gyn defects Flashcards
What is saline ultrasound used for
to image the uterine cavity and is important to assess the acquired defects such as polyps, intrauterine adhesions and fibroids
What is MRI used for
Diagnose mullerian anomalies, obstructive disorders and to identify functioning endometrium and blood
List the cardinal steps in mullerian development
1) elongation of the ducts, 2) fusion of the ducts, 3) canalization of the ducts, and 4) septal resorption between the ducts.
Which renal structures develop from the mesonephric system
ureters, renal calyces and collecting tubules
List the mullerian developmental stage defect for each of the following conditions: Mullerian agenesis, unicornuate uterus, uterine didelphys, vaginal agenesis, septate uterus
Mullerian agenesis: failure of bilateral elongation of ducts. Unicornuate uterus: failure of unilateral elongation of ducts. Uterine didelphys: failure of Fusion of ducts. Vaginal agenesis: failure of canalization. Septate uterus:failure of septal resorption
list the American Fertility Society classifications of mullerian anomalies
class 1: hypoplasia/agenesis. Class 2: unicornuate. Class 3: didelphus. Class 4: bicornuate. Class V: septate. Class VI: Arcuate. Class VII: DES drug related
List the transverse Mullerian defects
Failure of fusion of Mullerian system (upper 2/3 of vagina) with urogenital sinus (lower 1/3 of vagina) causes transverse vaginal septum. Failure of union can rsult in complete vaginal atresia.
Transverse vaginal septum presentation
Obstructive- No menses and periodic lower abdominal pain (due to accumulation of blood above obstruction known as hematocolpos). A growing abdomino-pelvic mass may occur.
Transverse vaginal septum diagnosis/ treatment
PE: blind upper vaginal pouch. MRI to assess septal thicknes. Treatment: surgery if pain is sufficient. Skin grafts may be necessary if septum is thick to prevent strictures and allow for good mucosal healing
Imperforate hymen
obstructive- not mullerian defect. Cyclic pain and growing abdominopelvic mass.
Most common type of mullerian hypoplasia- presentation and concerns
Combined agenesis where the uterus, upper vagina and cervix are all missing. Presents with primary amenorrhea. Concerns include sexual function and reproduction
Vaginal agenesis treatment
A neovagina is created by opening the potential space btw bladder and rectum. A skin graft is placed in this space and allowed to graft to underlying tissues
unicornate uterus Sx
Non-communicating will have obstructive Sx. renal agenesis on same side as missing duct, high rate of spontaneous abortions (most likely due to poor vascularity)
Rudimentary horn
Unilateral elongation defect which is only partial. Can be cavitary (contain functional endometrium) and/or communicating with properly formed horn. Pregnancies that implant in this horn can rupture causing maternal death in 1st or 2nd trimester. They should be removed. A cavitary horn that does not communicate can accumulate blood and lead to obstructive symptoms
How does an ectopic gestation occur in a non-communicating rudimentary horn
Sperm can get to the rudimentary horn by going around the dominant cavity, to the peritoneum and into the rudimentary horn. If the rudimentary horn has functioning endometrium, ectopic gestation can result
Rudimentary horn treatment
remove the horn if it contains functioning endometrium to prevent ectopic pregnancy and obstructive outcomes
unicornuate uterus reproductive potential
Poor- spontaneous abortion rate of 50%
What is didelpys
two uterine horns resulting from failure of the mullerian ducts to fuse at the level of the
what is bicolis
two cervices
Describe lateral fusion failure at the level of: vagina, cervix, above cervix
Vagina: results in a longitudinal vaginal septum, which may or may not be obstructive, and bicolis on either side of the septum. Cervix: leads to two uterine horns (didelphys) and two cervices. Above cervix: leads to two uterine horns (didelpys). For all three, defects of renal system are possible
Reproductive outcomes in uterus didelphys and treatment
Good outcomes- This is likely because of improved vascularity ascompared with the unicornuate uterus. Fetal survival rates are quite reasonable at >55%, which makes this the most reproductively benign of the lateral fusion defects. Surgery is rarely performed
didephys vs bicornuate uterus
As opposed to the didelphic uterus, the bicornuate uterus has communicating endometrial cavities. The bicorunate uterus has a cleft/indentation of at least 1cm seen on MRI
Bicornuate uterus reproductive outcomes and treatment
Reproductive outcomes are reasonably good, with a spontaneous abortion rate of 30% and fetal survival of 60%. Rates tend to be better in women with partial than complete bicornuate uterus. Surgery is rarely performed
List the most common uterine anomaly seen
septate uterus- accounts for 55% of mullerian anomalies
Reproductive outcomes in septate uterus and treatment
The septate uterus has an extremely high rate of first trimester pregnancy loss, with pooled data suggesting a 65% pregnancy loss rate. If pt has a complete septum, the dital portion is poorly vascularized fibrous tissue. Removal of the septum has good outcomes (hysteroscopic metroplasty)
Arcuate uterus repro outcomes
The arcuate uterus reflects only minimal non-resorption of the septum and as such there is no adverse reproductive outcome associated with the condition.
What is Diethylstilbestrol
a synthetic estrogen that was introduced in 1948 for the treatment of recurrent spontaneous abortion, premature deliveries, and other pregnancy complications. It interferes with mesenchyme of reproductive tract of the fetus and can cause spontaneous abortion, ectopic gestation, premature labor and perinatal mortality
During what gestational time period is DES mostly safe
Very early in pregnancy only, or after 22 weeks only
List types of uterine malformations seen with DES use
T shaped uterus (most common), the small hypoplastic uterus, constriction bands, a widened lower uterine segment, a narrowed fundal segment of the endometrium, irregular endometrial margins and intraluminal filling defects. Also fallopian tube abnormalities and cervical incompetence
How can cervical incompetence be treated
cervical cerclage
List malformations seen in males due to DES exposure in utero
cryptorchidism, hypospadias and infertility
What kind of cancer is associated with DES exposure in utero
vaginal clear cell carcinoma
