Jha N*, More V**, Chaudhari HK***.
(* Junior Resident, ** Assistant Professor, *** Associate Professor, Department of Gynecology and Obstetrics, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Hysterotomy is rarely required as a procedure for first trimester abortion. Here we present a case of a Gravida 5 Para 2 Living 2 MTP 2 with three prior scars on uterus. In the current pregnancy, pregnancy was evacuated with suction evacuation, with direct visualization of the uterus under laparotomic guidance to prevent any breach in uterine integrity.
Hysterotomy is a surgical technique where abdominal access into the gravid uterus is attained with the aim of evacuating the conceptus before viability. Hysterotomy is rarely required as a procedure for abortion. The scar of hysterotomy has almost similar complication profile as with upper segment cesarean section. Some of the complications include injury to the bladder base and haemorrhage, overstretching of the bladder to a higher anatomical position during covering of incision resulting in increased risk of bladder injury in subsequent surgeries and increased risk of uterine rupture in subsequent pregnancies. One case where difficulty was encountered in management due to a prior hysterotomy scar is presented here.
A 28 year old female married since 10 years gravida 5 para 2 living 2 MTP 2, with 6 weeks gestation was admitted for medical termination of pregnancy with bilateral tubal ligation. The couple was using barrier method of contraception and was not keen on having further children. There was no significant history of medical or surgical illness. Her first two pregnancies were both uneventful lower segment cesarean sections, resulting in live births, both alive and well. Her third was an induced abortion, done by medical method. In her fourth pregnancy, at 3rd month of gestation, she wanted termination of pregnancy and was posted for surgical termination. During the procedure, a false passage was created with an anterior forniceal tear. Hence, an exploratory laparotomy was done with suturing of anterior vaginal wall to uterus. A vertical incision on the uterus was necessitated and products of conception were evacuated. Uterine incision was closed in polygalactin. Contraception counseling was done. However, she conceived again, and came with 6 weeks pregnancy for medical termination of pregnancy. Abdomen was soft with obesity. Pfannensteil incisions of prior cesarean sections and vertical midline incision of previous hysterotomy were present. On speculum examination, cervix high up. On vaginal examination, uterus was anteverted and bulky. The exact size could not be assessed due to obesity. There was anterior vaginal puckering.
Ultrasonography showed a single live intrauterine gestation of 7.2 weeks and there was no evidence of implantation at scar site. MRI also ruled out caesarean scar site implantation. However, scar thickness was only 5 mm on the posterior wall of uterus. In view of multiple scars on the uterus, there was a dilemma about the surgical procedure for termination of pregnancy. There were high chances of perforation with suction and evacuation, since MRI was suggestive of scar thinning. After due deliberation, she was posted for suction evacuation with tubal ligation under laparotomic vision in presence of surgeon.
Surgeons were called over, and abdominal wall was opened in layers. Multiple flimsy bowel adhesions were found and adhesiolysis was done. After this, the uterine contour was easily visualised. With the uterus in constant vision, the products of conception were aspirated with MVA syringe. Following this, all walls of uterine cavity was curetted under vision. During this step, an assistant stabilized the fundus and the posterior wall of uterus. The previous hysterotomy scar was seen on anterior wall of uterus extending on the fundus and posterior wall of uterus. Though the hysterotomy scar was thinned out and approximately 2 mm in thickness, a perforation was avoided due to constant visualization. Though tubal ligation was planned, bilateral salpingectomy was necessitated due to multiple adhesions. Patient tolerated the procedure well and post-operative course was uneventful. She was discharged on day 14 after suture removal.
Hysterotomy is a surgical technique where abdominal access into the gravid uterus is attained with the aim of evacuating the conceptus before viability. Hysterotomy is rarely required as a procedure for abortion in second trimester. Inability to negotiate the internal os may necessitate hysterotomy in the first trimester also. Complications of hysterotomy include increased risk of uterine rupture in subsequent pregnancies and increased risk of bowel and bladder adhesion and injuries. There is little literature on scar integrity of previous hysterotomy incision. In uterus with previous scars, vaginal procedures like dilatation, suction and evacuation, hysteroscopies can lead to creation of false passages. There is also substantial risk to continue pregnancy after previous hysterotomy. In this case, a false passage was created during first trimester medical termination of pregnancy, for which hysterotomy was performed with evacuation of products of conception by vertical incision on uterus. Moreover, there were already two scars on the uterus. The dilemma in the current pregnancy was about the procedure due to high chances of perforation with suction and evacuation, and radiological investigation suggestive of scar thinning.
Hysterotomy should be best avoided, due to substantial risk of perforation of the uterus. Other risk factors for creation of false passage include nulliparous cervix, scarred uterus, stenotic cervix, menopausal flushed cervix and obesity. It usually occurs when instrument enters in wrong direction or in uterine cavity during adhesiolysis when dissection is done in wrong plane and intramyometrial space is created. It can be prevented by proper cervical traction, use of misoprostol 200 mcg 8 hrs before surgery, use of USG guidance and laparoscopic assistance.[5,6]
In both laparoscopic assistance and laparotomy, perforation is prevented by direct visualisation of the uterine contours. However, in laparotomy, there is a possibility of tactile sensation also, which we used in our case, to our advantage. Salpingectomy could also be performed in a quick manner.
Uterine perforation should be avoided while attempting medical termination of pregnancy in uteri which are scarred. While ultrasound guided and laparoscopy are also options, direct laparotomy remains a good option to avoid uterine perforation and bowel injury.
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Jha N, More V, Chaudhari HK. Scar Integrity Of A Hysterotomy Scar. JPGO 2018. Volume 5 No.12. Available from: https://www.jpgo.org/2018/12/scar-integrity-of-hysterotomy-scar.html