Pawde A*, Chauhan AR**, Mayadeo NM***.
(* Senior Registrar, ** Additional Professor, *** Professor, Department of Obstetrics and Gynecology, Seth G S Medical College and KEM Hospital, Mumbai, India.)
With increasing rates of cesarean section (CS), complications in cases of previous CS such as dense adhesions and adhesions between bladder and uterus are on the rise. These may be identified on speculum and vaginal examination, or by ultrasound. We report a case of dense anterior abdominal wall adhesions which was misdiagnosed as a large intramyometrial collection in a first trimester termination of pregnancy which was abandoned due to hemorrhage.
Adhesions are a common complication after any abdominal surgery. They may present depending upon their location and severity. in cases of previous lower segment cesarean section (LSCS), adhesions have been reported between posterior surface of urinary bladder and uterus. The anterior abdominal wall may also be densely adherent to either the bladder or the uterus itself. Bladder is pulled up due to dense adhesions, and there may be acute anteversion of the uterus leading to change the cervico-uterine angle. These adhesions may be asymptomatic or patients may have chronic pelvic pain; more importantly they pose difficulty in subsequent surgeries.
G3 P2 L2 with 12 weeks’ gestation with previous LSCS was referred to our tertiary care hospital 6 hours after attempted first trimester abortion at a peripheral hospital with history of torrential intraoperative bleeding. The referral note stated that the procedure had been abandoned in view of profuse bleeding while dilating the cervix with metal dilators. She did not have any other complaints such as abdominal pain or hematuria. On examination, her vital parameters were normal; abdomen was soft and non-tender, without any obvious lump or signs of perforation. On speculum examination cervix and vagina were healthy, the cervix was high-up and pulled suprapubically; there was no bleeding coming through cervix. On vaginal examination uterus was non- tender, corresponding to 12 weeks' size, and a firm lump was felt anterior to the uterus with restricted mobility. Sonography reported a large intramyometrial collection (7 x 8 cm) with vascularity, with intact serosa suggestive of perforation in the region of the lower uterine segment. MRI confirmed the sonography report. β HCG was 70,000 mIU/ l. Other biochemical investigations were normal.
Laparotomy was performed: abdomen was opened through the previous Pfannenstiel incision. On inspection, the uterus was acutely anteverted and pulled up, approximately 6 to 8 weeks’ size, with thick bands of adhesions extending from anterior surface of the uterus to the anterior abdominal wall. This gave the appearance of a large sealed off “collection” which was reported on USG and MRI. No obvious hematoma or collection was noted over the anterior uterine wall. Sharp dissection and cautery helped to separate the dense bands. With great difficulty, the region of the previous scar was reached, which was deeply situated; probably the original incision was supracervical. The bladder was densely adherent below it. An extremely small contained collection and perforation in the anterior uterine wall at this level was noted and after evacuation of the products of conception, uterus was sutured with delayed absorbable sutures of polyglactin 910 No 1. Integrity of the bladder was checked with retrograde instillation of methylene blue dye and bladder was found to be intact. Patient recovered uneventfully.
Figure 1. Adhesions between uterus and the anterior abdominal wall.
This case highlights the problems both of MTP and laparotomy in patients of previous cesarean section, as adhesions are a common complication. Thorough examination prior to the MTP may have demonstrated a pulled up cervix or puckering or dimpling i.e. tightly held vaginal mucosa at the bladder, which would have allowed the surgeon to anticipate the possibility of adhesions between uterus, bladder and anterior abdominal wall. Care must be exercised prior to MTP in cases of previous LSCS; USG prior to MTP may have diagnosed adhesions or discrepancy between the clinical estimation of uterine size (12 weeks) and actual gestational age. Technique of first trimester MTP in such patients especially to prevent perforation and other complications needs emphasis. If forceful dilation is attempted in an acutely anteverted uterus it may lead to perforation, hence should be avoided. During dilatation, straightening of the utero- cervical angle by traction on cervix with the vulsellum is a simple step which helps to align the canal and prevent perforation. Methods such as pre-operative cervical ripening with misoprostol and use of manual vacuum aspiration syringe make dilatation easier and procedure less traumatic, respectively. Hence evacuation is simpler and associated with fewer complications, namely perforation and bleeding. MTP was abandoned in this case due to bleeding; this usually signifies perforation or incompleteness of the procedure. USG if available in the operation theatre may have helped.
On ultrasound examination, adhesions are visible in tissue with same density as uterine muscle, reported as horn or beaking of uterus. Rarely as in our case do these adhesions form thick bands which appeared as serosa on ultrasound and MRI. Exploratory laparotomy helped to correctly identify the adhesions. When such adhesions are encountered during a surgery which requires separation of bladder from the uterus, sharp dissection should be performed to prevent inadvertent injury to bladder and integrity of bladder should be confirmed whenever in doubt; it should be tackled at the same sitting.[1,4]
Previous caesarean section may be associated with varied degrees of adhesions and may pose difficulty in subsequent procedures. These should be anticipated with thorough preoperative examination and tackled cautiously.
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Pawde A, Chauhan AR, Mayadeo NM. Anterior Abdominal Wall Adhesions Mimicking Intramyometrial Collection. JPGO 2015. Volume 2 Number 10. Available from: http://www.jpgo.org/2015/10/anterior-abdominal-wall-adhesions.html