Author
information
Tanksale SJ*, Parulekar SV**, Samant
PY***.
(* Fourth Year Resident, ** Professor, *** Associate Professor,
**** Assistant Professor. Department of Obstetrics and Gynecology, Seth GS Medical College & KEM
Hospital , Mumbai , India
Abstract
Amongst the Mullerian duct anomalies, a bicornuate uterus is a common anomaly.
Bicornuate uterus has two Uterine cavities with single cervix. In this case report, we have a patient with Bicornuate uterus with
single cervix but with partial fusion defect. The previous missed abortion was
in one horn and next pregnancy in other horn.
Introduction
Uterine malformation
occur as a result of fusion defect in Mullerian duct development during
embryogenesis. Bicornuate uterus is one of the common Mullerian duct anomaly.
The fusion process of upper part of Mullerian duct is affected and as a result
caudal part is fused normally whereas the cephalic part is bifurcated.
Mullerian duct anomalies are associated with miscarriage, preterm labor and
malpresentations. Pregnancies in a bicornuate uterus are therefore considered
as high-risk due to their association with poor reproductive outcome and
require extra monitoring.
Case Report
A 28 year old gravida 3
with no living issues with previous one neonatal death and one medical
termination of pregnancy (MTP) was registered at our hospital at 22 weeks. She
had one preterm delivery 3 years ago. That baby died in neonatal period. She
had undergone one first trimester MTP 2 years ago, which had not been
successful. So she was subjected to a repeat procedure at a municipal
peripheral hospital, which was abandoned due t creation of a false passage, and
she was referred to this hospital. She was found to have the missed abortion in
the right horn of a bicornuate uterus. An attempt to enter the horn under
laparoscopic control failed, a false passage was created between the two horns,
and a hysterotomy had to be performed to remove the dead fetus. Two years later
she conceived again and registered with us at 22 weeks. She had an
ultrasonography (USG) report of 19 weeks gestation with pregnancy in left horn
of a bicornuate uterus. Both the kidneys were normal. She had regular follow up
in the antenatal clinic. At 33 weeks of gestation, she was admitted with
preterm labor and complaints of leaking per vaginum. There was no evidence of
leaking per vaginum and preterm labor was controlled with nifedipine. She was
given dexamethasone for fetal lung maturity. USG showed evidence of
intrauterine growth restriction (IUGR) of he fetus. She was observed in
antenatal ward with fetal surveillance. At 35 weeks, USG and obstetric Doppler
was performed which showed IUGR with fetal parameters corresponding to 29 weeks
and fetoplacental insufficiency. An emergency lower segment cesarean section
was performed, delivering the baby weighing 1800 g through a lower segment
transverse incision taken on the left horn. The right horn measured 10 cm in
length, was of normal shape, and did not show any scar or adhesions (figure 1).
The separation of the two horns was up to the level of middle of the cervix,
such that there was a single external os, and a separate internal os for each horn.
The APGAR scores of the baby were of 9 at 1 and 5 minutes.
Figure 1. Operative
findings during cesarean section.
Discussion
Antenatal diagnosis of a
mullerian anomaly is important so as to ensure appropriate management. A study
by Hua et al. found that the presence of a maternal uterine anomaly detected at
the time of anatomic survey is associated with an increased risk of preterm
birth, preterm premature rupture of membranes, breech presentation, and
cesarean section.[1] American
Congress of Obstetrics and Gynecology guidelines for management of IUGR recommend
serial biomery by USG for monitoring growth of the fetus in pregnancies
complicated by maternal mullerian anomalies, to screen for IUGR.[2]
Raga et al found that the chances of having a term pregnancy were 60%, with a
take-home baby rate of 62.5%.[3] These percentages disagree with
previous reports on a poor reproductive outcome associated with a bicornuate
uterus. There are some reports which found the poorest prognosis when the
defect was partial rather than complete. Bicornuate uterus has single cervix
and two uterine cavities. In this case, there was single external os and a
separate internal os for each horn. This could explain the failed attempt to
evacuate uterine cavity in previous missed abortion. Behavior of such a cervix
during labor has not been reported in literature.
Conclusion
When a mullerian anomaly
is identified, the woman should be counseled about reproductive prognosis and
adverse pregnancy outcome. Though management guidelines exist for most of the
mullerian anomalies, some cases require individualized management.
References
- Hua M, Odibo AO, Longman RE, Macones GA, Roehl KA, Cahill AG. Congenital uterine anomalies and adverse pregnancy outcomes. Am J Obstet Gynecol 2011;205:558.e1-5.
- American Congress of Obstetrics and Gynecology Committee on Practice Bulletins-
- Obstetrics. ACOG practice bulletin: intrauterine growth restriction. Obstet Gyncol 2000;
- 95(Suppl):1-12
- Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simon C, Pellicer A. Reproductive impact of congenital Mullerian anomalies. Human Reproduction 1997;12(10):2277–2281.
Tanksale SJ, Parulekar SV, Samant PY. Successful Obstetric Outcome in a Case of Uterus Bicornis Partial Bicollis. JPGO 2015. Volume 2 No. 4. Available from: http://www.jpgo.org/2015/04/successful-obstetric-outcome-in-case-of.html