Re: Abnormal implantation location--the answer and more!
From: Efrain Ramirez (eramirez@icepr.com)
Fri Apr 13 19:29:26 2001
Serial quantitative hCG's.
Good job.
At Fri, 13 Apr 2001, Garry Siegel wrote:
>
>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
>
--
"Life is neither the notes nor the silence between the notes, but the music that
arises out of sound and silence felt as a living whole. Stop choosing...between
chaos and order, and live at the boundary between them, where rest and action
move together..." David Whyte
