Cervical stenosis and hematometra: a rare complication of cesarean section and VVF repair.
Congenital causes of hematometra formation are imperforate hymen and transverse vaginal septum. Hematometra formation following cervical stenosis due to cesarean section & VVF repair is very rare. We report a case of cervical stenosis leading to hematometra due to previous cesarean section and VVF (Vesico Vaginal Fistula) repair.
CASE REPORT: A 30 years old lady P1L1 presented to us with complaints of pain in abdomen since 2 months, dribbling of urine through the vagina since 6 months.
She had undergone cesarean section 14 months back in view of non-progress of labour and was also abdominally operated for VVF (Vesico vaginal fistula) 10 months back followed by secondary amenorrhea. During her second surgery she had required 2 units of blood transfusion.
She was admitted and on examination her vitals were stable and abdominal examination revealed pfannenstiel scar of LSCS and midline vertical scar of VVF repair. On per speculum examination cervix and vagina were normal.
Per vaginal examination showed the uterus was bulky corresponding to 8 week size, anteverted with restricted mobility and bilateral forniceal fullness and tenderness was present. Ultrasonography was done which was suggestive of large endometrial collection (Hematometra) with bilateral endometriotic ovarian cysts. Large multicystic ovarian mass with fine echoes of 9x10x7cm size and left ovarian cyst with septation of 7x5 x5cm were noted.
She was posted for drainage of hematometra and operative laproscopy for endometriosis. On laparoscopy omental adhesions were seen and there were dense bowel adhesion on the fundus of uterus. Entire uterus with bilateral adnexa were not visualised due to adhesions. Per vaginally os was dilated gradually with serial hegars dilators which was difficult. Hysteroscopy was done. Omentum was seen protruding through anterior cervical wall giving the diagnosis of uterine perforation.
Retrograde filling of bladder with methylene blue dye was done and dye was seen coming through vagina and also into abdominal cavity but exact site was not made out due to dense adhesion.
Case was discussed with urosurgeons and after taking consent from relatives decision of exploration was made. Bowel adhesions on fundus of uterus were separated by sharp dissection.
Uterus was enlarged and bilateral fallopian tube were distended and stuck up due to adhesions. Bilateral endometriotic cysts were drained and cyst wall was removed as much as possible.
Due to these intraoperative findings decision of hysterectomy was taken and subtotal hysterectomy was done. Cervix was adherent to the posterior wall of bladder and was separated with sharp dissection. Bladder was opened by urosurgeons. Ureteric openings were found normal. 3 small fistulae were noted on antero superior surface of bladder. Guide wire inserted through all the three tracts were found coming through vagina.
All the three fistulae tracts were excised with sharp dissection and bladder was closed in two layers. A omental patch was interposed in between post surface of bladder and the left over cervix. Patient had uneventful post-operative period. Foley's catheter was removed on 12th post op day and patient was discharged.
DISCUSSION: Hematometra denotes retention of menstrual products in the uterine cavity which can be due to congenital or acquired causes.
Congenital causes are cervical stenosis, transverse vaginal septum or imperforate hymen. (1) Hematometra has also been described in elderly women secondary to radiotherapy. (2)
Cone biopsy can also rarely lead to cervical stenosis followed by hematometra formation. (3,4) Cases of hematometra formation after cesarean section have been reported in literature. Multiple hemostatic sutures at the placental bed in a case of placenta previa section can lead to synechiae formation, cervical stenosis and hematometra. (5) Inappropriate closure of anterior and posterior wall of uterus during lscs can creat a uterine pouch and lead to hematometra. (6)
We report this unusual case of cervical stenosis which could be a result of cesarean section or VVF repair leading to hematometra formation. In this case cervix could not be dilated causing perforation through the anterior wall of cervix so we proceeded with hysterectomy and secondary VVF repair.
CONCLUSION: Cervical stenosis causing hematometra is an uncommon complication of cesarean section. The diagnosis can be made in a case of prior cervical surgeries, VVF repair, cesarean sections presenting with sub-acute or chronic pelvic pain with secondary amenorrhoea.
Investigational modalities like ultrasonography, CT SCAN, MRI help in confirmation of diagnosis.
(1.) Hall DJ. An unusual case of urinary retention due to imperforated hymen. J Accid Emerg Med. 1999 May; 16(3):232-3.
(2.) Speas CK, Gallup DC, Gallup DG. Hematocolpos in elderly women. South med J. 1998; 6:815-8.
(3.) Reuter KL, Young SB, Daly B. Hematometra complicating conization with radiologic correlation. A case report. J Reprod Med 1994; 39:408-10.
(4.) Luesley DM, McCrum A, Terry PB, et al. Complications of cone biopsy related to the dimensions of the cone and the influence of prior colposcopic assessment. Br J Obstet Gynaecol 1985; 92:158-64.
(5.) MB Poothavelil, I Hamidi, G Hamidi. Occlusion of upper genital tract following lower segment cesarean section for placenta praevia. Sultan Qaboos university medical journal. 2008; 8(2):215-18.
(6.) GA Saeed. Case of postoperative haematometra in 40year old women. Eastern Mediterranean Health journal. 2010; 16(2):237-39.
Pallavi S. Vishwekar , Ganpat Sawant 
[1.] Pallavi S. Vishwekar
[2.] Ganpat Sawant
PARTICULARS OF CONTRIBUTORS:
[1.] Assistant Professor, Department of Obstetrics and Gynaecology, Dr. D.Y. Patil Medical College, Nerul, Navi Mumbai.
[2.] Professor and HOD, Department of Obstetrics and Gynaecology, Dr. D.Y. Patil Medical College, Nerul, Navi Mumbai.
FINANCIAL OR OTHER COMPETING INTERESTS: None
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Pallavi S. Vishwekar, Flat B606, Sea Queen Excellency, Plot No. 63 to 65, Sector 44A, Seawoods, Nerul (West), Navi Mumbai-400706, Maharashtra,
Date of Submission: 15/09/2015.
Date of Peer Review: 18/09/2015.
Date of Acceptance: 29/09/2015.
Date of Publishing: 08/10/2015.
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|Title Annotation:||CASE REPORT|
|Author:||Vishwekar, Pallavi S.; Sawant, Ganpat|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Oct 8, 2015|
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