A uterocutaneous fistula is an abnormal tract between the endometrium of the uterus and the skin. It is a rare but significant postcesarean section complication. This is a case of a 39-year-old female who presented with cyclical bleeding from her cesarean section scar during menstruation over the past 4 years. The assessment revealed a discharging sinus in the scar and an acutely anteverted, fixed uterus. Symptoms persisted despite medical treatment for the provisional diagnosis of endometriosis. The diagnosis was updated as uterocutaneous fistula based on a computed tomography scan of the pelvis and abdomen and a hysterosalpingogram. The fistula was surgically excised, and a hysterectomy was performed. This report elaborates on the rare presentation, diagnosis, and definitive surgical management. The surgical management resulted in a successful resolution, highlighting the importance of choosing the appropriate treatment modality while adhering to a patient-centered approach.
Cesarean Section

A 40-year-old, gravida 3 para 2 (1-1-0-2), previous primary cesarean section for nonreassuring fetal status, presented at a tertiary hospital for confirmation of cesarean scar pregnancy (CSP). Transvaginal ultrasound confirmed a CSP at 8 2/7 weeks age of gestation with good embryonic cardiac activity, raising concern for early placenta accreta spectrum. A multidisciplinary team composed of an obstetrician, advanced pelvic surgeon, urologist, and anesthesiologist managed the patient. The patient underwent total abdominal hysterectomy with bilateral salpingectomy, as the patient has a completed family size. Before the procedure, she was given cefuroxime as prophylactic antibiotic. Intraoperatively, there were dense adhesions between the posterior bladder wall and the previous cesarean section scar. Inadvertent injury to the bladder wall was incurred during adhesiolysis. Cystorrhaphy was done by a urologist, while the rest of the surgery was unremarkable, with a 450 ml estimated blood loss. The postoperative course was unremarkable. Bladder rest was achieved by maintaining an indwelling Foley catheter, which remained in place upon discharge on postoperative day 3 and was continued for 7 days thereafter. At follow-up, a successful voiding trial was conducted, confirming the return of normal bladder function.

Human ; Female ; Adult: 25-44 Yrs Old ; Cesarean Section ; Salpingectomy ; Hysterectomy ; Fetal Distress ; Placenta Accreta ; Cefuroxime ; Catheters ; Cicatrix

Objective: To investigate the clinical characteristics of induced labor in twin pregnancy and the related factors of induced labor failure. Methods: The clinical data of twin pregnant women who underwent induced labor in Peking University Third Hospital from January 2016 to December 2022 were retrospectively analyzed. According to whether they had labor or not after induction, pregnant women were divided into the success group (pregnant women who had labor after induction, 72 cases) and the failure group (pregnant women who did not have labor after induction, 30 cases). Logistic regression was used to analyze the related factors of induction failure in twin pregnant women. Results: The parity and cervical Bishop score in the failure group were significantly lower than those in the success group, while the proportion of dichorionic diamniotic twins, assisted reproductive technology pregnancy and cervical Bishop score <6, postpartum hospital stay and total hospital stay in the failure group were significantly higher than those in the success group (all P<0.05). The proportion of induced labor by artificial rupture of membranes ± oxytocin intravenous infusion in the success group was 72.2% (52/72), which was significantly higher than that in the failure group (46.7%, 14/30; P=0.030). There were no significant differences between the two groups in the gestational age at delivery, the incidence of severe postpartum hemorrhage and blood transfusion, the amount of postpartum hemorrhage, the neonatal weight of two fetuses, the incidence of neonatal asphyxia, and the proportion of neonates admitted to the neonatal intensive care unit (all P>0.05). There were no severe perineal laceration and hysterectomy in all pregnant women. Multivariate logistic regression analysis showed that primipara (OR=3.064, 95%CI: 1.112-8.443; P=0.030) and cervical Bishop score <6 (OR=5.208, 95%CI: 2.008-13.508; P=0.001) were the independent risk factors for induction failure in twin pregnancy. Conclusions: Elective induction of labor in twin pregnancy is safe and feasible. It is helpful to improve the success rate of induction of labor by strictly grasping the timing and indications of termination of pregnancy, choosing the appropriate method of induction according to the condition of the cervix, and actively promoting cervical ripening .
Infant, Newborn ; Pregnancy ; Female ; Humans ; Pregnancy Trimester, Third ; Pregnancy, Twin ; Postpartum Hemorrhage/etiology* ; Retrospective Studies ; Labor, Induced/methods* ; Cervical Ripening

