Symptomatic Chronic Uterine Dehiscence: A Different Approach, Non-surgical Successful Closure

Abstract

A 37-year-old gravida 3, para 2 with suspected abruption at 36 5/7 weeks gestation had an emergency repeat lower segment cesarean section. Her obstetrical history was significant for a normal vaginal delivery followed by a lower segment cesarean section with two layer closure for a suspected placenta previa. She had multiple cardiac surgeries including patent ductus arteriosus ligation, pulmonary stenosis repair, and Konno procedure, replacement of aortic valve with prosthetic St. Jude valve, requiring several transfusions. She was on therapeutic dose of subcutaneous low-molecular-weight heparin (Enoxaparin). At the emergency cesarean section partial abruption of placenta and markedly thinned out ecchymotic scar of previous urgent cesarean section were noted. During cesarean section, scar which was found to be friable, was repaired in 2 layers of 0 Vicryl suture: the first, locking and the second, imbricating the first. She also underwent tubal ligation by Pomeroy method, and then her anticoagulation was resumed 6 h postop. Her post-operative period was uneventful.Three months following her delivery, she presented with continued periodic spotting and bleeding. She was then on warfarin and INR in low 2 0 s. There was no chorionic tissue on USG with thin endometrial stripe, normal beta HCG \ 5, TSH 2.4, and no local source of bleeding. She received progestogens in an attempt to control bleeding along with oral iron therapy. She returned 6 months postpartum for continuous bleeding, when a bulky firm lower

Uteroperitoneal fistula post-caesarean section—Uterine conservation through a combined medical and surgical approach

“…Those who do desire maintenance of fertility, debridement, and resuturing may be attempted [13,14]. However more recently, several case studies have described effective medical management of uterocutaneous fistulae with GnRH analogues [15][16][17], the results of which were replicated in a case of chronic uterine dehiscence post-caesarean section which demonstrated successful, nonsurgical closure [18].…”

An unexpected connection: getting to know uteroperitoneal fistulas

“…In contrast to surgery, one case was medically managed in a 37-year-old patient with multiple medical comorbidities who was deemed a poor surgical candidate 3 months after cesarean delivery. Monthly intramuscular gonadotropin-releasing hormone analog for 6 months resulted in the closure of the defect on ultrasound imaging and improvement in symptoms (4).…”