and studies vary. Sometimes, the hormones prescribed before or after surgery can interfere with conception as well.

Sometimes a surgeon will shorten the recuperation time to one cycle, depending in part on the scale of the surgery. Some list members have become pregnant even without an intervening menstrual period and the pregnancies have gone well.

Recuperation time for an abdominal metroplasty will be longer; 3–6 months' waiting is a common recommendation, because of the full-thickness wound in the uterine wall.

It is prudent to have a follow-up HSG to confirm the results of surgery before trying to conceive. An HSG can be done after the first menstruation, ideally before the next ovulation, while the lining is thin and compact. It will show not only the changed configuration of the uterine cavity, but may reveal perforations.

What is surgery like?
Hysteroscopic metroplasty (uterine septum resection via the vagina) ; a.k.a. septoplasty, septotomy
During this procedure, a uterine (and also a vaginal septum, if applicable) can be incised to open the uterus up for a better pregnancy result. This surgery is usually done at the same time as a laparoscopy (see below) and is often referred to on the board as a “lap/hyst.” It can be done with scissors, an electrocautery tool or a laser tool, depending on what the surgeon is most experienced with.

"Resection" is not an accurate term for what happens, since no tissue is removed from the uterus; instead, the surgeon parts the septum, like cutting a swatch of material in half. On parting, the septum retracts close to the normal uterine wall on each side, where it is covered with endometrium within days or weeks.

It is a day surgery in most cases. Recovery is different from woman to woman, but most agree that 3–5 days are required. It is important to know that some women require more than one surgery to adequately resect a septum.

Laparoscopy
You prepare for laparoscopy by fasting and discontinuing meds as ordered (aspirin or metformin, for example). You may or may not be ordered to do a bowel prep (laxative, enema, clear liquids), and wash your abdomen with special soap such as Phisoderm for a period of time preceding the surgery, as well as trim back or shave the pubic hair.

When you are under anesthesia (usually general), you’ll be put in the lithotomy position (a lot like a Pap smear), draped and prepped. The surgeon will make two to four puncture wounds in your abdominal wall—one inside the navel (for the laparoscope) and one to three in the bikini line fold just above the pubic hair, for other implements. Sometimes a minilaparotomy incision, about an inch wide, is made on the bikini line at the midline, though this is not usually the case. The surgeon will then inflate your abdominal cavity with carbon dioxide to improve visibility, and have a look with the lighted scope at your pelvic organs.

The main purpose of a laparoscopy is to monitor the outside of the uterus for imminent or actual perforations as the surgery goes on inside the uterus, but other fertility-related surgery may be done as needed: lysing adhesions, removing fibroids or endometriosis, or ovarian laser drilling.

After the surgery, you can expect to feel sleepy, forgetful and possibly nauseated from the anesthesia and the pain medication, and that may last over 24 hours. You may feel pain in your abdomen, under the ribcage and even referred to your shoulders from remaining carbon dioxide within your abdomen. Expect to have a sore abdomen for the next week or so. Many women compare the feeling to that of having done too many sit-ups.

Hysteroscopy (HSC)
A hysteroscopy involves distending the uterus with a fluid or gas, inserting a scope and then doing one of two things: either operating (e.g. removing a polyp or fibroid, resecting a septum) or just documenting any abnormality and then withdrawing the instrument. You prepare for laparoscopy by fasting and discontinuing meds as ordered (aspirin or metformin, for example). You may or may not be ordered to do a bowel prep (laxative, enema, clear liquids), and you may be on progestins, danazol or GnRH analogs in order to thin the uterine lining prior to surgery. Surgeons' preferences vary widely. It seems to be most useful in improving visibility with a wide septum or a complete septum (one that extends to the cervical os or beyond).

While it is a minor surgery, any instrumentation of the uterus creates the risk of injury or infection, and HSC carries with it about a 1% risk of perforating the uterine wall. Most perforations are minor in nature, but if the wound is large or bloody, or injures other abdominal structures, such as the intestines, complications can be serious. Perforation also increases the likelihood of rupture during pregnancy or childbirth. HSC also creates a risk of fluid overload and serious electrolyte imbalance as the distending medium enters the bloodstream, although fluid status is continually monitored during surgery. There is also the risk that the surgery will not accomplish its purpose and may need to be repeated.

The advantage of HSC, of course, is avoiding abdominal metroplasty, a major surgery with all the attendant risks.

Hysteroscopy itself does not seem to cause pain during recuperation, although the accompanying laparoscopy tends to give a sore abdomen. Expect to bleed for a day or two, then to see the flow lighten to a watery pink. After a few days, the flow should change to a watery, slightly yellowish serous fluid, and disappear at roughly two weeks post surgery. Foul-smelling discharge or a fever warrants an immediate call to the surgeon because of possible infection.

Some surgeons like to leave an inflated Foley catheter in place to hold the sides of the uterus apart, or to leave some other adhesion barrier in there. Barriers tend to increase bleeding and cramping beyond a few days, and some surgeons believe that barriers increase the risk for intrauterine adhesions and ascending infections.

