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Re: Wha' do I do now? From: Richard Chudacoff, MD (richardc@bcm.tmc.edu) Fri Aug 29 13:37:08 1997 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: zygote@ICSI.Net: "Re: Delivery mode in a patient with a previous rectovaginal fist" Previous message: Len2976@aol.com: "Re: Delivery mode in a patient with a previous rectovaginal fistula" >Dear Listmates > >What would YOU do for this lady? > >69 yr old woman started on Premarin/Provera 3 months ago by FP. >The cervix was stenotic (os completely epithelialized...not even a >dimple) > >She presented to me with pevic pain, an enlarged central pelvic mass and >and the ultrasound showed distended fluid filled uterine cavity. > >Today on Exam under anestrhesia, no os could be located or probed. > >What to do next? >Doubt pyometra, but she may indeed have a hematometra. How to drain it? >Consider hysterectomy? > >Doug Totally amazing, but we just did a similar case this week. This patient either had severe cervical stenosis or agglutinated the vagina just distal/caudal to the cervix. The problem is that the hematocolpos dilated the LUS or upper vagina (still waiting for path to tell us from biopsy) and also dissected into the right broad ligament, up to the level of the IP (which leads me to believe the agglutination etiology rather than the stenosis). We performed a TAH, BSO, but had to go below to find the actual path of the vagina. Imagine that without someone above and below we would have tracked out into the broad ligament and possibly ruptured the iliac vessels. Her original evaluation showed HGSIL, but I questioned the primary doc (I just assisted on this case) whether this was CIN or VaIN. Here is the problem. We closed the cuff above the sight of agglutination. Now she will need follow-up colposcopy, but the sight of the agglutination may cause a stenosis leaving an 'hour glass' shaped vagina, the proximal/cranial sight which may be hidden from view. Now how would you preceed? So, to answer Doug's question, I think a TAH/BSO would be appropriate, keeping in mind that you may end up with some redundant LUS or vagina unless you take it down to the level of the stenosis. Wierd, but fun. Ours was one of the most intellectually stimulating cases I have worked on in a while. Rick -- Richard Chudacoff, MD Assistant Professor, OB/GYN Baylor College of Medicine Practice Medical Director BaylorMedCare 1601 Main St., STE 505 Richmond, TX 77469 tel 281-344-0277 fax 281-344-0288 Advisory Board-OBGYN.net http://www.obgyn.net/board/chudacoff.htm Next message: zygote@ICSI.Net: "Re: Delivery mode in a patient with a previous rectovaginal fist" Previous message: Len2976@aol.com: "Re: Delivery mode in a patient with a previous rectovaginal fistula"

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