Page 23 - World Journal of Laparoscopic Surgery

Okohue JE et al
counseled against further pregnancies but refused as it was bones has been reported by various authors. 11,12 All three
customary where she comes from to deliver 12 times! patients had previous second trimester termination of
Adhesiolysis for intrauterine adhesions constituted 67.2% pregnancies by dilatation and curettage between 3 and 25 years
of all the surgical procedures performed. This was much higher prior to presentation and were experiencing regular normal
than the 16.6% reported at the Aga Khan hospital in Kenya. 6 menstrual periods. One achieved a spontaneous pregnancy
Majority of our patients (71.1%) had previously terminated one two months after the fetal bone retrieval and had a vaginal
or more pregnancies and these are usually unsafe abortions, as delivery of a 2.8 kg female baby. It was suspected at transvaginal
abortion is still illegal in Nigeria. The result could be an increase ultrasound scan that one of the patients probably had some
in uterotubal infections and hence adhesions. There is equally retained bones within the myometrial tissues following repeated
a high-rate of pelvic inflammatory disease in Nigeria. 7 attempts at uterine evacuation for suspected adhesions on
Prior to the advent of hysteroscopy, the diagnosis of hysterosalpingogram. Our suspicion was based on the finding
intrauterine adhesions depended upon historic criteria, physical of the same hyper echoic shadow within the endometrial cavity
findings and laboratory data while the treatment consisted of and myometrium at transvaginal ultrasound scan. Her last
an attempt to bluntly disrupt the adhesions by using a uterine pregnancy was terminated at 16 weeks gestation, 25 years before
8
sound or small curette. Presently the use of hysteroscopy for presentation!
the diagnosis and treatment of intrauterine adhesions has been The complication rate was 1.2%. This compares favorably
6
shown to be mandatory and is equally the preferred method for with the 0.7% reported in Kenya and 0.28% by Jansen et al. 3
+1
the treatment of intrauterine septa, removal of foreign bodies, The patient in our study was a 33 years old para 1 lady who
8,9
polyps and submucous myomas. Unfortunately there is still had general anesthesia for combined hysteroscopy and
a paucity of both instruments and hysteroscopic skills in Nigeria. laparoscopy. She developed apnea after the procedure for which
As at the time of this study only six centers had a functional she needed mouth to mouth resuscitation, cardiac massage
hysteroscope, serving a population of over 140 million people! and oxygen by face mask. Intermittent positive pressure
Only one of the six centers is a public institution. ventilation was instituted by the anesthetist. She recovered
Of the 43 patients who had hysteroscopic adhesiolysis, fully an hour later.
majority (21 or 48.8%) had IUCD inserted following adhesiolysis. Hysteroscopic diagnosis and treatment has become very
An inert IUCD with a large surface area is generally important in patients with infertility. It is one of the safest and
1
10
recommended. Lippes loop will fit effectively into this most easily acquired surgical skills in gynecology. Acquisition
description but is no longer being marketed. We usually of the equipment and skills especially in the public hospitals in
improvise with a copper T 380A, with the copper element Nigeria are urgently needed to obviate the need for blind
removed before insertion into the uterine cavity to prevent any procedures like endometrial curettage within the endometrial
inflammatory reaction that may be caused by the copper element. cavity.
Foley’s catheter has however been shown to be significantly
superior to IUCD in terms of improvement in normal menses as REFERENCES
10
it reduces the need for a repeat adhesiolysis. Fortunately,
only 2 of the 21 patients needed repeat adhesiolysis. All the 1. Bradley LD. Cutting the risk of hysteroscopic complications.
Obg management 2004;16(1):1-12.
patients were placed on prophylactic antibiotics for 7 days while 2. Bradley LD, Widrich T. Flexible hysteroscopy a state-of-the-
those with an indwelling intrauterine device had oral estrogen art procedure for gynaecologic evaluation. J Am Assoc Gynaecol
to promote a regrowth of the endometrium and later a Laparosc 1995;2:263-67.
progestogen for withdrawal bleeding. Although 23 patients had 3. Jansen FW, Vredevoogd CB, Ulzen K, Hermans J, Trimbos JB,
endometrial polyps at hysteroscopy, 21 had hysteroscopy et al. Complications of hysteroscopy: A prospective, multicentre
guided polypectomy with the use of hysteroscopic forceps study. Obstet Gynaecol 2000;96:517-20.
and scissors. In the other two patients, one had a blind curettage 4. Konig M, Meyer A, Aydeniz B, Kurek R, Wallwiener.
as the polyps were too numerous to be removed individually Hysteroscopic surgery: Complications and their prevention.
under hysteroscopic guidance. The other had a large solitary Contrb Gynaecol Obstet 2000;20:161-70.
polyp which was removed blindly with an oven forceps. One 5. Valle RF. Hysteroscopy in the evaluation of female infertility.
submucous fibroid was successfully removed with a Am J Obstet Gynaecol 1980 June 15;137(4):425-31.
hysteroscopic scissors, it measured approximately 1.2 × 1 cm 6. Parkar RB, Thagana NG. Hysteroscopic surgery at the Aga
Khan Hospital, Nairobi. East Afr Med J 2004;81(7):336-40.
and had no myometrial extension. A resectoscope is the preferred 7. Bello TO. Pattern of tubal pathology in infertile women on
instrument of choice for submucous myomectomy but hysterosalpingography in Illorin Nigeria. Annals of African
unfortunately was unavailable at the center during the study Medicine 2004;3(2):77-79.
period. Fetal bones within the endometrial cavity were an 8. March CM. Hysteroscopy as an aid to diagnosis in female
interesting finding. Secondary infertility due to intrauterine fetal infertility. Clin Obstet Gynaecol 1983;26(2):302-12.

28