An experienced surgeon may choose to waive the laparoscopy during HSC, but this is the exception, not the rule.

As often as not, an operative HSC is followed up with a course of conjugated estrogens to help promote regrowth and proper healing of the endometrium, especially if the patient has taken premedication to thin the uterine lining. Studies increasingly show postoperative estrogen to make little difference in re-epithelialization of the cut septum.

Antibiotics during or after surgery are also commonly given, although risk of endometritis is low.

An exploratory (rather than operative) hysteroscopy is an office procedure, frequently done while the patient is awake. Since the uterus needs to be expanded with saline, glycine or carbon dioxide, this can be quite painful, similar to having a hysterosalpingogram (HSG).

Cerclage
Cerclage is a stitch placed around the opening of the uterus, usually the cervix, to hold the uterus closed as pregnancy advances, and is done in cases where there has been a loss due to painless prolapse of the membranes in the second trimester of pregnancy. The McDonald stitch is the most common form of cerclage done. It is a suture done with mersilene or proline suture material, under local anesthesia (usually a low, short-acting spinal block). It takes only a few minutes to place, and recovery and monitoring following the procedure take only a few hours. Bedrest for 48 hours after the procedure is recommended

The patient is placed in the lithotomy position following the spinal or epidural anesthesia, and the area is draped and swabbed with antiseptic. A kind of caliper called a tenaculum is used to pull the cervix closer to the mouth of the vagina and manipulate the cervix as the surgeon makes the sutures. The patient may feel a painless tugging sensation as this is done. Sedation is optional; some surgeons feel that tranquilizers or general anesthesia pose an unnecessary risk to the developing fetus.

The patient is monitored closely for signs of bleeding, contractions and ruptured membranes and then usually discharged the same day, after she is able to void her bladder into the toilet. Sometimes an overnight stay is needed. The surgeon may or may not prescribe bed rest beyond 2–3 days, depending on individual circumstances. "Pelvic rest," or refraining from intercourse and orgasm, is also frequently advised, because of the infection risk and tendency for a cerclaged uterus to be irritable. At minimum, pelvic rest is advised for one wekk prior to and one week following surgery.

Cerclages work well (up to 90% success rate), but some do fail. In that case, a second stitch can be placed, and the patient is put on strict bed rest, which involves taking meals lying down and using a bedpan. One alternative to cerclage is strict bed rest by itself, beginning in the early second trimester; some studies show it to be just as effective as cerclage. The advantage of cerclage is, of course, avoiding the health risks of lying in bed for several months.

One contraindication for having a cerclage is active labor, since this may cause the stitch to tear through the cervix. Consequently, most cerclages are removed around 37 weeks, to allow effacement and dilation to occur naturally. Some women with very weak cervices experience labor and birth almost immediately after cerclage removal, but not always. Sometimes the cervix develops scar tissue from the cerclage and does not thin out or open up easily (cervical dystocia), which may necessitate a c-section.

Opinions vary as to when it is appropriate to place a cerclage. Current trends point to earlier placement—at 10 weeks or as soon as the embryo looks viable on ultrasound. Prior conventional wisdom indicated placement at 12–14 weeks, after it becomes 97% certain that the pregnancy will continue. However, ultrasound technology can predict a positive outcome with 95% certainty at 10 weeks, LMP.

A cerclage done to salvage a threatened pregnancy, after the membranes have begun to prolapse, is called an emergent or rescue cerclage. A rescue cerclage requires bed rest, and the prognosis is not as good as that of a cerclage done well before cervical shortening begins.

For patients with underdeveloped cervices or repeated cerclage failures, an abdominal cerclage promises some success. Prior to conception, the suture is placed around the lower segment of the uterus, deep to the uterine arteries, and is done through a laparotomy. Delivery must be by c-section, and the cerclage can be left in place for the next pregnancy.

C-section
If your c-section is planned, you will be asked to take nothing by mouth for several hours prior to surgery. At the hospital, you will be hooked up to a fetal monitor for a time and an IV of normal saline or Ringer's lactate will be started in your non-dominant hand. You may be shaved, prepped (enemas are passé!) and catheterized prior to the spinal anesthesia. The nurses will put tight anti-embolic stockings on your legs to reduce the risk of blood clotting while you are immobile.

Regional anesthesia is increasingly the method of choice for controlling pain. Shortly before surgery, the nurse anesthetist or anesthesiologist will start a spinal anesthetic of a fairly short-acting substance, such as lidocaine. You will be asked to lean forward and "shove" your back towards the anesthetist, to make room for the needle to enter the spinal space. You will feel a small prick right about at kidney-level, slightly off-center. When the anesthetic is introduced, you will lose a sense of having a lower body from the nipple line on down, and a warm, not unpleasant feeling may overtake you. Assistants help you lie back on the operating table and one or both arms are strapped at 90° angles to your body. Someone will apply a pulse oximeter, EKG leads and an oxygen mask or nasal cannula. You may begin to feel tingling or numbness in your thumbs and a difficulty swallowing, and while disconcerting, this is seldom a problem. A medication may be introduced into your IV to help with any feelings of anxiety.

