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Abstract
Severe adhesions between the bladder and uterus necessitated an atypical incision in the cesarean section of a woman with endometriosis. This could not be predicted with pre-surgery MRI. No methods in the literature are able to predict adhesions with true certainty; it is therefore still difficult to diagnose intra-abdominal adhesions.
Introduction
The lower transverse incision is a basic surgical technique for cesarean sections, but other uterine incisions may be selected in certain cases, such as placenta previa and accreta. We present a case of fundal uterine incision delivery due to severe adhesions between the bladder and uterus caused by endometriosis. There is no description of such adhesion caused by endometriosis in the recent literature review regarding difficult cesarean sections by Visconti et al.1 Moreover, we could not find a report that clarifies the provides solutions to the difficulties of performing cesarean surgery in women with endometriosis; hence, we could not predict abdominal adhesions or uterine displacement by magnetic resonance imaging (MRI) before delivery. As a consequence, we searched for methods predicting intra-abdominal adhesions preoperatively.
Case
A 41-year-old nulliparous woman diagnosed with endometriosis during treatment for infertility was referred to our hospital at 13 weeks of gestation after in vitro fertilization (IVF) and frozen embryo transfer (FET). She was prescribed low-dose estrogen progestin pills before the IVF-FET. We suspected placenta previa based on transvaginal ultrasound findings at 24 weeks of gestation and diagnosed the patient with total placenta previa at 30 weeks of gestation by MRI (Fig. 1a). Massive genital bleeding and uterine contractions appeared at 31 weeks of gestation. The patient was hospitalized and prescribed magnesium sulfate intravenously (1.0 g per hour) and antenatal corticosteroids (betamethasone 12 mg twice every 24 hours) intramuscularly. The symptoms recurred four days later, and intravenous ritodrine hydrochloride was administered. Since tocolysis was infeasible due to the side effects of the beta-mimetic agent, including parotid gland swelling and elevated serum amylase (3074 U/L), we performed a cesarean section under spinal anesthesia.
After a lower vertical abdominal incision, the right round ligament and oviduct were located in the center of the surgical field, and there were firm adhesions between the bladder and the anterior uterine wall. We made a midline vertical (classical) incision to avoid bladder injury, and a male infant weighing 1884 g was delivered in the cephalic position, with Apgar scores of 3 and 8. The infant was admitted to the Neonatal Intensive Care Unit (NICU) due to prematurity and low birth weight. The placenta was placed on the internal ostium of the uterus and was separated smoothly without massive bleeding. After the uterine suture, the incision was found to cross through the uterine fundus toward the posterior wall (Fig. 2). Consequently, the incision was similar to a transverse fundal uterine incision. We also found lesions of endometriosis, and adhesions between the posterior wall of the uterus and the sigmoid colon (Fig. 3). Anti-adhesion agents were placed on the fundal uterine incision, and the abdominal wall was sutured. The estimated blood loss, including amniotic fluid during surgery, was 1605 mL, and the operation time was 56 min.
One day post-surgery, the patient’s hemoglobin level was 9.2 g/dL; blood transfusion was therefore avoided. The mother was discharged six days after surgery. At 41 days postpartum, we found a hyperechoic lesion, representing the wound, located in the uterine fundus (Fig. 4). The baby was discharged from the NICU 60 days after birth, without any major complications.