Uterine malformations

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It deals with uterine abnormalities and its nursing care

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Uterine malformations M.Santhoshkumari M.Sc ( Nursing) - OBG MTPG&RIHS Puducherry

INTRODUCTION: 

INTRODUCTION For pregnancy and labour to be achieved with minimal difficult, a woman must have normal reproductive anatomy. When structural abnormality of the pelvic organs exists, problems arise that can place an extra burden on mother and fetus.

Definition: 

Definition A uterine malformation is the result of an abnormal development of the Mullerian ducts) during embryogenesis. Symptoms range from amenorrhoea, i infertility, recurrent pregnancy loss, and pain, to normal functioning depending on the nature of the defect.

Embryological development of uterus: 

Embryological development of uterus The female genital tract is formed in early embryonic life when a pair of ducts develops. These paramesonephric or mullerian ducts come together in the midline and fuse into a Y- shaped canal. The open upper ends of this structure lead into the peritoneal cavity and the unfused portions become the uterine tubes. The fused lower portion forms the uterovaginal area, which further develops into the uterus and vagina.

incidence: 

incidence The prevalence of uterine malformation is estimated to be 6.7% in the general population, slightly higher (7.3%) in the infertility population, and Significantly higher in a population of women with a history of recurrent miscarriages (16%).

American Fertility Society Classification : 

American Fertility Society Classification Class I : Agenesis or hypoplasia: segmental or complete (absent uterus). Class II : Unicornuate uterus with or without rudimentary horn (a one-sided uterus). Class III : Didelphys uterus also uterus didelphis (double uterus) Class IV : Bicornuate uterus: complete or partial (uterus with two horns)

Classification – Cont’d: 

Classification – Cont’d Class V : Septate Uterus: complete or partial (uterine septum or partition). Class VI : Arcuate uterus: There is a concave dimple in the uterine fundus within the cavity. Class VII : DES-related abnormalities: The uterine cavity has a "T-shape" as a result of fetal exposure to diethylstilbesterol

Another Classification: 

Another Classification Imperfect fusion of two mullerian ducts. Aplasia and hypoplasia of the mullerian ducts.

Imperfect fusion of two mullerian ducts. : 

Imperfect fusion of two mullerian ducts. Uterus Didelphys Uterus Bicornis Bicollis Uterus Bicoris Unicollis Septate uterus. Subsepted Uterus unicornis

DOUBLE UTERUS: 

DOUBLE UTERUS

Aplasia and hypoplasia of the mullerian ducts.: 

Aplasia and hypoplasia of the mullerian ducts. There can be absence of uterus or rudimentary, infantile and hypoplastic uterus. Congenital atresia of cervix may very rarely occur. Likewise, congenital elongation of cervix may also occur.

Classification of congenital uterine malformations: 

Classification of congenital uterine malformations A. Malformations due to arrested development of the Mullerian ducts They occur during the first phase of embryonic development, i.e. in the phase of craniocaudal growth of the Mullerian ducts. They may be (a) Symmetrical or bilateral: uterine aplasia (b) Asymmetrical or unilateral: uterus unicornis unicollis.

B. Malformations due to failure of fusion of the Mullerian ducts : 

B. Malformations due to failure of fusion of the Mullerian ducts The malformations vary according to whether failure of fusion is total or partial: (a) Uterus didelphys (b) Uterus bicornis bicollis (c) Uterus bicornis unicollis (d) Uterus arcuatus : the least marked degree of failure of fusion.

C. Malformations from incomplete resorption of the sagittal septum : 

C. Malformations from incomplete resorption of the sagittal septum uterus septus, due to non-resorption of the sagittal septum, residuum of the primitive duality Uterus subseptus, due to partial resorption of the septum.

D. Developmental defects of the uterine cavity : 

D. Developmental defects of the uterine cavity Uterine hypoplasia in the strict sense Infantile uterus with disproportion between body and cervix Uterus with gaping cervix and isthmus Pencil uterus; Star-shaped uterus.

