Abnormalities of the Reproductive Tract
Chapter 28. Abnormalities of the Reproductive Tract
1st year resident S.B. Cho M.D.
I. DEVELOPMENTAL REPRODUCTIVE TRACT ABNORMAITIES
Most of defects : sporadically
? ? Even minor defects : increased incidence in significant fetal & maternal hazards
A. Vulvar Abnormalities
1. Atresia
B. Vaginal, cervical, uterine Abnormalities
Brief embryology of female genital tract
1. Genesis and Classification of Mullerian Abnormalities
Classification of embryological defects
Types of Cervices
Types of Vaginas
2. Diagnosis of Vaginal Septa
By pelvic examination
3. Diagnosis of Cervical & Uterine Malformations
Simple inspection, bimanual examination,
During surgery,
Ultrasound,
Hysteroscopy & hysterography,
MRI
4. Urologic Evaluations
Up to one thirds of women with mullerian defects --> have auditory defects
C. Obstetrical Significance of Vaginal Abnormalities
1. Septa & Strictures
2. Atresia
D. Obstetrical Significant of Cervical Abnormalities
1. Atresia & Stenosis
E. Obstetrical Significance of Uterine Hypoplasia & Agenesis
1. Buttram & Gibbons Class 1.
2. Buttram & Gibbons Classes ¥± through ¥´
3. Reproductive Performance of Women with Unicornuate Uterus (Buttram & Gibbors Class ¥±)
4. Reproductive Performance in Women with Uterine Didelphys (class ¥²)
5. Reproductive Performance in Women with Bicornuate & Septate Uteri (class ¥³ & ¥´)
# Management of Uterine abnormalities
1. Cerclage
2. Metroplasty
F. Diethylstilbesteral - Induced Reproductive Tract Abnormalities
1. Structural Abnormalities
2. Reproductive Performance
3. Treatment
II. ACQUIRED REPRODUCTIVE TRACT ABNORMAITIES
A. Vulvar Abnormalities
B. Vaginal Abnormalities
C. Cervical Abnormalities
D. Uterine Displacement
E. Uterine Leiomyomas
1) Cervical Myomas
2) Imaging of Myomas
3) Myomectomy during Pregnancy
4) Myomectomy Before Pregnancy
F. Endometriosis
G. Adenomyosis
H. Ovarian Tumors
1. Benign Ovarian Tumors
2. Carcinoma of the Ovary.
1st year resident S.B. Cho M.D.
I. DEVELOPMENTAL REPRODUCTIVE TRACT ABNORMAITIES
? ? Even minor defects : increased incidence in significant fetal & maternal hazards
A. Vulvar Abnormalities
1. Atresia
- Complete atresia of vulva : precludes conception
- Incomplete atresia of vulva due to adhesions & scars following injury or infection
B. Vaginal, cervical, uterine Abnormalities
- 3 ~ 5wks ; metanephric duct + cloaca.
- 4 ~ 5wks ; two ureteric buds develops distally from the mesonephric ducts, begin to grow cephalad toward the mesonephros
- Mullerian (paramesonephric) ducts : form bilaterally between the developing gonads 2 mesonephros.
- Mullerian duct --> extends downward & laterally to the mesonephric ducts --> finally turn medially to meet & fuse together in the midline
- Fused mullerian ducts --> descends to the urogenital sinus to join the mullerian tubercle.
- Mullerian duct & mesonephric ducts --> damage to either duct system will most often be associated with damage to both - uterine horn, kidney & ureter
- 10th week : union of two mullerian ducts --> uterus formation, fusion begins in the midline --> caudally & cephalad.
- Uterine cavity formed as the septum dissolved slowly
- The vagina --> forms between the urogenital sinus & mullerian tubercle by a dissolution of the cell cord between the two structures
1. Genesis and Classification of Mullerian Abnormalities
- Defective canalization of the vagina --> transverse vaginal septum
- Unilateral maturation of mullerian duct, with incomplete or absent development of the opposite duct & upper urinary tract defects
- Absent or faulty midline fusion of the mullerian ducts
- Single
- Septate ; single muscular ring partitioned by a septum
- Double ; two distinct cervices
- Single
- Longitudinally septated ;
- Double ; double introitus
- Transversely septate
2. Diagnosis of Vaginal Septa
3. Diagnosis of Cervical & Uterine Malformations
4. Urologic Evaluations
C. Obstetrical Significance of Vaginal Abnormalities
1. Septa & Strictures
- Complete septum ; no problem, incomplete septum ; cause dystocia
- Congenital annular stricture or band --> during labor, softening & dilatation occurs
- Transverse septum ; slight pressure or cruciate incision
2. Atresia
- Complete atresia --> bar to pregnancy
- Incomplete atresia --> due to tissue softening, during pregnancy, obstructions are gradually overcome
D. Obstetrical Significant of Cervical Abnormalities
1. Atresia & Stenosis
- Complete stenosis --> pregnancy (-)
