I had one such patient who had an induced labor in the second trimester. Intrauterine stillbirth, failed to induce labor 4 times, and then developed infection. After communicating with the patient and family about the condition, a cesarean section was performed, and the truth was discovered during the operation.
Labor induction process
Patient, 26 years old, 1 pregnancy with 0 births, without regular obstetric examination. Admission to hospital due to request for induction of labor due to stillbirth at 4+ months of gestation. After admission, the blood routine, blood coagulation routine and other necessary tests and examinations showed no abnormality. Ultrasound showed intrauterine stillbirth, amniotic fluid depth was 4 cm, the cervix was not dilated, and the cervical canal was present.
After admission, rivanol 100 mg was injected into the amniotic membrane. The patient had regular uterine contractions 24 hours after the injection. No labor, no contractions.
The second dose of rivanol amniotic injection was performed. After the injection, the patient had the same reaction as the first time, and she still did not give birth 72 hours after the injection, and there was no uterine contractions.
Review obstetric ultrasound is the same as admission. Misoprostol tablets were administered into the posterior vaginal fornix to induce labor, but no uterine contractions were initiated. At this time, it has been 1 week since the induction of labor, and the patient is still requesting vaginal delivery as much as possible.
Internal diagnosis of cervical canal exists, cervix volume is 1 fingertip, and the cervix is hard. Induction of labor was performed with a hydropouch, but the placement of the hydropouch failed. Next, I plan to try intravenous oxytocin, and re-examination of the blood routine shows that the increase in white blood cells is 15×10^9/L, and the blood coagulation routine is normal, but the patient has fever and a body temperature of 38.5 °C, indicating an infection.
Truth found during surgery
Analyze the case and the treatment process after admission, consider that the patient may have special reasons that lead to the failure of labor induction, even with antibiotics, antipyretic and other treatments, intravenous oxytocin, it is difficult to induce labor successfully in the short term, and Stillbirths exist in the body, infection is not easy to control, and may cause adverse consequences.
Communicate with the patient and family about the condition and perform cesarean delivery. The truth was discovered during the operation. The patient was pregnant with a stump horn. The stump hysterectomy was performed during the operation, and the postoperative recovery was smooth.
Asymmetric development of the mesonephric ducts on both sides, one side of which is not fully developed, forming a lumen or solid uterine horn, not communicating with the cervix and vagina, not communicating with the contralateral uterus, or Only the gap is connected, called the residual horn of the uterus. In 1979, Buttram classified the stump uterus into 3 types:
Type I: The uterine cavity of the residual horn communicates with the uterine cavity of the normal uterus;
Type Ⅱ: the residual horn uterine cavity does not communicate with the normal uterine cavity, accounting for 90%;
Type III: The stump uterus has no uterine cavity.
Type I has an endometrium, which communicates with the uterine cavity on the developing side, and can produce menstrual blood, which flows out through the uterine cavity on the developing side. Patients rarely have adverse reactions.
Type II has an endometrium, but it is not connected to the uterine cavity on the developing side, and it can produce menstrual blood, which is not smooth or flows retrogradely into the pelvic cavity through the fallopian tubes. The patient may experience periodic abdominal pain and abdominal distension and endometriosis symptoms.
Type III is the primordial uterus, without uterine cavity, without cervix, not connected with the developing uterus, connected with the developing uterus by fibrous bands, without menstrual blood, and the patient is generally asymptomatic.
The stump uterine pregnancy is an ectopic pregnancy in which the fertilized egg implants and develops in the stump uterus. It mostly occurs in type I and type II stump uterus. Pregnancy with stump uterus is very rare, with an incidence of 1 in 140,000 to 1 in 100,000.
Because the myometrium of the residual horn is often poorly developed and cannot bear the growth and development of the fetus, most of the myometrium ruptures or incompletely ruptures between 14 and 20 weeks of gestation, causing severe internal bleeding. Occasionally Pregnancy extended beyond 20 weeks or full term, fetal death often occurs after labor.
