Engin Oral_Konjenital uterus anomalileri.ppt [Uyumluluk Modu]
Engin Oral_Konjenital uterus anomalileri.ppt [Uyumluluk Modu]
Engin Oral_Konjenital uterus anomalileri.ppt [Uyumluluk Modu]
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P.O. Number Terms Rep Ship Via F.O.B. ProjectQuantity Item Code Description Price Each Amount<strong>Konjenital</strong> Uterus Anomalileri(Güncel Yaklaşım)Dr. <strong>Engin</strong> <strong>Oral</strong>İ.Ü. Cerrahpaşa Tıp FakültesiKadın Hastalıkları ve Doğum Anabilim DalıReprodüktifEndokrinoloji Bilim DalıTotal
<strong>Konjenital</strong> Uterus <strong>anomalileri</strong>– SıklığınedirSorular– İnfertilite yapar mı– Düşük (spontan, tekrarlayan) yapar mı– Diğer sistem <strong>anomalileri</strong> beraberinde olurmu– Tanı için hangi yöntemler kullanılmalı– Ne zaman cerrahi yapılmalı– Cerrahi tedavi hangi anomalilerde ne kadarbaşarılı– Sağlıklı bebek olma ihtimali nedir
Saravelos SH, 2008
• Out of 21.961 deliveries116(0.45%) were in women withuterine anomalies:– Septate <strong>uterus</strong> 37.1%– Uterus didelphys 24.2%– Bicornuate <strong>uterus</strong> 10.3%– Unicornuate <strong>uterus</strong> 12.9%– Arcuate <strong>uterus</strong> 15.5%Yan Z , 2010
EndometriozisAmenoreİnfertilite
% 15-30% 10-15% 10-15
Tanı•HSG•USG–TA, TV, Doppler–SİS(Sonohisterografi)–2D-3D•MRI•H/S ve L/S (Altın standart)
<strong>Konjenital</strong> uterin anomaliler(Sınıflama)American Fertility Society Classification, 1988
AGENESIS/HYPOPLASIA• On USG/MRI:Hematocolpos,rudimentary, absent <strong>uterus</strong>can be identified.
MüllerianAgenezi (Mayer-Rokitansky-Küster-Hauser Sendromu)Normal ssk, normal external genitaliaUterusveFallopiantüplerinyokluğu,Vajeninhipoplazisi46 XXRenalve iskelet <strong>anomalileri</strong>Primer AmenoreCerrahpasa deneyimi 80 olgu Mullerian agenezi 25 (31.2)
Uterus UnicornusA. Rudimenter horn var (%65)1) Endometrial kavite var (%32)a) Kommunikan (%10)b) Non-kommunikan (%22)2) Endometrial kavite yok (%33)B. Rudimenter horn yok (%35)•Rudimenter horn da gebelik: % 13•% 40 ipsilateral renal agenezi
UNICORNUATE UTERUSHSG: banana shapedlat flexed cavity, if noncom.rudimentary cavity exists,can’t be seenUSG:It may easily be overlookedSmall ut w ellipsoid fundalshape.Rud. Horn w.o cavitymay be mistaken as fibroid inbroad lig.
UNICORNUATE UTERUSMain etiologies explaining poor obstetrical outcomes:– Small cavity– Diminished muscle mass– Abnormal uterine blood flow– Cervical incompetenceManagement• Expectant management• Cervical lenght measurement• Cervical suturing in selected cases• Remove rudimentary horn if presentReichman D , 2009
Bikornuat UterusFundusa doğru birbirinden uzaklaşanendometrial kavitelerAradaki doku muskuler, myometriumekosunda değilFundal notch derinliği >1cm
BICORNUATE UTERUSObstetrical outcomes are reported to be betterthan unicornuate <strong>uterus</strong>.Cervical cerclage is often recommended, although there isno good evidence to support it.
UterusDidelfisHSG: Clearly shows but if eithercavities cannot be detected mistaken asunicornuate
• USG: Two widelyspaced fundi, deep cleftseparating two cavities
Resection of the vaginal septum using unipolar coagulation.