- Incomplete stenosis --> tissue softening during pregnancy --> dilation occurs
E. Obstetrical Significance of Uterine Hypoplasia & Agenesis
1. Buttram & Gibbons Class 1.
- Vaginal Hypoplasia or agenesis --> pregnancy (-)
- Septate cervix ¢¡ possible danger of rupture & hemorrhage
2. Buttram & Gibbons Classes ¥± through ¥´
- Associated with abortion, ectopic pregnancy, preterm delivery, fetal growth restriction, abnormal fetal lie, uterine dysfunction, uterine rupture.
3. Reproductive Performance of Women with Unicornuate Uterus (Buttram & Gibbors Class ¥±)
- Abortion --> partially explained by smaller uterine size & possible implantation of the zygote in a communicating rudimentary horn
- Preterm labor, fetal growth retardation breech presentation, dysfunctional labor increased C-sec
delivery ; can be explained by small size
- Tubal pregnancies & pregnancies in the rudimentary horn --> uterine rupture prior to 20wks.
4. Reproductive Performance in Women with Uterine Didelphys (class ¥²)
- Complete reduplication of cervices & hemiuterine cavities
- Overall successful pregnancy outcome --> 68%
- Same complication as class ¥±.
5. Reproductive Performance in Women with Bicornuate & Septate Uteri (class ¥³ & ¥´)
- Marked increased in abortions ; due to abundant muscular tissue in the septum
- 70% of bicornuate, 88% of septate uterus --> pregnancy loss occurs prior to 20wks
- It pregnancy established --> preterm delivery, abnormal fetal lie, cesarean delivery rate increased
# Management of Uterine abnormalities
1. Cerclage
- Uterine didelphys & unicornuate & bicornuate Uterus --> therapeutic & prophylactic cervical cerclage
- Partial cervical atresia & cervical hypoplasia ; transabdominal cerclage
- DES exposed Women with cervical hypoplasia --> transvaginal cerclage
2. Metroplasty
- Bicornuate Uterus - septal resection & recombination of fundi
- Septate uterus
- Hysteroscopic resection of the septum
- Postoperative intrauterine device insertion & hormonal therapy --> not necessary to prevent septal fusion
- Uterine didelphys - transabdominal metroplasty
- Hysteroscopic resection of the septum
F. Diethylstilbesteral - Induced Reproductive Tract Abnormalities
1. Structural Abnormalities
- One forth to one half of women exposed to DES in utero --> identifiable structural variations in the cervix & vagina ; transverse septa, circumferential ridges
- Two thirds of exposed women --> uterine cavity abnormalities (evident on hysterography)
; smaller uterine cavities, shortened upper segments, T-Shaped cavities
- Half of women with uterine defects --> cervical detects cf) esp. hypoplastic cervix
- Oviduct abnormalities - shortening, narrowing, absence of fimbriae
2. Reproductive Performance
- Lower conception rates
- Spontaneous abortions, ectopic pregnancies, preterm birth; increased
- Ectopic Pregnancies
- Increased ; 7%, may be due to tubal abnormalities, decreased uterine size
- Abortions & Preterm Labor : increased incidence due to cervical incompetence --> prophylactic cerclage
- Infertility
- Poorly understood ; associated with cervical hypoplasia & atresia
- Successful pregnancies ¢¡ by using zygote intrafallopian transfer technigues
- Poorly understood ; associated with cervical hypoplasia & atresia
3. Treatment
II. ACQUIRED REPRODUCTIVE TRACT ABNORMAITIES
A. Vulvar Abnormalities
- Edema
- During labor --> Venous thromboses & hematomas can cause
- Inflammatory Lesions
- Extensive perineal inflammation & scarring form hidradenitis supprative, lymphogranuloma venereum, Crohn disease. --> may create difficulty with vaginal delivery, episiotomy repair
- Bartholin Abscess
- Drainage & suturing : bleeding (+)
- Broad - spectrum antibiotics
- Drainage & suturing : bleeding (+)
- Bartholin Cysts
- Asymptomatic cyst ¢¡ Treatment after delivery
- If dystocia (+) ¢¡ needle aspiration
- Asymptomatic cyst ¢¡ Treatment after delivery
- Urethral Diverticulae, Cysts, & Abscesses
- Due to trauma & infection of periurethral gland
- Abscess --> usually resolve spontaneously, asymptomatic cyst formation
- Diverticulae --> can cause proteinuria of obscure cause
- Treatment --> after delivery
- Due to trauma & infection of periurethral gland
- Condyloma Accuminata
- Extensive lesion --> Vaginal delivery (-)
