Hysterotomy for Retained Placenta in a Bicornuate Uterus
Abstract Number: 130
Abstract Type: Case Report/Case Series
Introduction: Congenital uterine abnormalities are reported to occur in approximately 3-4% of the population. Such anomalies are associated with infertility, recurrent spontaneous abortions, premature labor, malpresentation, retained placenta, and need for Cesarean section. Case: A 31 y.o Caucasian G3P0020 presented for term induction of labor at 39 weeks. Her pregnancy was complicated by polyhydramnios and gestational diabetes. Past medical history included Factor V Leiden, MTHFR mutations and PAI 4G/4G genotype. She had a history of an irregularly shaped uterus without specific details. The patient elected epidural analgesia for labor and vaginally delivered a female with Apgars 7/ 9. Multiple maneuvers to extract the placenta were unsuccessful. After 10.5 hours the patient was scheduled for manual exam under anesthesia and possible hysterectomy for retained products of conception and placenta accreta. A second intravenous access and arterial line were obtained in anticipation of blood loss and/or use of vasoactive agents for uterine relaxation. General anesthesia was elected with rapid sequence induction to optimize uterine relaxation with nitroglycerin and deep inhalational anesthesia. Manual exploration under ultrasound guidance failed to separate the placenta from the uterine wall. An exploratory laparotomy was then performed, and the uterus was found to have two horns. A decision to attempt a hysterotomy prior to hysterectomy was made and an incomplete septum with a 3cm foramen was discovered between the second horn of the uterus where the placenta was contained. The fetus had developed in the left horn of the uterus and was attached by the umbilical cord through the 3cm opening in the septum to the placenta in the right horn of the uterus. A hysterotomy was successfully completed to remove the retained placenta, and the patient’s course was subsequently uncomplicated. Conclusions: This report describes an unusual case of bicornuate uterus with retained placenta. This case illustrates the potential complication of retained placenta in such an anomaly and the successful anesthetic management. Management of future pregnancies in this patient will be based upon lateralization of fetal/placental implantation, either requiring cesarean section or allowing attempted vaginal delivery.