Ruptura uterina espontánea e inadvertida. Reporte de caso / Spontaneous and undetected uterine rupture. Case report

Resumen ANTECEDENTES: La ruptura uterina es la separación de las tres capas del útero que se asocia con una cicatriz. La mayoría de los casos se relacionan con intento de trabajo de parto, después de una cesárea. La ruptura es una complicación grave, que pone en riesgo a la madre y al feto. De forma excepcional puede haber ruptura uterina sin síntomas, y el hallazgo se advierte durante la cesárea de repetición. CASO CLÍNICO: Paciente de 27 años, programada para cesárea de repetición por disfunción de una prótesis valvular. A la apertura de la cavidad abdominal no se encontró hemoperitoneo y se visualizó un defecto transverso en el segmento uterino inferior de las tres capas uterinas, con saco amniótico íntegro, coincidente con ruptura uterina. Se obtuvo un recién nacido sano, de 2610 g y Apgar de 9-9. La herida uterina se suturó en dos planos y se practicó la oclusión tubaria bilateral. La evolución durante el puerperio fue satisfactoria. CONCLUSIONES: La ruptura uterina puede pasar inadvertida por algún descuido en la historia clínica y ausculatación, de ahí la necesidad de ser más minuciosos para poder indicar el tratamiento adecuado.

Abstract BACKGROUND: Uterine rupture is a separation of the three layers of the uterus and is associated with a uterine scar. Most cases are related to an attempted labor after a cesarean section. Uterine rupture is a serious complication that puts both mother and fetus at risk. Exceptionally uterine rupture can occur without symptoms, being a finding during a repeat cesarean section. CLINICAL CASE: A 27-year-old patient scheduled for repeat cesarean section due to dysfunction of a prosthetic valve. Upon opening the abdominal cavity, no hemoperitoneum was found and a transverse defect was visualized in the lower uterine segment of the three uterine layers, with an intact amniotic sac, coinciding with uterine rupture. A healthy newborn was obtained, weighing 2610 g and Apgar 9-9. The uterine wound was sutured in two planes and bilateral tubal occlusion was performed. The evolution during the puerperium was satisfactory. CONCLUSIONS: Uterine rupture may go unnoticed due to an oversight in the clinical history and auscultation, hence the need to be more thorough in order to indicate appropriate treatment.

Study on Comparative Diagnostic Efficacy of HSG & Laparoscopy in Infertility.

Tubal occlusion is one of the most frequent causes of infertility in women. The evaluation of the fallopian tube is necessary in female infertility. The two most important diagnostic procedures for evaluation of tubal patency are hysterosalpingography (HSG) and laparoscopy. We wanted to compare the diagnostic efficacy of HSG & diagnostic laparoscopy in evaluation of tubal patency in infertility.METHODSA hospital OPD based prospective study was conducted among fifty patients fulfilling the inclusion and exclusion criteria who attended the OPD for treatment of infertility in the Department of Obstetrics and Gynaecology, Medical College and Hospital, Kolkata from 1st January 2016 - 31st December 2017. After taking proper history, thorough examination and basic investigations for infertility work-up, HSG and Laparoscopy were performed.RESULTSAnalysis showed that most of the patients were in the age group of 30 to 35 years. Incidence of primary and secondary infertility was 64% and 36% respectively. Right proximal and distal blockage in HSG, and DL were 56% and 40% in HSG and 48% and 28% in DL respectively. p=0.0001. Left proximal and distal blockage in HSG and DL were 32% and 56 % in HSG and 40% and 28 % in DL. Right and left hydrosalpinx on HSG and DL were 32% and 12% in HSG and 40% and 16 % in DL. p<0.005. Right and left peri-tubal adhesions on HSG and DL were 36% and 20% at HSG and 52% and 28 % in DL. p<0.005. Thus, laparoscopy is superior in detection of hydrosalpinx and peritubal adhesions than HSG. In this analysis, the incidence of submucosal, intramural and subserous fibroids was 16%, 12% and 8 % respectively. Incidence of septate, unicornuate, bicornuate & arcuate uterus was 8%, 6%, 6%, 2% respectively. Intrauterine adhesions were detected in 12% and endometrial polyp in 4% of patients.CONCLUSIONSHSG is considered to have a high sensitivity and specificity to detect tubal block. HSG and laparoscopy are not alternative, but are complementary in the evaluation of tubal block.