However, stump uterus is often asymptomatic during non-pregnancy period, and there is no clear clinical manifestation before rupture after pregnancy. The misdiagnosis rate of ultrasound examination during pregnancy is as high as 74%, and only 26% of stump uterus are pregnant. Diagnosed before surgery. Therefore, it is necessary for clinicians to raise their awareness, carefully analyze abnormal clinical manifestations during the diagnosis and treatment process, and discover potential risks.
Clinical diagnostic criteria for stump uterine pregnancy:
If artificial abortion or curettage is performed in the first trimester, the pregnancy tissue is not scraped out during curettage, only the decidua tissue is scraped out, and the miscarriage fails, it is necessary to consider the presence of residual horn uterine pregnancy or uterine horn pregnancy;
If the pregnancy is terminated in the second or third trimester, labor induction is unsuccessful, the cervical canal is hard, the cervix cannot be opened, the amniotic sac and fetal presentation cannot be touched, and the presence of residual Corner uterine pregnancy.
Anatomical characteristics of stump uterine pregnancy:It is mostly bounded by the ligamentum teres, and the fetal sac located inside the attachment point of the ligamentum teres is the pregnancy with the stump horn, and the one located outside the attachment point of the ligamentum teres is tubal pregnancy.
It should be noted that the corneal pregnancy is also located within the round ligament, but the ultrasound of corneal pregnancy shows that the uterus is normal, the gestational sac is located at one side of the uterus, the horn is bulging, and the gestational sac Continuing with the uterine cavity, the peripheral myometrium is thicker; while the gravid stump uterus is mostly located next to the unicornuate uterus on the developing side and is connected to the middle and lower segments of the developing uterus. Master the anatomical and ultrasound characteristics of the two, and it is not difficult to distinguish them clinically.
Case Review
The patient had no previous ultrasound examination of uterine appendages before pregnancy, and ultrasound at a small clinic during the first trimester failed to reveal any abnormality. Ultrasound for stump uterine pregnancyThe diagnostic sensitivity of rheumatoid arthritis decreases further as pregnancy progresses beyond 12 weeks, and the enlarged uterine horns can obscure surrounding anatomical structures, making the diagnosis of stump horn uterine pregnancy difficult. Therefore, the patient lost the best time to diagnose stump uterus pregnancy in the first trimester.
The patient failed multiple times to induce labor, and because of the first child, she had a strong desire to deliver vaginally, which interfered with further processing.
If the cervix remains unopened, will continued strengthening of uterine contractions lead to adverse consequences such as uterine rupture and massive intrapartum hemorrhage? This requires thought and decision. However, the patient had no uterine contractions, and the physical examination indicated that short-term vaginal delivery was hopeless, and that the stillbirth remained in the uterine cavity for too long may cause maternal coagulation dysfunction, resulting in severe bleeding during childbirth. At the same time, during the diagnosis and treatment, the patient developed fever, leukocytosis and other infectious symptoms, and the delivery should be terminated as soon as possible. These evidences suggest that the mode of delivery can be changed to perform cesarean delivery.
Intraoperative exploration and diagnosis of stump uterus pregnancy, the stump uterus and the normal uterine cavity have no pores, which is type II stump uterus. Because the stump uterus is extremely harmful to pregnancy, and type II stump uterus often produces dysmenorrhea symptoms and affects the quality of life, stump uterus + ipsilateral salpingectomy is performed.
Luckily, 2 years later, the patient delivered at term at our hospital.
Teacher Lin Qiaozhi told us: Modern science and technology have improved our ability to recognize and deal with diseases to a certain extent, but they cannot completely replace the direct work of doctors on patients. Practice and experience are still very important. important and valuable. Teacher Lin asked our obstetricians and gynecologists to inquire about the medical history in detail, observe the condition closely, detect changes in time, and handle the problem correctly.
Therefore, for each patient, we must go to the patient to do face-to-face work, and have a clear understanding of the disease and its diagnosis and treatment process. When there is an abnormality in the routine diagnosis and treatment process, even if there is a lack of meaningful auxiliary examination results, we can make in-depth analysis, thinking, and make correct decisions.
Planning: dongdong