- Predelivery eradication to prevent dystocia, secondary infection, hemorrhage which may result in amnionitis, preterm labor, episiotomy dehiscence
- Vertical transmission & it's treatment; controversy
- Extensive lesion --> Vaginal delivery (-)
B. Vaginal Abnormalities
- Partially Atresia
- By infection or trauma
- Partial atresia --> can be overcomed during labor
- By infection or trauma
- Gartner Duct Cyst
- May protrude into the vagina --> can be confused with a cystocele
- May or may not slip above presenting part --> if may not, aseptic aspiration is needed
- May protrude into the vagina --> can be confused with a cystocele
- Genital Tract Fistulas form Parturition
- Due to compression of fetal head & bony pelvis
- Vesicovaginal fistula, vesicouterine fistula, vesicocervical fistula
- With no infection ¢¡ heal spontaneously
- Due to compression of fetal head & bony pelvis
C. Cervical Abnormalities
- Stenosis
- By extensive cauterization, difficult labor associated with infection & considerable tissue destruction
- Cryotherapy & laser therapy --> less likely to produce stenosis
- LLETZ --> not associated with pregnancy outcome
- By extensive cauterization, difficult labor associated with infection & considerable tissue destruction
D. Uterine Displacement
- Anteflexion
- Frequently observed in early pregnancy
- In late pregnancy, particularly when the abdominal wall is very lax --> anteflexion can occur
- Marked anteflexion --> associated with diastasis recti & a pendulous abdomen
- Cervical dilatation & engagement can be inhibited
- Abdominal binder
- Frequently observed in early pregnancy
- Retroflexion
- No pathologic state
- Incarcerated uterus : growing of retroflexed uterus remains incarcerated in the hollow of the sacrum
- Symptom ; abdominal discomfort, inability to void
- Bladder catheterization & kneechest position
- No pathologic state
- Sacculation of the Uterus
- Persistent entrapment of the pregnant uterus in the pelvis by old inflammatory diseases or endometriosis --> anterior uterine sacculation
- Aggressive treatment of Asherman syndrome --> posterior uterine sacculation
- Elongated vaginal passing above the level of a fetal head deeply placed into the pelvis
- Extension of abdominal incision
- Persistent entrapment of the pregnant uterus in the pelvis by old inflammatory diseases or endometriosis --> anterior uterine sacculation
- Prolapse of the Pregnant Uterus
- In early pregnancy --> cervix may protract through vagina, bat resolves as pregnancy progresses
- No change of uterus position --> incarceration develop during the third or fourth months
- Treatment ; pessary, recumbent position
- In early pregnancy --> cervix may protract through vagina, bat resolves as pregnancy progresses
- Cystocele & Rectocele
- Large cystocele --> UTI, large rectocele ¢¡ constipation
- Both of lesions --> associated with blocking the normal descent of fetus.
- Cystocele --> often associated with stress incontinence ; worsened by pregnancy
- Large cystocele --> UTI, large rectocele ¢¡ constipation
- Enterocele
- It symptomatic --> replacement & recumbent position
- Surgical treatment of enterocele --> after delivery
- It symptomatic --> replacement & recumbent position
- Torsion of Pregnant Uterus
- Rotation of pregnant uterus --> most often to right
- If torsion (+) --> sufficient to arrest circulation ; rare condition
- Rotation of pregnant uterus --> most often to right
E. Uterine Leiomyomas
- Rice & colleagues (1989) : 6700 pregnancies ¢¡ 1.4% complicated
- Pedunculated subserosal myoma --> torsion with necrosis ¢¡ detachment
- Change of Myoma during pregnancy ; red, carneous degeneration ¢¡ hemorrhagic infarction
- Focal pain, with tenderness on palpitation & low-grade fever moderate leukocytosis
- DDx : with appendicitis, placental abruption, ureteral stone, pyelonephritis
- Effects of Pregnancy
- By estrogen, progesterone & other growth factors ¢¡changes of myoma size during pregnancy
- Estrogen receptor of myoma ¢¡its estrogen level increases too much, down regulation can occur
- Lev-Tott & co-Workevs (1987)
- lst trimester ; myomas of all sizes ¢¡ unchanged or increased (early response due to increased
estrogen)
- 2nd trimester ; small myomas (2~6cm) remained unchanged or increased larger myomas ¢¡ become smaller
- 3rd trimester ¢¡ regardless of initial myoma size, usually remained uncharged or decreased in size.
