Engin Oral_Konjenital uterus anomalileri.ppt [Uyumluluk Modu]

P.O. Number Terms Rep Ship Via F.O.B. ProjectQuantity Item Code Description Price Each AmountKonjenital Uterus Anomalileri(Güncel Yaklaşım)Dr. Engin Oralİ.Ü. Cerrahpaşa Tıp FakültesiKadın Hastalıkları ve Doğum Anabilim DalıReprodüktifEndokrinoloji Bilim DalıTotal

Konjenital Uterus anomalileri– SıklığınedirSorular– İnfertilite yapar mı– Düşük (spontan, tekrarlayan) yapar mı– Diğer sistem anomalileri 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 uterus 37.1%– Uterus didelphys 24.2%– Bicornuate uterus 10.3%– Unicornuate uterus 12.9%– Arcuate uterus 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)

Konjenital uterin anomaliler(Sınıflama)American Fertility Society Classification, 1988

AGENESIS/HYPOPLASIA• On USG/MRI:Hematocolpos,rudimentary, absent uteruscan be identified.

MüllerianAgenezi (Mayer-Rokitansky-Küster-Hauser Sendromu)Normal ssk, normal external genitaliaUterusveFallopiantüplerinyokluğu,Vajeninhipoplazisi46 XXRenalve iskelet anomalileriPrimer 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 uterus.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 uterusİnkomplet 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 uterusand 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 uterus, 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 uterus(n=10)– septa consisting ½ of the uterus(n=18)– septa consisting greater than½ ofthe uterus (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 aseptateuterus compared with women who haveundergone metroplasty. For this reason,hysteroscopicmetroplastyshouldbe considered inwomen before undergoing IVF, an emotionallyandfinanciallyexpensiveprocedure• However, women with a septateuterus 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 uterus, 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 uterus,constriction bands• T configuration• Bulbous lower ut segment