The incidence of congenital uterine malformation is estimated to be 3-5% in general population. Abnormal fusion of Mullerian duct in embryonic life results in variety of malformations. Here, we report a case of successful pregnancy outcome in a complete septate uterus with pregnancy in the right horn. An emergency lower segment caesarean was performed instead of delivery because of a non reassuring foetal heart rate. The diagnosis was confirmed intra operatively. A septoplasty prior to a new gestation was performed.
MRI; Mullarian ducts; Preterm labour; Septate uterus; Ultrasound
Uterine anomalies can lead to infertility and problems with reproduction among women. A lot of uterine malformation like septate uterus, unicornuate uterus and bicornuate uterus result from abnormal development of paramesonephric (mullarian) duct fusion during uterus development. The prevalence of uterine anomalies in the general population is about 0.5% [1]. Acien, in a review study, found a mean incidence for septate uterus 22% (complete septate 9%, partial septate 13%) among the all other types of mullarian defects [2]. In 1988 American Fertility society described congenital uterine anomalies relateted to mullarian ducts according to figure1. Septate uterus is the most frequent uterine malformation [3,4] and characterized by a muscular or fibrous wall, called the septum. The septum affects only the cranial part of the uterus (partial septate uterus) or it may reach as far as the cervix (complete septate uterus) figure1. It is diagnosed by medical image techniques, i.e., ultrasound or an MRI.
Figure 1: Classification of congenital uterine anomalies as described by the American Fertility Society (1988).
A 26 yr old 2nd gravida, presented to the OBG dept of Navarra with 2months amenorrhoea. She had a first trimester abortion in first pregnancy. She had no complaints, but an early ultrasound done at 7 wks of gestational age detected a complete septate uterus with pregnancy in the right horn (Figure 2). Per speculum examination showed one cérvix and vulva, urethra and vagina were normal. She had regular antenatal visits which are uneventful till 8 month. At 32 wks of gestation she was admitted with complain of abdominal pain. Tocolysis given and patient steroided for lung maturity. USG done revealed cervical shortening. Doppler was normal. Tocolysis stopped 48 hrs after giving corticosteroids.
Figure 2: Three dimensional ultrasound: complete uterine sept.
At 34 wks of gestation the patient presented with prelabour premature rupture of membranes. In view of non-reassuring foetal heart rate, an emergency lower segment caesarean section was done with the following intra operative findings: A complete uterine septus with pregnancy in the right horn seen. A live male child in right occipito posterior position weighing 1.7 kg was delivered. Placenta is located anteriorly in the upper segment. By exteriorizing the uterus, findings are confirmed. She had uneventful post operative period and was discharged on 8th post operative day.
One year later, she cames to the hospital for gestational desire and after the hysterosalpingography (Figure 3) we recommend the possibility of performing a septoplasty prior to a new gestation (Figure 4). 6 months later she got pregnant and had a eutocic deivery without any problem during pregnancy.
Figure 3: Hysterosalpingography.
Figure 4: Histeroscopy after septoplasty.
Uterine anomalies are related to an increased risk of infertility, miscarriage, premature birth, fetal loss and cesarean delivery [5,6]. In present case, according to the patient history, septate uterus has influenced her fertility and there was a previous history of abortion. Other than a miscarriage or recurrent miscarriage, there aren’t any symptoms of a septate uterus. It’s often only diagnosed after an investigation into the cause of miscarriages. Sometimes it can be picked up during a routine pelvic exam if the septum extends beyond the uterus to include the cervix and vagina as well.
Most of the uterine septi are diagnosed by fertility subspecialists, after the patient presents with recurrent pregnancy loss. It is important that fertility specialists make the correct diagnosis of the uterine septum versus a bicornuate uterus. The uterine septum contains a separation in the uterine cavity, however the outer appearance of the uterus is normal. A bicornuate uterus at the other hand has a completely separated upper end both internally and externally. Diagnosing this properly is very important since an attempted resection of the bicornuate uterus, that is improperly diagnosed as a uterine septum might create a uterine perforation.
Ultrasonography is a simple, quick, and non invasive technique for detecting and diagnosing uterine anomalies. Despite the notable advantages of this technique, unfortunately the obstetric ultrasound scan done on our patient in her first pregnancy could not detect the septate uterus as anomalies accordance with uterus exactly and it could be probably as a result of lack of experience and poor ultrasound quality. However, our MRI images diagnosed this problem accuracy. Grimbizis et al., reported that 12 (26.1%) out of their 46 infertile patients with septate uterus had laparascopic finding of endometriosis [7]. Fayez also found endometriosis in three (43%) out of seven similar patients [3]. It seems possible that septate uterus may be involved in the pathogenesis of endometriosis and thereby plays an important role in indirect relationship within fertility. Therefore, it seems that any finding about endometriosis should be followed by careful investigation for uterine malformation especially in women affected by septate uterus.
Hysteroscopy remains the standard for evaluation of intracavitary abnormalities. Its use is especially practical, as it offers the opportunity for treatment at the time of diagnosis. The septum incision is performed with a hysteroscopic resectoscope and it may be controlled under laparoscopic supervisión.
Hysteroscopy without damaging the intact hymen is feasible and helpful for the diagnosis in the treatment of pathologic endometrial changes in women [8,9]. Although hysteroscopy is now the preferred method for treatment of the septate uterus, a report of two cases described successful removal of the septum at the time of cesarean section. The difficulty in achieving complete uterine septum caesarean has been reported [10,11], however in the in present case we didn’t found any trouble.
