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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.