Objective: To investigate the clinical characteristics, treatments and fertility recovery of rudimentary horn pregnancy (RHP). Methods: The clinical data of 12 cases with RHP diagnosed and treated in Peking University Third Hospital from January 1, 2010 to December 31, 2022 were retrospectively analyzed. Clinical informations, diagnosis and treatments of RHP and the pregnancy status after surgery were analyzed. Results: The median age of 12 RHP patients was 29 years (range: 24-37 years). Eight cases of pregnancy in residual horn of uterus occurred in type Ⅰ residual horn of uterus, 4 cases occurred in type Ⅱ residual horn of uterus; among which 5 cases were misdiagnosed by ultrasound before surgery. All patients underwent excision of residual horn of uterus and affected salpingectomy. After surgery, 9 patients expected future pregnancy, and 3 cases of natural pregnancy, 2 cases of successful pregnancy through assisted reproductive technology. Four pregnancies resulted in live birth with cesarean section, and 1 case resulted in spontaneous abortion during the first trimester of pregnancy. No uterine rupture or ectopic pregnancy occurred in subsequent pregnancies. Conclusions: Ultrasonography could aid early diagnosis of RHP while misdiagnosis occurred in certain cases. Thus, a comprehensive judgment and decision ought to be made based on medical history, physical examination and assisted examination. Surgical exploration is necessary for diagnosis and treatment of RHP. For infertile patients, assisted reproductive technology should be applied when necessary. Caution to prevent the occurrence of pregnancy complications such as uterine rupture, and application of cesarean section to terminate pregnancy are recommended.
Pregnancy ; Humans ; Female ; Young Adult ; Adult ; Cesarean Section/adverse effects* ; Retrospective Studies ; Pregnancy, Ectopic/surgery* ; Pregnancy, Cornual/surgery* ; Uterus/surgery* ; Uterine Rupture/etiology* ; Abortion, Spontaneous

Ruptured Sinus of Valsalva (RSOV) is a rarely encountered cardiac anomaly that can potentially lead to adverse clinical outcomes. RSOV increases the risk of morbidity during pregnancy due to the physiological changes associated with gestation, that can exacerbate the underlying cardiac pathology. We present the case of a 29-year-old female with an uncorrected RSOV who required an emergency cesarean section for abruptio placenta. The patient underwent the procedure under spinal anesthesia, with careful titration of norepinephrine infusion and close monitoring of hemodynamic parameters using an invasive intra-arterial line. Given the absence of established anesthetic protocols for parturients with RSOV undergoing cesarean delivery, a comprehensive understanding of the complex interaction between the hemodynamic effects of RSOV, pregnancy, and anesthesia is essential. This understanding enables the safe use of spinal anesthesia in urgent situations, leading to favorable patient outcomes.
Sinus of Valsalva ; Aortic Rupture ; Cesarean Section ; Anesthesia, Spinal

Pregnancy ; Humans ; Female ; Cesarean Section ; Consensus ; Trial of Labor

BACKGROUND

Hysteroscopic myomectomy is regarded as the gold standard in the management of intracavitary myomas. With its increased use, it is essential to explore its effectiveness for better therapeutic planning and patient selection.

OBJECTIVES

This study aimed to determine the effectiveness of hysteroscopic myomectomy performed in a tertiary hospital in the Philippines.

METHODS

A retrospective cross-sectional study of women who underwent hysteroscopic myomectomy in 5 years was performed.

RESULTS

A total of 167 women were included. Completeness of resection was achieved in 88.46% of the cases. In the final multivariate model, older age, pretreatment with gonadotropin-releasing hormone (GnRH) agonist, and lesser total fluid input were associated with increased odds of complete resection. Submucous myoma at least 3 cm in size had greater total fluid input, greater blood loss, the presence of complications, and a greater need for transfusion. Pretreatment with GnRH agonists had more International Federation of Gynecology and Obstetrics Grade 1 and 2 myoma, higher frequency of ≥3 myomas, lower frequency of complete resection, and increased operative time compared to those without pretreatment with GnRH agonists. Pretreatment with other hormonal therapy had a lesser need for transfusion compared to those without pretreatment with hormonal therapy.

CONCLUSIONS

Hysteroscopic myomectomy is a generally safe and effective procedure for the treatment of submucous myomas. The odds of complete resection are greater with older age and decreased with pretreatment with GnRH agonist and more distention fluid used. Larger submucous myoma was associated with greater total fluid input and blood loss, more complications, and greater need for transfusion. Pretreatment with GnRH agonist had no significant benefit and was associated with longer surgical time and lesser complete resection.

Human ; Female ; Fibroids ; Leiomyoma ; Hysteroscopy ; Myomectomy ; Uterine Myomectomy

BACKGROUND

Simulated video training has emerged as an effective method to enhance the surgical skills. However, in the local context, there is an absence of data contrasting the outcomes of unsupervised video training with the conventional supervised approach in surgical skill development.