MALFORMATION OF THE FALLOPIAN TUBES AND OVARY : 

MALFORMATION OF THE FALLOPIAN TUBES AND OVARY Congenital elongation accessory abdominal ostium small diverticulum or atresia absence of the fallopian tube may seldom occur. Absent, rudimentary or accessory ovary or ovarian aplasia are the congenital failure of the ovarian function.

PREGNANCY AND LABOUR IN UTERINE MALFORMATION: 

PREGNANCY AND LABOUR IN UTERINE MALFORMATION Minor degrees of developmental defects of the uterus do not usually interfere with pregnancy and labour. In most cases of uterine deformities, the two portions of the uterus and a false decidua may form in the other half. Abortion does not occur infrequently – in some cases premature labour is the result; in the minor malformations, the pregnancy often goes on to term and ends normally.

UTERUS DIDELPHYS: 

UTERUS DIDELPHYS Pregnancy may take a normal course. Occasionally, delivery may be impeded by the septum in the vagina In the early weeks of pregnancy the presence of the non-gravid uterus may give rise to the mistaken diagnosis of an extrauterine gestation In some of these cases menstruation may occur throughout the course of pregnancy form the non pregnant uterus. The pregnancy may be complicated by abortion, preterm delivery, fetal growth restriction and malpresentation.

UTERUS BICORNIS BICOLLIS : 

UTERUS BICORNIS BICOLLIS Pregnancy may occur either half of the uterus, and when it occurs in one horn of a bicornuate uterus, the other undergoes some degree of hypertrophy and a decidua is formed in its cavity. Repeated abortions and breech presentations may occur more frequently than in a normal uterus. Usually, the pregnancy takes a normal course and the delivery is spontaneous.

UTERUS BICORNIS BICOLLIS: 

UTERUS BICORNIS BICOLLIS In rare instances, the non pregnancy horn of the uterus may impede the progress of labour of labour by obstructing the passage of the head in the pelvic cavity. It is difficult to make a positive diagnosis till the delivery is completed. The presence of a double vaigna or a double cervix ay possibly gives a clue. With uterus bicornis unicollis, the difficulty of diagnosis is even greater, and some cases are not diagnosed till after delivery.

UTERUS SEPTUS AND SUBSEPTUS: 

UTERUS SEPTUS AND SUBSEPTUS The fundus of the uterus may be normal in outline or occasionally there may be a depression at the fundus (arcuate uterus). In some, pregnancy and labour proceed normally but sometimes repeated abortion may occur Malpresentations, specially breech, may be more frequent. In some cases, the placenta may be retained or adherent and it is during the manual removal of the placenta that the condition is generally diagnosed. In a few cases, the head or part of the fetus may pass through the septum

UTERUS UNICOLLIS : 

UTERUS UNICOLLIS Pregnancy is extremely rare in this type of uterine deformity. Pregnancy in the rudimentary horn is attended with grave risks. Increased Incidence of abortion, preterm labour, IUGR, breech presentation, uterine dysfunction in labour and caesarean section occur.

ARCUATE UTERUS : 

ARCUATE UTERUS There is depression at fundus. Fundal notching can be detected at late pregnancy. This results in transverse lie.

EFFECTS OF ABNORMALITY ON PREGNANCY: 

EFFECTS OF ABNORMALITY ON PREGNANCY When pregnancy occurs in the woman with an abnormal uterus, the outcome depends on the ability of the uterus to accommodate the growing fetus. A problem exists only if the tissue is insufficient to allow the uterus to enlarge for a full-term fetus lying longitudinally. If there is insufficient hypertrophy, the possible difficulties are aborton, premature labour and abnormal lie of the fetus. In labour, poor uterine function may be experienced.

EFFECTS OF ABNORMALITY ON PREGNANCY: 

EFFECTS OF ABNORMALITY ON PREGNANCY Minor defects of structure cause little problem and might pass unnoticed with the woman having a normal outcome to her pregnancy. Occasionally problems arise when a fetus is accommodated in one horn of a double uterus and the empty horn has filled the pelvic cavity. In this situation the empty horn had grow owing to the hormonal influences of the pregnancy, and its size and position will cause obstruction during labour. Caesarean section would be the method of delivery.

