Q & A: Uterine Adhesions to post per. wall

Q.

I have a case that I've known for some time. She is a case of diagnosed endometriosis. I did her adhesiolisis in 1993 and then she got pregnant, then she had a big endometriotic cyst and I removed it and then she got pregnant again. In the last six years, she got 2 endometriotic cysts that were very big and causing agonizing pains and had to be surgically removed in 2 occasions. Last year she got pregnant spontaneously but missed abortion at 14 weeks and had to evacuate by extramniotic PG. Now she is 12 weeks pregnant but she is in continuous pain for the last 4 weeks. Yesterday I did her ultrasound to find the uterus acutely RVF with the cervix extremely anterior, by manual examination the uterus couldn't be erected, so I suppose the fundus is adherent to the post peritoneum, Now what can I do?... I thought of waiting till 16 wks gestation and attempt laparotomy removal of the adhesions if the spontaneous anteversion doesn't take place (with the possibility of subsequent bleeding and possible hysterectomy) or evacuation of the pregnancy now (which I don't like)...what can I do?

A. 

Dr Farouk Fikry: This is a rare case. Endometriosis was expected to improve with the occurance of pregnancy. I think what you can do now is to wait till 16 weeks pregnancy, do laparotomy try to correct the impacted uterus if need remove any adhesions or cysts. good luck.

Dr Abdul Rahman Lilla, FRCOG: This reminds me of a case I was called to theatre for recently; she must have started off with a retroverted gravid uterus and progressed to term; I was called because, after elective c/s on a 38 yr old primi with mutiple uterine fibriods the surgeon discovered that the uterus was completely seperated from the vaginal vault and that there was a transverse scar in the lower segment on the posterior wall. I reatteched the uterus to the vagina.

Inspecting the uterus it became clear what had happened; there was a fundal fibriod which must have got stuck behind the sacral promontory early in pregnancy and the uterus continued to grow with sacculation of the anterior wall, without causing any harm to the conceptus or mother.

At the time of surgery the vagina was stretched beyond the symphysis pubis, the gravid uterus was still 'retroverted' with the cervix where tha fundus should have been and vise-versa.

The incision was made through both ant and post wall of vagina and to get to the fetal head an incision was made through the pat uterine wall.

So its possible that above pregnancy can proceed withour much effect on the mother! 

J. Glenn Bradley, MD: The assumption that adhesions are the cause for the fixation could be completely conjecture. Incarceration of the retroverted expanding fundus is IMHO more likely than dense posterior adhesions.

Note: This is an extract from the Medical Professional Forum. Click here to view the original thread.