Author
Information
Goel A*, Shende D**, Tiwari N**, Chauhan AR***.
(*Third
Year Resident, ** Assistant Professor, ***Additional Professor, Department of Obstetrics and Gynaecology, Seth G.S. Medical College and
K.E.M. Hospital, Mumbai, India.)
Abstract
Transverse
vaginal septum is an uncommon mullerian congenital malformation. We present an
incidentally diagnosed case of spontaneous conception and successful pregnancy
outcome with incomplete transverse vaginal septum.
Introduction
Transverse
vaginal septum is a rare entity.[1] Incomplete vertical fusion or faulty
canalization of mullerian ducts and urogenital sinus leads to the formation of
transverse vaginal septum. It may present as an incidental finding in a woman
attending antenatal clinic. Our patient presented as a case of complete
transverse vaginal septum with possible channels through which the sperms
ascended and resulted in pregnancy.
Case
Report
Twenty
two years old primigravida registered antenatally at 24 weeks gestation and had
a routine course in pregnancy. She was 5 feet and 3 inches, weighing 58 kg,
well developed and well nourished. Her general examination, per abdominal
examination and routine antenatal investigations were unremarkable. At 37 weeks
gestation, vaginal examination was done which revealed normal external
genitalia, a blind vaginal pouch of good caliber and depth with a dimple at its
apex; cervix was not visualized. On direct questioning, patient revealed late
menarche at the age of 17 years after some surgery, probably drainage of
hematocolpos and hematometra. She subsequently had regular menstrual cycles and
no sexual dysfunction or dyspareunia.
She
was examined under anesthesia and findings of blind pouch of good caliber and a
dimple at its apex and non – visualization of cervix were confirmed. A
provisional diagnosis of transverse vaginal septum was made as previous
antenatal scans in first and second trimester showed a normal cervix.
Ultrasonography
showed normal cervix and vagina; MRI showed a linear isointensity extending
antero-posteriorly at the level of mid vagina which divides hyperintense
vaginal mucosa into two parts representing a transverse vaginal septum. There
were no associated renal anomalies.
Figure 1.
T1-weighted MRI image showing transverse vaginal septum.
She
underwent elective cesarean section at 39 weeks of gestation and delivered a
female child of 2.9 kg. After expulsion of placenta and membranes, uterus was
examined; there was no associated uterine anomaly. Metallic Hegar dilator No. 6
was inserted through the cervical canal which was well formed and normal, with
simultaneous per vaginal examination. However the dilator could not be felt
vaginally as there was a thin layer of intervening tissue. After cesarean
section, patient was examined in lithotomy position. Local examination revealed
bulging of the transverse vaginal septum with blood flowing as a jet through a
pinpoint opening. Urethral opening was normal. When gentle pressure was applied
on the septum, blood clots started to come out; the pinpoint opening was
enlarged to approximately 2 – 3 cm using artery forceps. A finger could easily
be inserted through this opening and the cervix was now felt at a distance of
4- 5 cm from the septum. Postpartum course of the patient was uneventful with
normal lochia. The mother and the baby were discharged on day 5 of the surgery and
advised to follow up after 6 weeks for septum resection.
Figure 2.
Bulging out of the transverse vaginal septum, cervix is not visualized
Figure 3. Arrow pointing at the jet of blood
coming out through the pinpoint opening in the perforated transverse vaginal
septum
Figure 4. Pinpoint opening in the transverse vaginal
septum enlarged using hemostat.
Discussion
Transverse
vaginal septum was first described by Delaunay in 1877.[2] Transverse vaginal
septum is formed due to failure of complete canalization of primitive vaginal
plate or due to lack of union of urogenital sinus and mullerian duct. The
incidence varies from 1:30,000 to 1: 84,000 females. Its etiology is unknown;
may result from female sex related autosomal recessive transmission.[3] It may
be present in upper, middle and lower thirds of the vagina in 46%, 35%, 19 % of
the patients and varies in thickness from 0.5 to 6 cm.[4,5] It may be complete
or incomplete. It is composed of fibrous connective tissue and vascular muscle
elements. Lower surface of the septum is always covered with squamous
epithelium. It may be associated with genitourinary anomalies as the
development of urinary system parallels with that of genital tract.[6]
The
diagnosis of complete transverse vaginal septum is often delayed until after
menarche, when patient presents with progressive cyclical pain secondary to
hematocolpos. An incomplete transverse vaginal septum is usually asymptomatic
as central aperture allows the vaginal secretions and menstrual blood to flow;
may be found incidentally during routine antenatal checkup. Transverse vaginal
septum divides the vagina into two segments and reduces its functional length.
Patient may present with complaints of dyspareunia. Examination under
anesthesia may be required for establishing the diagnosis. Clinical management
includes renal imaging and ultrasonography and MRI. Elective cesarean section
rates are higher in these patients; however, vaginal delivery is also possible
in established cases of transverse vaginal septum.[7] Cruciate incision is
given during labor. Surgical correction may be required depending upon the
location of the septum and its thickness. Surgical correction is more difficult
in high transverse vaginal septum as the septum is usually thick and dissection
between bladder and rectum is required.[8] Low and mid septum are usually thin
and can be excised with multiple radial incisions.
Conclusion
Rare
anatomic congenital defects can be found incidentally during routine antenatal
examination. Correct timely diagnosis of the defect can help in successful
pregnancy outcome.
References
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Goel
A, Shende D, Tiwari N, Chauhan AR. Spontaneous Conception Through
Perforated Transverse Vaginal Septum. JPGO 2016. Volume 3 No. 3. Available from: http://www.jpgo.org/2016/03/spontaneous-conception-through.html