- lst trimester ; myomas of all sizes ¢¡ unchanged or increased (early response due to increased
- By estrogen, progesterone & other growth factors ¢¡changes of myoma size during pregnancy
- Effects of Myoma Size, Location & Number on Pregnancy
- Rice & associates (1989)
- Myomas greater than 5cm ; significantly, increased rates of preterm labor, placental abruption, pelvic pain, cesarean delivery
- Hasan & co-workers (1990)
- No association with respect to myoma size except for on increased incidence of obstructed labor.
- Postpartum hemorrhage
- Not increased incidence, but if occur ¢¡ massive hemorrhage (+) & corrected by hysterectomy (Hasan & associates, 1990)
- Lower uterine segment myomas
- Increased incidence of retained placental (Lev-Toaff & colleagues, 1987)
- Conclusions
- Growth of myomas during pregnancy ¢¡ unpredictable
- Placental implantation over or in contact with a myoma ¢¡ increases the likelihood of placental abruption, abortion, preterm labor, postpartum hemorrhage
- Multiple myoma ¢¡ associated with fetal malposition & preterm labor
- Degeneration of myoma ¢¡ associated with a characteristic sonographic patterns
- The incidence of cesarean delivery ¢¡ increased
- Growth of myomas during pregnancy ¢¡ unpredictable
- Rice & associates (1989)
1) Cervical Myomas
- Myomas in the Cervix or in the lower uterine segment ¢¡ obstructed labor, confusion with fetal head
2) Imaging of Myomas
- By ultrasonography : can be confused with ovarian masses, molar pregnancies, ectopic pregnancies, missed abortions, bowel abnormalities
- MRI : superior to US, especially in correctly identifying uterine myomas
3) Myomectomy during Pregnancy
- Limited to pedunculated type
- Dissection of Myoma during pregnancy or at the term of Delivery ¢¡ contraindicated due to
bleeding
- Typically, myomas will undergo remarkable involution after delivery ¢¡ myomectomy
4) Myomectomy Before Pregnancy
- After myomectomy ¢¡ significant risk of uterine rupture during subsequent pregnancy
- Rupture may occur early in gestation (Golan & associates 1990a)
F. Endometriosis
- Most women ¢¡ No complication
- Rupture of endometrial cyst ¢¡ DDx with pyelonephritis, acute appendicitis, tubal pregnancy,
- Enlarging pelvic endometriosis ¢¡ dystocia
G. Adenomyosis
- Rarely associated with complication
- If, complication (+) ¢¡ uterine rupture, ectopic pregnancy, uterine atony, placenta previa
H. Ovarian Tumors
1. Benign Ovarian Tumors
- Serious complication during pregnancy ¢¡ torsion, infarction, obstruction to vaginal delivery
- Most common type ; cystic tumor
- Beischer & associates (1971) - 164 ovarian tumors diagnosed during pregnancy
- one forth ¢¡ cystic teratoma
- one forth ¢¡ mucinous cystadenoma
- 2.4% ¢¡ malignant
- one forth ¢¡ cystic teratoma
- The most frequent & serious complication of benign ovarian cyst during pregnancy ¢¡ torsion
- Most common in 1st trimester may result in cystic rupture
- Diagnosis of Ovarian tumor during pregnancy ¢¡ difficult due to abdominal enlargement
- Early in pregnancy ¢¡ less than 6cm enlargement ; d/t corpus luteum formation
- Thornton & Wells (1987)
- 5cm or less ; left alone
- 5~10cm ; it cystic ¢¡ observation , it contains septae or nodules ¢¡resection
- Over 10cm ; resection
- 5cm or less ; left alone
- Hess & colleagues (1988)
- Elective resection of any ovarian mass 6cm or large that persists after 16 weeks
- Serial ultrasonography & color doppler sonography & MRI
- Ovarian tumor markers ¢¡ rarely helpful in doubtful cases
- Laparotomy
- Malignancy suspected ¢¡ surgery must be done
- Tumor is impacted in the pelvis ¢¡ C-sec delivery & tumor resection
- Malignancy suspected ¢¡ surgery must be done
2. Carcinoma of the Ovary.