Patrón menstrual y reserva ovárica en pacientes con salpingectomía y oclusión tubárica para esterilización definitiva / Menstrual pattern and ovarian reserve in patients undergoing to salpingectomy and tubal occlusion for definitive sterilization

Resumen Objetivo: Evaluar el patrón menstrual y la reserva ovárica mediante la determinación de FSH y conteo de folículos antrales en pacientes con salpingectomía y oclusión tubárica bilateral como métodos de esterilización definitiva. Material y métodos: Estudio prospectivo, longitudinal, comparativo, experimental, con asignación al azar, ciego simple, al que se incluyeron pacientes con deseos de esterilización definitiva como método anticonceptivo. Las pacientes se asignaron al azar a dos grupos, el primero con oclusión tubárica bilateral y el segundo con salpingectomía. A los seis meses posprocedimiento se evaluaron en forma ciega el patrón menstrual y la determinación sérica de hormona folículo estimulante (FSH) y el recuento de folículos antrales por ultrasonido transvaginal como marcadores de reserva ovárica. El análisis estadístico se llevó a cabo con t de Student para muestras independientes (comparación entre los grupos) y dependientes (comparación intragrupo) para comparación de medias y la prueba x2 para comparación de proporciones. Resultados: Se estudiaron 60 pacientes, 31 con oclusión tubárica bilateral y 29 con salpingectomía. Se registraron aumentos significativos en los días de sangrado menstrual con respecto a la basal después de la oclusión tubaria bilateral (p = .002) y salpingectomía (p = .008). No hubo diferencias entre oclusión tubárica bilateral y salpingectomía con respecto al tiempo quirúrgico para llevar a cabo la técnica de esterilización (p = .83), duración del ciclo menstrual (p = .35), duración de los días de sangrado menstrual (p = .40). Tampoco resultaron diferencias en las concentraciones séricas de FSH (p = 0.75) ni en el recuento de folículos antrales (p = .44) entre los grupos. Conclusiones: El patrón menstrual y la reserva ovárica son muy similares en pacientes con oclusión tubárica bilateral o salpingectomía. Ambas técnicas incrementan la duración del sangrado menstrual posterior al procedimiento. La salpingectomía implica un aumento ligero en el tiempo quirúrgico, sin diferencias en la frecuencia de complicaciones.

Abstract Objective: To evaluate the menstrual pattern and ovarian reserve in patients undergoing salpingectomy and bilateral tubal occlusion as definitive sterilization methods. Material and methods: A prospective, longitudinal, comparative, experimental, randomized, single blind study was carried out in patients with a desire for definitive sterilization as a contraceptive method. Patients were randomly assigned to perform bilateral tubal occlusion or salpingectomy. Six months after the procedure in each patient, the menstrual pattern and the serum determination of follicle stimulating hormone (FSH) and the antral follicle count were evaluated by transvaginal ultrasound as markers of ovarian reserve. The statistical analysis was carried out using the student's t-test for independent samples (comparison between groups) and dependent samples (intra-group comparison) for comparison of means and the x2 test for comparison of proportions. Results: Sixty patients were studied, 31 with bilateral tubal occlusion and 29 with salpingectomy. Significant increases were observed in the days of menstrual bleeding with respect to the baseline after bilateral tubal occlusion (p = .002) and salpingectomy (p = .008). No differences were observed between bilateral tubal occlusion and salpingectomy with respect to the surgical time to carry out the sterilization technique (p = .83), menstrual cycle duration (p = .35), duration of the days of menstrual bleeding (p = .40). No differences were observed in the serum levels of FSH (p = .75) nor in the antral follicle count (p = .44) between the groups. Conclusions: The menstrual pattern and the ovarian reserve are very similar in patients who undergo bilateral tubal occlusion and salpingectomy, although the two techniques increase the duration of menstrual bleeding after the procedure.