Arcuat <strong>uterus</strong>İnkomplet septumKomplet septum
USG/ Uterus Septum• Uterus dış konturu genelde konveks ya da düz• Bazen fundal konkavite (
BİKORNİS - SEPTUM
L/SMRISonohysterographyHysteroscopy
Septum infertilite yapar mı?• Fertilve infertil populasyonda benzer prevelans• İnfertil septumluolgularda izah edilemeyen infertilite sıklığı,genel infertil populasyondan farklı değil (Grimbizis et al. Hum Reprod13: 1188-93, 1998)
Reproductive outcome after hysteroscopicmetroplasty in infertility% 11.5• 61 patients with septate <strong>uterus</strong>and otherwise unexplainedinfertilityRecai Pabuccu and Victor Gomel, 2004
Hysteroscopic resection of the septum improves thepregnancy rate of women with unexplained infertility:a prospective controlled trialSurgeryAntonio Mollo, 2008
RANDOMİZE ÇALIŞMALAR:Septum-İnfertilite•1•2•3•4•5•6(Tedavi vs. Bekleme)
HisteroskopiDeneyim sınıflandırılması• 1.seviye– Diagnostik histeroskopi– Biopsi– Polipektomi– RİA cıkartılması• 2.seviye– Pedinküle myom çıkarılması– Basit adezyolizis– Fallop tübü kanalizasyonu• 3.seviye– Septum rezeksiyonu– Major adezyolizis– Transservikal myom rezeksiyonu– Endometrial rezeksiyonRCOG
When shouldweoperate uterinterine septum?CUT IT or SEE ITTekrarlayan gebelik kayıplarıDüşükler1 Düşük2 Düşük3 DüşükErken doğumİnfertilitePrimerSekonderARTÖncesindeBaşarısız denemeler sonrasıAsemptomatik/primer dismenore
Septum surgery-Clinical pearls• timing of surgery• Use of Misoprostol• use of gonadotropin-releasing hormone (GnRH) agonist or agents suchas danazol before surgery• scissors, resectoscopic incision, laser metroplasty, and bipolar needleelectrodes.• Laparoscope (To differentiate accurately between a septate and abicornuate <strong>uterus</strong>, To monitor hysteroscopic surgery (Perforation)• Septum removal or incision• End point• Complet servical septum (use pediatric Foley and methylene blue inone of the cavities)• fluid input and output• Intravenous antibiotics• balloon catheters or occasionally inert intrauterine devices (IUDs)• Estrogen, routine antibiotic• reevaluated with HSG or hysteroscopy• there is no reason to delay attempts at pregnancy for >2 cycles
Intrauterine device or estrogen treatment after hysteroscopicuterine septum resectionE A Tonguc , T Var, N Yilmaz, S Batioglu. IJOG; 109 (2010)226–229• 100 olgu ,4 grup• NeIUD uygulama, neestrogen tedavisi, ne de herikisi intrauterin adezyonları önlemede ya dagebeliği arttırmada etkin değil
Preoperative preparation of theendometrium•Progestins•Danazol•GnRH analogs•OC•Wide septa•Complete septa
Teknik•Mekanik (makas)•Elektrocerrahi: Resektoskop (Monopolar),Versapoint (bipolar)•Fiberoptik laser:Argon-krypton(KTP532),Nd:YAG, Argon
Septum resection
Nerede durmalı ?v Histeroskop kavitede serbestçe gezdirilebilince ve her iki tubal ostiumaynı anda görünür hale gelince işleme son verilir.v Laparoskopi de yapılıyorsa fundusta ışığın görülmesi yeterli rezeksiyonuifade eder.v Myometrium kanamaya başlayınca işleme son verilir.v Kalan septum 1 cm den küçükse fertiliteyi etkilemez.v Fundusun aşırı inceltilmesi gebelikte rüptür olasılığını arttırır.
Resectoscope or Versapoint for hysteroscopicmetroplastyN:63It could be used predominantlyin nulligravida women, especially in those with cervical canal stenosisPietro Litta, 2008
Complete Septate Uterus: Should the CervicalSeptum Be Removed?• The incidence of cervical incompetence after removal ofthe complete septum is rare.• Possibly impeding vaginal delivery in a subsequentpregnancy.
Hysteroscopic metroplasty of the complete uterineseptum, duplicate cervix, and vaginal septum n: 28sMohammad Ebrahim Parsanezhad, 2006
Complicationsq Wide septumcan cause more intraoperative bleeding.To decreasebleeding:• Preoperative GnRH analogue ordanazol.• Servical vasopressin .• Fundal vasopressin injection.• “thinning” technique for thick septaqIf bleeding persists , the application of a Foley catheter balloon isneeded for 6 hours to the cavity.q Peroperativeperforationq Liquid loadingq Infectionq Rupture during pregnancy and complications associated withplacentaq Intrauterine syneshia(regardless of techniques)
Uterine malformation: diagnosisand results afterhysteroscopic metroplasty114 patients with uterine septa• Septum size was evaluated– septa consisting ¼ of the <strong>uterus</strong>(n=10)– septa consisting ½ of the <strong>uterus</strong>(n=18)– septa consisting greater than½ ofthe <strong>uterus</strong> (n=86)Istre et al, Fertil Steril2010
Women with a septum occupying more than ½ of theuterine cavity have a very high chance of successfulpregnancy after metroplastyIstre et al, Fertil Steril 2010
• Finally, IVF is less successful in women with aseptate<strong>uterus</strong> compared with women who haveundergone metroplasty. For this reason,hysteroscopicmetroplastyshouldbe considered inwomen before undergoing IVF, an emotionallyandfinanciallyexpensiveprocedure• However, women with a septate<strong>uterus</strong> and otherwiseunexplained infertility may benefit from metroplasty,althoughthe improvement in pregnancy rate isrelatively modestin comparison with those whoexperienced recurrentpregnancylossElizabeth Taylor and Victor Gomel, 2008
Uterine rupture at the 29th week of subsequentpregnancy after hysteroscopic resection ofuterine septumŞatıroğlu MH, 2009
•Most of studies report an increase in adversereproductive outcomes, mostly second trimester loss.Tulandi et al., 1980; Acien, 1993; Raga et al., 1997; Woelfer et al., 2001, Zlopasa, 2009.
Arkuat <strong>uterus</strong>, fundan indentasyon < 10 mm
Inkomplet Uterin septum-IVF öncesirutin düzeltilmelimi?•119 inkomplet septum olan hasta•H/S insizyon uygulamış. H/S sonrası IVFsonuçları kontrol grubu ile benzer. Ancakinkomplet septum olgularda abortus oranlarıve başarısız IVF siklus oranları –daha fazlasaptanmışÖzgür K, 2007
DES• HSG:• Perfect imaging modality• Hypoplasic <strong>uterus</strong>,constriction bands• T configuration• Bulbous lower ut segment