OBJECTIVE

The objective of this study was to evaluate and contrast the performance score and total operating time between unsupervised video training simulations and supervised video training simulations, specifically in the domain of 30° hysteroscopic camera navigation.

MATERIALS AND METHODS

A single-blinded randomized controlled trial involved 24 obstetrics and gynecology residents in a tertiary government institution. Participants were randomized into Group A (unsupervised video training) and Group B (proctor-supervised simulation training). Utilizing a uterine model, both groups undertook nine designated tasks. The training process included a pretest simulation, 5 training repetitions, and a concluding posttest simulation. The principal investigator documented operating times and hand movements posteach session. Subsequently, a blinded Philippine Society for Gynecologic Endoscopy board-certified gynecologic endoscopist assessed these videos, using the Global Hysteroscopy Rating Scale for scoring.

RESULTS

The total operating time and performance score during posttest among Group A and Group B showed no significant difference (Group A 0.77 ± 0.19 min Group B 0.71 ± 0.15 min) (P = 0.377) (Group A 13.50 ± 1.73 Group B 13.83 ± 1.53) (P = 0.622) which suggest that participants performed comparably regardless of instructional method. On the Global Rating Scale (GRS) score, higher percentage of participants from Group B showed improved performance on respect for tissue, time and motion, and handling of hysteroscope as compared to Group A.

CONCLUSION

The video-based training simulation is effective as expert proctoring in hysteroscopic camera navigation. However, there was slightly greater improvement in the GRS scores in the proctor supervised group which suggest that feedback from proctors has a positive impact on the performance.

Human ; Hysteroscopy

INTRODUCTION

Hysteroscopy is the gold standard procedure for the evaluation and diagnosis of intrauterine pathologies. The optimal time to do hysteroscopy is during the proliferative phase. However, for women with irregular bleeding, the optimal time is unpredictable. Besides pharmacological means, mechanical endometrial preparation could be done.

OBJECTIVE

The objective of this study was to determine the effect of suction curettage on visualization, operative time, fluid deficit, and histopathologic diagnosis among perimenopausal women with abnormal uterine bleeding (AUB) and unprepared endometrium prior to operative hysteroscopy.

METHODOLOGY

Thirty-four (34) perimenopausal women admitted for AUB with unprepared endometrium for operative hysteroscopy who consented to participate were recruited and randomly divided into two groups: 18 women had suction curettage done prior to operative hysteroscopy and 16 women had operative hysteroscopy done alone. The following data were obtained for each group: (1) improvement in clarity (i.e., visualization of fundus and both tubal ostia), (2) operative time from entry to withdrawal of the resectoscope (measured in minutes), (3) fluid deficit, and (4) final histopathological diagnosis. P 

RESULTS

Women who underwent suction curettage prior to operative hysteroscopy had improved visualization (72.2%, P < 0.001), shorter operative time (29.06 ± 7.06 min vs. 35.5 ± 7.2 min, P = 0.013), no difference in fluid deficit (P = 0.276), and the histopathologic diagnosis (P = 0.470).

CONCLUSION

Suction curettage prior to operative hysteroscopy among perimenopausal women with AUB and unprepared endometrium improved visualization and shortened operative time without affecting fluid deficit and histopathologic diagnosis.

Hysteroscopy ; Suction Curettage ; Vacuum Curettage

The case report discusses a rare occurrence of tubal pregnancy in a patient with uterine didelphys, managed using combined hysteroscopy and laparoscopy. A 29-year-old Gravida 2 Para 0 (0010) with a right tubal ectopic pregnancy alongside incidental uterine didelphys detected via physical examination and three-dimensional transvaginal ultrasound. The patient underwent a combined diagnostic and operative laparoscopy, where a right salpingectomy was performed using a harmonic scalpel. Diagnostic laparoscopy showed two uterine horns with each attached fallopian tube and ovary with an interostial length of 4 cm. Diagnostic hysteroscopy confirmed the presence of two separate uterine cavities and cervices without communication. The procedure demonstrated that the technique for laparoscopic salpingectomy in cases of uterine didelphys parallels that for a normal uterus. The use of combined hysteroscopy and laparoscopy proved effective in evaluating both the external uterine structure and internal cavity, facilitating accurate diagnosis and treatment of Müllerian anomalies with ectopic pregnancy.

Human ; Female ; Adult: 25-44 Yrs Old ; Hysteroscopy ; Laparoscopy ; Pregnancy, Tubal ; Uterine Didelphys