CLINICAL FEATURES : 

CLINICAL FEATURES Gynecological: Infertility and dyspareunia are often related in association with vaginal septum Dysmenorrhoea in bicornuate uterus or due to cryptomenorrhoea (pent up menstrual blood in rudimentary horn) Menorrhagia – due to increased surface area in bicornuate uterus.

Obstetrical : 

Obstetrical Midtrimester abortion which may be recurrent. Cornual pregnancy – with inevitable rupture around 16 th week – if pregnancy occurs in the rudimentary horn Increased incidence of malpresentation – transverse lie in arcuate or subseptate., breech in biconuate, unicornuate or complete septate uterus Preterm labour Prolonged labour – due to incordinate uterine action Obstructed labour – obstruction by the non-gravid horn of the bicornuate uterus or rudimentary horn Retained placenta and postpartum hemorrhage where the placenta is implanted over the uterine septum.

DIAGNOSIS : 

DIAGNOSIS Physical examination Gynaecologic Ultrasonography Pelvic MRI Hysterosalphinography Laparoscopy and/or Hysteroscopy may be indicated. In some patients the Vaginal development may be affected.

TREATMENT : 

TREATMENT Uterine malformations like absence, rudimentary or infantile are not amenable to treatment. Hypoplastic uterus in young girls may gradually develop with advance of age. Oestrogen therapy may be temporarily given for amenorrhea, oligomenorrhoea; dilation and curettage may be helpful in some cases with dysmenorrhoea. Chance pregnancy develops in the hypoplastic uterus.

TREATMENT – Cont’d : 

TREATMENT – Cont’d Surgery of the double uterus is indicated in haematometra or pyometra in the rudimentary uterine horn or in cases with habitual abortion. Noncommunicating uterine horn with haematometra or pyometra is to be excised. Bicornuate uterus with habitual abortion or infertility may indicate for unification of both uterine cavities after the excision of the tissue in between two cavities. (Strassmann operation). Likewise removal of the septum may rarely called for septate uterus.

PowerPoint Presentation: 

Cerclage: cervical cerclage is indicated in women with uterine didelphys, unicornuate or bicornuate uterus and poor reproductive performance. Metroplasty: women with septate or bicornuate uterus, uterine didelphys and recurrent pregnancy loss are likely to benefit from uterine repair. A septate or bicornuate uterus may occasionally be the etiological factor in repeated abortions. Corrections of this abnormality by excision of the septum or any form of strassman’s operation will often result in successful pregnancies.

Strassmann Hysteroplasty Operation. : 

Strassmann Hysteroplasty Operation. Paul Strassmann from Berlin, 1907 first did the hysteroplasty by making a transverse incision on the double uterus and the septum and repaired on the anteroposterior plane. He did not remove the septum. His son, E.O.Strassmann, 1952 popularized this operation in U.S. Jones and Jones, 1953 from U.S.A. modified the operation by incising the uterus vertically from fundus to the internal os. A triangular wedge of tissue including the septum is removed and the walls of the two cavities are sutured in layers.

Nursing Diagnosis : 

Nursing Diagnosis Anxiety related to unknown outcome of diagnostic work up. Body image or self-esteem disturbance related to impaired fertility. High risk for impaired individual/family coping related to methods used in the investigation of impaired fertility. Decisional conflict related to therapies for impaired fertility and alternatives to therapy: childlessness or adoption. Altered family processes related to unmet expectations for pregnancy.

Nursing Diagnosis : 

Nursing Diagnosis Anticipatory grieving related to expected poor prognosis. Acute pain related to effects of diagnostic tests (or surgery) Powerlessness related to lack of control over prognosis. Altered patterns of sexuality related to loss of libido secondary to medically imposed restrictions. High risk for social isolation related to impaired fertility, its investigation and management.

COMPLICATIONS : 

COMPLICATIONS Abortion Weak uterine action Post partum hemorrhage Adhesion of the placenta Malpresentations Prolonged or obstructed labour Uterine rupture due to its poor development. The placenta, if it is formed on the septum, may be adherent and may cause post partum hemorrhage.

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