Comparison of Hysterosalpingography and Laparoscopy in Diagnosis of Tubal Occlusion.

Background: Infertility is one of the most common conditions confronting Gynecologists and tubal factor is one of the most common causes of infertility. Hysterosalpingography and laparoscopy are used as methods for diagnosis of tubal patency in infertility. HSG is an OPD procedure and, for many years has been used as an invaluable procedure for diagnosis of tubal patency and intrauterine pathology in infertility. Laparoscopy is an invasive procedure and is used for evaluation of tuboperitoneal factors. Aims and objectives: To evaluate the diagnostic accuracy of hysterosalpingography in the diagnosis of tubal pathology in infertility in comparison to laparoscopy Methods: 60 patients of infertility were evaluated in the department of Gynecology and obstetrics, Government Lalla Ded Hospital ,Srinagar from April 2013 to August 2014. A prospective cross sectional study was performed. HSG was performed in the pre-ovulatory phase .Laparoscopy was performed under general anesthesia at least three months after HSG in the premenstrual phase. Diagnostic laparoscopy was considered as the reference standard in detecting tubal blockade and findings of hysterosalpingography were compared with laparoscopy. Results: All the patients in the study group were complaining of infertility. The total number of patients in this study was 60 in which 41 were in primary infertility group and 19 were in secondary infertility group. The age of patients was between 21 and 39 years. The average duration of primary infertility was 4.08 years and secondary infertility was 5.15 years. The sensitivity of HSG was 90.91% (95%CI: 76.43-96.86) and specificity was 77.78% (95%CI 59.24-89.39) with positive predictive value of 83.33% (95%CI 68.11-92.13) and negative predictive value of 87.50% (95%CI 69.0- 95.66),when tubal pathology was defined as any form of tubal occlusion detected at laparoscopy, either one sided or two sided. The further advantage of laparoscopy is the possibility of visualization of some other pelvic abnormalities which may be the cause of infertility. In our study, in patients with tubal block, adnexal adhesions were found in 15 (45%), endometriosis in 8(25%) and suspected intratubal block in 10(30%). Conclusion: HSG is the first step diagnostic test for assessment of fallopian tubes. Although laparoscopy is more invasive than HSG, laparoscopy with chromotubation is the gold standard for diagnosis of tubal block, and for identifying periadnexal adhesions and endometriosis and thus to guide appropriate therapy.

The validity of hysterosalpinggography for the diagnosis of tubal occlusion

Study on 219 infertility patients treated at Tu Du Hospital from September 2002 to May 2003, in order to evaluate the validity of hysterosalpinggography (HSG) for the diagnosis of tubal occlusion by direct laparoscopic assessment of tubal patent degree. The results showed that: HSG is valuable for the diagnosis of proximal tubal occlusion with the specificity of 72.24% and the negative predictive value of 96.4%. HSG is also considered as a screening test for the diagnosis of distal tubal occlusion with the sensitivity of 88.55% and the positive predictive value is 76.66%

The validity of HSG for the diagnosis of tubal occlusion

The study was carried out on 219 infertility patients having hysterosalpingography (HSG) before surgery at Tu Du Hospital from Sept 2002 to May 2003 to evaluate the validity of HSG for the diagnosis of proximal and distal tubal occlusion. Results: HSG is highly valuable for diagnosis of proximal tubal patency, in case with proximal tubal occlusion it should be referred to laparoscopy. The role of HSG for diagnosis of distal tubal occlusion without hydrosalpinx is limited. In contrast, HSG is highly valuable in diagnosis of hydrosalpinx