Re: Abnormal implantation location--the answer and more!
From: Garry Siegel (garrys@mindspring.com)
Fri Apr 13 18:25:52 2001
The original post is below
Went to the OR, and put in a lapscope first after a vagscan was done
under anesthesia for a "baseline."
Her uterus was not bicornuate, but merely arcuate/septate? (didn't look
inside it), and she had extensive adhesive disease, likely from an old
Laparotomy for an ovarian cyst in elsewhere land, or PID. I was frankly
surprised that she hadn't had a tubal pregnancy, or that she's conceived
twice.
Anyway, the right side was a bit thinned on external inspection, and I
did a curettage with scope guidance, and then a vagscan to make sure the
uterus was empty.
What is your next step?
Garry
>
>30 YO P0010 is now 7 weeks pregnant.
>
>In her first pregnancy, she had spotting that led to a diagnosis of a
>missed Ab at 8 weeks, terminated by uncomplicated D and C in 4/99.
>
>In 10/2000, she had a LEEP for CIN 3 with clear margins.
>
>She is now 7 weeks pregnant, and was brought in prior to her first Ob
>visit with me for an ultrasound to assess viability at 6.5 weeks. The
>sonographer suggested that it represented a possible cornual pregnancy,
>and sent her to the MFM for a scan (I was in surgery and couldn't review
>at the time). The MFM scan concurred, raising the questions as to
>whether this was a cornual versus a right horn pregnancy in a bicornuate
>uterus. The MFM was quite concerned with the lack of thick myometrium
>surrounding the gestational sac, and after discussion, she had an MRI.
>
>The MRI clearly shows a right horn pregnancy (the original radiologist's
>report says the same, as do several that I reviewed the pictures with
>today on site), with 5 mm of myometrium surrounding the gestation.
>
>PS--I've not yet seen this woman, and she is coming in tomorrow. For
>the sake of discussion, let's call her asymptomatic and desirous of the
>pregnancy (she is!).
>
>MFM number one is fearful of uterine rupture, and suggests D and C soon
>(scheduled in a couple of days), with ultrasound guidance. MFM number
>two, who has reviewed the scan and the MRI report, says just peek with a
>lapscope, and if it looks bad, D and C if you can with lapscope
>guidance.
>
>My plan was to D and C with ultrasound and lapscope guidance (the
>ultrasound to make sure the uterus is empty, and the laparoscope to
>watch from above). We also kicked around methrotrexate and misoprostol
>(didn't kick around RU 486), and were a bit worried about "blowing out"
>the uterus with uterotonics.
>
>This is a tough one; no one wants to terminate a "good" pregnancy, but
>no one wants here to present at 18 weeks with a rupture uterus in shock
>requiring a laparotomy, either. Furthermore, to follow her with serial
>scans/MRIs might make a potential easy solution (D and C now) a
>difficult one.
>
>Any thoughts welcome; it is Monday 1700 Eastern time, and she's coming
>in Tuesday AM 1130.
>
>Garry
>
>--
>Garry E. Siegel, M.D., F.A.C.O.G.
>Roswell, GA
>Private Practice
>
--
Garry E. Siegel, M.D., F.A.C.O.G.
Roswell, GA
Private Practice
