(* 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 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.
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 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]
- Song D, Xia E, Xiao Y, Li TC, Huang X, Liu Y. Management of false passage created during hysteroscopic adhesiolysis for Asherman's syndrome. J Obstet Gynaecol. 2016;36(1):87-9
- Heys RF. Pregnancy after hysterotomy. Br Med J. 1973;1(5854):681-2
- Frick AC, Drey EA, Diedrich JT, Steinauer JE.Effect of prior cesarean delivery on risk of second-trimester surgical abortion complications.Obstet Gynecol. 2010 Apr;115(4):760
- Lederle L, Steinauer JE, Montgomery A, Aksel S, Drey EA, Kerns JL.Obesity as a Risk Factor for Complications After Second-Trimester Abortion by Dilation and Evacuation.Obstet Gynecol. 2015 Sep;126(3):585-92.
- Fritz RB, Rosenblum N, Gaither K, Sherman McCalla A. Successful Laparoscopically Assisted Transcervical Suction Evacuation of Interstitial Pregnancy following Failed Methotrexate Injection in a Community Hospital Setting. Case Reports in Obstetrics and Gynecology. 2014. 2014: 695293. Available from: http://dx.doi.org/10.1155/2014/695293
- Anagani M, B Radhika, P Vandana. Role of Laparoscopy in Management of Post Abortion Haemorrhage. SciFed Obstetrics & Women Healthcare Journal. 2017. Available from: http://scifedpublishers.com/fulltext/role-of-laparoscopy-in-management-of-post-abortion-haemorrhage-case-reports/21492