Re: VBAC uterus not palpable on bimanual exam.
From: art fougner, md (evsono@pipeline.com)
Thu May 17 07:18:56 2007
Commonly, after cesarean, when I perform tranvaginal sonar, I find the
uterus pulled up and out of the focal range of the transducer. Your
case seems an exaggerated example of that. Yes, I would perform an
annual ultrasound in lieu of the bimanual as her bimanual yields no
info.
Two considerations - first, why do bimanuals on anyone if you have
office ultrasound?
Second, look at the bright side - this patient will never have uterine
prolapse. In fact, this may be the mechanism whereby cesarean decreases
the incidence of prolapse.
Art
At Thu, 17 May 2007, Dr. John Provatopoulos B.Sc. M.D.C.M. F.R.S.C.
wrote:
>
>At Wed, 16 May 2007, Joanne Bulley, MD wrote:
>>
>>I saw a new patient with the following OB history
>>
>>First pregnancy (late 30's) PhD Psychologist - IN THE HOSPITAL at majore
>>center in Boston - abrupted and even with stat CS had a stillbirth.
>>Second pregnancy - hopsitalized for multitude of related issues:
>>spontaneous ruptured uterus at CS scar without labor - another STAT CS -
>>this with live baby. Uterus repaired rather than hyst.
>>
>>So that S**T can hit the rotating blades with disastrous results or very
>>lucky saves in a place with all the ducks ready to fly into action.
>>
>>Her uterus is totally unassessable by exam - I assume from adhesions:
>>nearly impossible to see the cervix and absolutely unable to feel it - I
>>assume it is bound way up high out of the true pelvis! I am getting an
>>US. The Boston docs did US on her for years after the second CS. They
>>finally stopped soing them because "the findings were too boring" (My
>>guess was they coudln't feel it either - even when she was a bit
>>thinnner) - they also told her to never let anyone do a TV US as nothing
>>can be seen with TV US!
>>
>>She had a ruptured appy after the second CS - and the surgeon said she
>>had some of the worst adhesions he had ever dealt with.
>>
>>She reports other general gyns have done horribly painful exams mashing
>>all over trying to find her uterus with a bimanual. When I could not
>>find anything I decided it was going to be not at all meaningful to put
>>her through an overly aggressive exam. She also reports that she had an
>>IUD - a doc said lets take it out (at menopause) - the strings broke off
>>and the doc said lets operate to get it and that might require a hyst.
>>She said "just leave it there" I agreed with that as long as no signs of
>>uterine infection.
>>
>>Since it was my fist visit with her ... I said - lets do another US (it
>>has been a number of years). Since a pelvic exam truly means nothing
>>here - how many of you would decide to never bother at all with a
>>bimanual? Should she have a yearly US??? More often - less often??? (I
>>will see what this one shows and let you know)
>>
>>>--
>>Joanne Bulley, MD, FACOG
>>Solo gyn
>>Keene, NH USA
>>
>Is she still menstrating? the few times I have not felt the uterus was
>in obese post menapausal women with multiple surgeries, previous cones
>or large leeps are often involved. I hope she never had cervical
>dsyplasia. I would not be surprsied if the uterus is stuck to her
>abdominal incision, midline verticle?
>
>--
> Take care, John
>
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
