Diagnostics and hysteroscopic picture
During the examination, an incomplete uterine septum may be visualized in the uterine cavity. Anatomically, it divides the single uterine cavity into two separate hemi-cavities.
As additional diagnostic methods at the evaluation stage, it is advisable to use magnetic resonance imaging (MRI) and spiral computed tomography (CT).
- Advantages: These methods have extremely high information value in diagnosing various uterine malformations. Their use in complex clinical cases allows for an accurate diagnosis and avoids unjustified invasive diagnostic methods.
- Limitations: These techniques are not routine in daily practice due to their high cost.
Surgical treatment of the uterine septum
In modern gynecology, there are two main approaches to determining indications for surgical treatment (metroplasty):
- Surgery is performed exclusively when there is already a pronounced impairment of reproductive function.
- Metroplasty is offered to the patient immediately after the septum is detected, without waiting for potential complications to develop.
The method of choice is transcervical resection of the septum via hysteroscopy. The choice of specific instruments directly depends on tissue thickness:
- A thin septum is easily transected using standard endoscopic scissors.
- A thick, wide, and vascularized septum requires the use of a hysteroresectoscope.
- A surgical laser can be used as an alternative method.
Important rule: in the presence of a complete septum that extends into the cervical canal, it is strongly recommended to preserve its cervical portion. This is necessary to prevent the development of secondary cervical incompetence in the future.
Postoperative management and prognosis
Following the resection of a wide uterine septum, the primary goal of postoperative management is the prevention of synechiae (adhesions) formation at the surgical site and the acceleration of tissue epithelialization.
For this purpose, hormone therapy is prescribed: estrogens are used (e.g., estradiol at a dosage of 2 mg daily in the 1st phase of the menstrual cycle). The duration of such treatment is 2 to 3 months.
Prognosis: Hysteroscopic resection is a sparing and low-trauma surgery, which distinguishes it favorably from the previously used abdominal metroplasty. Since no scar remains on the uterus after endoscopic intervention, subsequent delivery can be safely performed via the vaginal route.
Management of life-threatening bleeding (Level of Evidence C, Grade of Recommendation 4)
In conditions associated with a high risk of life-threatening bleeding (e.g., trophoblastic invasion), surgical treatment is an absolute indication.
The scope and methods of surgery vary:
- Total hysterectomy (complete removal of the uterus).
- Organ-sparing surgery.
Factors determining the choice of surgical volume include: the current clinical situation, the patient's hemodynamic status, the degree of trophoblastic invasion, age, and future reproductive plans.
The organ-sparing technique involves hysteroresectoscopic removal of the gestational sac. To increase efficacy and safety, the procedure is performed against the background of specific cytostatic therapy (methotrexate combined with folinic acid is prescribed). Combining this method with uterine artery embolization (UAE) is also possible. The main goal of this comprehensive approach is to avoid hysterectomy and preserve the woman's reproductive function.
To remember the management of a complete septum, use the rule "Cervix is the foundation": the cervical part of the septum is always left intact. If it is resected, the "foundation" will weaken, leading to secondary cervical incompetence.
Class and exam questions
In which cases is a hysteroresectoscope used to resect the septum, and when are scissors used?
The choice depends on tissue characteristics. A thin septum is transected with endoscopic scissors. If the septum is thick, wide, and vascularized (contains many vessels), it is necessary to use a hysteroresectoscope.
Is a C-section mandatory after hysteroscopic septum resection?
No, it is not mandatory. Unlike traditional open abdominal metroplasty, hysteroresectoscopy leaves no scar on the uterine wall. Therefore, delivery can be performed via the natural birth canal.
Why is estradiol prescribed after surgery and how long should it be taken?
Estrogens (estradiol 2 mg daily in the 1st phase of the cycle) are prescribed for 2–3 months. This is necessary to accelerate the epithelialization of the wound surface and prevent the formation of intrauterine synechiae after the resection of a wide septum.
What is the alternative to hysterectomy in deep trophoblastic invasion and bleeding risk?
Organ-sparing management includes hysteroresectoscopic removal of the gestational sac. The intervention is performed alongside cytostatic therapy (methotrexate + folinic acid) and may be supplemented by uterine artery embolization (UAE).
What else to study on this topic
- Comparative characteristics of MRI and spiral CT in the diagnosis of uterine malformations
- Two approaches to indications for metroplasty: expectant management versus prophylactic surgery
- Pathogenesis of secondary cervical incompetence development
- Mechanism of action of methotrexate and folinic acid in trophoblastic invasion
- Uterine artery embolization (UAE): technique and role in combination treatment
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