Meanwhile, nurses expose your abdomen, scrub it with antiseptics and drape it with sterile drapes. Your surgeon will probably make a 10-cm. horizontal incision just superior to the pubic bone, above the hair line—a pfannensteil incision. Working very quickly, the surgeon will part and retract the underlying tissues, exposing the uterus. The uterus is opened with (usually) a horizontal incision, and the amniotic sac incised. Amniotic fluid is allowed to drain away. In many cases, the patient may not even have realized that surgery has begun.

While an assistant presses downward on the fundus, the surgeon reaches into the uterus and delivers the fetus' head. Taking gentle traction on the head, he or she delivers the baby rapidly. You may feel a pressure or rocking as they work.

Then comes the joyful part, as the baby is assessed and begins to cry. You may be able to touch, kiss or hold the baby, or even nurse the baby immediately following birth (this is something to work out beforehand in your birth plan with your obstetrician).

Meanwhile, the uterus itself is often delivered outside the laparotomy incision, inspected, suctioned, massaged and sutured, then replaced into the pevlic/abdominal cavity. This may be a good time to have a tubal ligation performed, if you do not want any more children. And your surgeon may ask if you want any septum present to be resected. One school of thought holds that childbirth is a risky time for a metroplasty because of increased vascularity and risk of infections and adhesions, but there are two documented cases of septa being successfully resected during a c-section.

Expect to spend an hour or two in recovery, being assessed and reassessed, and having your fundus massaged. With luck, you will be able to bond with your baby during this time. You will remain in bed, catheterized, until the anesthesia wears off, possibly with pneumatic sleeves on your feet or lower legs that periodically inflate to stimulate circulation in your legs. Once the catheter is out and you are able to void, you will be encouraged to stand, sit and walk around as soon as possible.

The level of discomfort following a c-section varies widely, and you may or may not require much pain medication. If it is painful to nurse your baby, a pillow over the incision may distribute pressure more comfortably. You will have lochia (postpartum flow), but it tends to be lighter than that of a vaginal birth. A typical hospital stay following a c-section is 2-5 days. Following hospital discharge, you will be asked not to lift anything heavier than your baby, or to drive, to minimize the risk of adhesion fomration immediately following the surgery. The stitches or staples closing the incision usually come out within a few days following surgery, and are replaced with steri-strips or other dressing. The scar gradually thins and fades in color.

Vaginal birth following a lower segment incision is definitely possible, with the right provider.

An emergency c-section is done after the mother goes into labor and it becomes apparent that she needs a section. A crash c-section is done when the fetus is at risk of hypoxia or death. In both these cases, anesthesia may be by epidural block or general.

7 comments:

hiking said...

Just found your site and am so happy! It's nice to see a comprehensive and clear explanation of these conditions and surgery that I suddenly find myself facing.

Erica Ciaccio said...
This comment has been removed by the author.
copper.top77 said...

It was great to find your site! There is so much misinformation out there about MAs, and unfortunately a lot if it is given by doctors!

To Erica,
In case you come back to this, I just wanted to say it's great that you're going to see a specialist! I am so sorry for your losses. :(

Ultrasound is not very reliable as a means of diagnosing MAs on its own, and (same with MRIs) it depends a lot on the angle they get AND who is interpreting the pics. The best diagnosis is from a laparoscopy/hysteroscopy, which is a minor outpatient surgery. (More info on this site.) It would be wise for you to have this procedure and find out which MA you have before TTC again.

Many doctors call all MAs Bicornuate Uterus or Septate Uterus, and think they are the same thing, when in fact they have very different reproductive outcomes! SU has a much higher m/c rate than BU, because the septum in the middle does not get enough blood supply to sustain the embryo if it implants there. There is also a higher chance of late-term m/c. :(

Surgery to remove the septum improves this significantly, to almost normal. Ladies with BU can often have a pretty normal pg without surgery. For this reason, make sure you have a good diagnosis before you let a doctor tell you to continue TTC!

Also, I highly recommend joining the Yahoo group for Mullerian Anomalies--the ladies there are very helpful and many have your history and kids as well. :) There is also ton of info on the site, and a list of recommended docs/surgeons.

Sending good wishes!
Rachael

Here's a link to the site:
http://health.groups.yahoo.com/group/MullerianAnomalies/

copper.top77 said...

Forgot to mention that reparative surgery can be done at the same time as the diagnosis if you get a lap/hyst. Sometimes more than one surgery is required--insist on an "after" image to be sure it is fixed! And make sure to find a Reproductive Endocrinologist/Surgeon that knows his MAs. :) Cheers!

sasha said...

here i love to share about tubal reversal and pregnancy
is a surgical procedure that restores fertility to women after a tubal ligation

kate spade said...

At your preconception check you will need to discuss any medical conditions you may have, some of which can affect your ability to conceive, or which may in them selves be affected by pregnancy

get pregnant after miscarriage

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