A 33-year-old female gravida 2 para 0110 presented to the obstetric and gynecologic clinic to establish prenatal care. Her estimated gestational age determined by last menstrual period was 10 weeks 6 days. A diagnosis of missed abortion was made after ultrasound revealed a crown rump length of 9.2 mm, consistent with a gestational age of 7 weeks 0 days, with no fetal heartbeat identified.
The patient had a history of normal 28-day menstrual cycles and used a combined oral contraceptive pill prior to this pregnancy. She reported a history of polycystic ovary syndrome, human papillomavirus infection, and CIN grade 3 (CIN 3) diagnosed 3 years prior. Two years prior to the current visit, the patient received cryotherapy treatment for CIN 3 that failed to resolve her cervical dysplasia as evidenced by a repeat Pap smear. She was offered CKC but declined, and instead opted for homeopathic treatment with topical black salve. She reported that her cervical dysplasia was confirmed as resolved by Pap smear after one treatment with black salve; however, she applied another treatment that resulted in significant vaginal pain.
Pelvic examination at presentation revealed normal external genitalia without lesions and normal hair distribution. The vagina was moist and well rugated without lesions or discharge. The vaginal canal appeared shortened, and the cervix appeared pink and flush with the vaginal cuff. The uterus was of normal size, mobile, without tenderness, and with no evidence of adnexal masses or tenderness. She was prescribed oral misoprostol 800 mug for management of missed abortion, and she passed fetal tissue without complication.
Three months after her initial presentation, the patient returned to the clinic with complaints of oligomenorrhea, with her last menstrual period occurring 38 days prior to this visit. She denied any fevers or pelvic pain. The patient was afebrile, and vital signs were normal. Pelvic examination findings were identical to those from the previous examination. A uterine sound was placed through the external cervical os, and purulent material with a small amount of red blood was passed through the cervix. Human chorionic gonadotropin level was <1.2 mIU/mL. Transabdominal ultrasound revealed no sonographic abnormality of the uterus.
Aerobic cultures were collected at the time of examination. Three days later, the cultures grew Klebsiella pneumoniae sensitive to ciprofloxacin. The patient was treated with ciprofloxacin 500 mg orally twice daily for 10 days and instructed to return if signs or symptoms of pelvic abscess developed.
The patient returned to clinic 6 weeks later with continuing oligomenorrhea to discuss a management plan. Hysteroscopy was scheduled 5 days later for evaluation and management of cervical stenosis. On the day of the procedure, visual examination revealed a shortened vaginal canal measuring approximately 5 cm in length and a cervix that appeared flush against the vagina. The cervix was serially dilated to accommodate a 5-mm rigid hysteroscope. Once through the dilated os, the hysteroscope entered a blind pouch measuring approximately 3.5 cm in length, and the true cervix was visible on the right anterior vaginal wall (Figure). Two attempts to advance the hysteroscope through the cervical os failed because of the distorted anatomy. The procedure was terminated after the second attempt, and the hysteroscope was withdrawn without complication.
The patient was referred to the urogynecology service to discuss management of her newly diagnosed vaginal stenosis. Vaginoscopy and hysteroscopy were scheduled for 3 months later. Vaginoscopy findings were consistent with the prior attempted hysteroscopy. Hysteroscopy revealed a normal cervix leading to an arcuate uterus with normal-appearing ostia. Postoperatively, the patient was recommended to use a cervical dilator daily for 5 to 10 minutes. Future plans were to perform a vaginal adhesiolysis and to place an indwelling vaginal stent to relieve the stenosis.