(109) Successful Resection of Transverse Vaginal Septum with Microperforation During Cesarean Section: A Case Report

Background: In patients who have transverse vaginal septum (TVS) with microperforation, diagnosis may be delayed due to the perforation allowing egress of menstrual blood; surgical management can be challenging due to lack of bulge to guide entry into the correct space. There is a paucity of literature describing surgical techniques in this scenario. Here we describe the presentation and management of a pregnant patient diagnosed with TVS with microperforation at term.

Case: IRB exempt status was confirmed through our IRB process. A 24-year-old G1P0 at 37w0d presented for return prenatal visit. Cervix was not palpable, and speculum exam revealed a previously unknown blind-ending vagina measuring 4 cm. She reported prior normal menses and had never attempted tampons. She endorsed history of vaginal rupture at coitarche with bleeding requiring stitches. Transvaginal ultrasound and MRI were obtained but characterization of the anomaly was difficult due to distortion from the gravid uterus. Exam by pediatric gynecology found cervix palpable behind the septum, with estimated septum thickness < 1 cm and no visible or palpable perforation. She underwent combined cesarean section and TVS resection at 38 weeks gestation. Following uncomplicated delivery via low transverse hysterotomy, a Foley catheter was introduced through the hysterotomy and cervix into the proximal vagina (PV) and inflated. On vaginal exam, a 3 mm perforation was identified when the tip of the catheter pushed through the perforation. The catheter was then used to guide entry into the PV from below, and the septum was fully excised. Post-op, the patient was initiated on vaginal estrogen. Exam at 4-weeks post op demonstrated minimal scarring without stenosis; she began vaginal dilation. She attended her 6-week postpartum visit with no complications.

Comments: During typical TVS resection, the bulge of the obstructed septum guides entry into the PV, with blood from hematocolpos confirming correct entry into the obstructed space. TVS with microperforation presents a unique surgical challenge: because the PV is decompressed, identification and entry into the correct space is difficult, increasing risk for injury. Although diagnosis of TVS in pregnancy is rare, this case highlights utilization of uterine access to enter the PV from above. The foley catheter threaded into the space recreated the septal bulge and identified the perforation. Patients with complex anomalies may require creative surgical solutions; our case highlights a combined abdominal/vaginal approach which can be considered to aid entry into the PV and could be translated to non-pregnant patients.