Nonisthmic communicating uteri. Report of 3 new types in a new subclass of communicating uteri

OBJECTIVE

To describe 3 new malformations and propose a new subclass of malformations, nonisthmic communicating uteri.

STUDY DESIGN

Review of 17,511 hysterosalpingograms revealed 19 cases of communicating uteri. Three cases were identified that showed nonisthmic communications, previously unreported.

RESULTS

The 3 new types of communicating uteri were (1) bicornuate uterus with 2 sites of communication, midcervical and isthmic; (2) septate uterus with a midcorporeal communication; and (3) bicornuate uterus with a low cervical communication and atretic hemicervix.

CONCLUSION

The 3 new types of nonisthmic communicating uteri constitute a new subclass of communicating uteri. We are aware of only 1 other reported type of nonisthmic communicating uteri. Nonisthmic communications may arise from a different mechanism than isthmic communications.

Laurence-Moon-Biedl syndrome with vaginal atresia

A 15-year-old girl presented with the rare Laurence-Moon-Biedl syndrome, accompanied by vaginal atresia, and cervical dysgenesis. She was treated by hysterectomy and construction of a neovagina with bilateral pudendal thigh flaps. Two brothers and a sister (one of twins) were unaffected but the remaining brother also had the disease.

Congenital malformations of the genital tract and their management

While congenital malformations of the genital tract are not common, the sequelae of their presence can be serious. The practising gynaecologist must be aware of the range of congenital abnormalities that may occur and the symptoms that may result from them. Failure to manage these patients correctly may have long-term sequelae for their psychological, sexual and reproductive health. The involvement of a multi-disciplinary team in dealing with these patients is imperative, and preparation for surgery-particularly in congenital malformations of the vulva and the vagina-is imperative if the long-term sexual function in these patients is to be fulfilled. Surgical correction of vulval abnormalities in adolescence is related solely to sexual function as most of the reconstructive surgery is done in childhood. For the management of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, the recommendation is now that passive dilatation by Franks' technique is the treatment of first choice and only if that fails should surgical approaches be embarked upon. The results of the surgery are similar in all techniques and the particular surgical centre will have its own preference of which technique it adopts. Congenital absence of the cervix is a complex surgical problem and should be dealt with solely in centres with expertise.

Uterus didelphys with cervical agenesis associated with adenomyosis, a leiomyoma and ovarian endometriosis. A case report

BACKGROUND

Elevated level of serum CA-125 was detected in a 48-year-old woman who was diagnosed with a lateral fusion defect in association with congenital agenesis of the uterine cervix. This unusual case combined two developmental anomalies of the müllerian duct.

CASE REPORT

A 48-year-old woman consulted our outpatient department due to persistent abdominal pain for six months. Bimanual pelvic examination showed absence of the cervix, an anteverted uterus and a 6-cm, left adnexal mass. Ultrasound and computed tomography revealed a uterus didelphys with a 3-cm cystic mass over the right ovary. Serum level of CA-125 was 641.4 U/mL. The patient underwent exploratory laparotomy, and total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Pathology confirmed adenomyosis and a leiomyoma of the uterus with functional endometrium in conjunction with endometriosis of the right ovary.

CONCLUSION

Multiple müllerian anomalies associated with adenomyosis and endometriosis should be considered in patients presenting with primary amenorrhea. Thorough evaluation, careful planning, fertility preservation and postoperative outcomes should be reviewed.

Two cases of the caudal duplication anomaly including a discordant monozygotic twin

We present two unrelated patients with various duplications in the caudal region. One patient presented with a duplication of the distal spine from L4, left double ureter, duplication of the vagina and cervix, and duplication of the distal colon. The second patient was diagnosed with a duplication of the colon, bladder, vagina and uterus. The first patient had an unaffected monozygotic twin sister. Dominguez et al. [1993: Am J Dis Child 147:1048-1052] presented six similar cases, and introduced the name "caudal duplication syndrome." The pathogenesis of the caudal duplication anomaly is unclear. The possibility of a polytopic primary developmental field defect or a disruptive sequence are discussed. On the other hand, somatic or germline mutations in certain developmental genes could be involved, as illustrated by the mouse mutations disorganisation and fused. DNA-analysis of the AXIN1 gene, the human homologue of the gene responsible for fused, performed in our first patient, did not show any apparent pathogenic mutation.

Laparoscopic ultrasonography for uterovaginal canalization of a didelphic uterus with agenetic cervix

Mullerian duct anomaly is often characterized by any of a number of disorders of the outflow tract and uterus. A 17-year-old woman suffered from cyclic lower abdominal pain for 3 years. Pelvic examination showed a small uterus with blind-ended vaginal canal about 3 cm in length. Three-dimensional pelvic ultrasonography showed a compact uterine corpus with fundal notch regarded as bicornuate uterus, and no evidence of uterine cervix. The same features were also proved by magnetic resonance imaging. Intraoperative ultrasonography showed a small uterine cavity, and uterovaginal canalization was performed. The patient had regular menses without further low abdominal pain after 6 months of follow-up. Uterovaginal canalization with the aid of intraoperative ultrasonography may be effective in managing the difficult didelphic uterus with an agenetic cervix and hypoplastic vagina.

Pregnancy and transvaginal septation

Patients with an imperforate transverse vaginal septum typically present in adolescence with primary amenorrhea and require surgical correction. Pregnancy in these women is associated with a high spontaneous abortion rate, but no association with incompetent cervix has been reported. We describe a patient with a high transverse vaginal septum and a short cervix requiring transabdominal cerclage.

Management of missed abortion in a patient with congenital cervical atresia

OBJECTIVE

To describe a patient with congenital cervical atresia who became pregnant through IVF and thawed transmyometrial ET and then experienced a missed abortion.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A patient with congenital cervical atresia who underwent reconstructive surgery at 23 years of age and underwent IVF twice at 28 and 30 years of age.

INTERVENTION(S)

Abortion management.

MAIN OUTCOME MEASURE(S)

Medical follow-up of IVF-ET, resultant pregnancy, and abortion.

RESULT(S)

After the second cycle of IVF with frozen-thawed transmyometrial ET, the patient became pregnant but then experienced a missed abortion. Serum beta-hCG levels decreased, the two gestational sacs disappeared, and genital bleeding without signs of infection occurred 14 weeks after diagnosis of the abortion. The abortion was managed conservatively.

CONCLUSION(S)

When assisted reproductive techniques are used in patients with congenital cervical atresia, the risks (including those relating to the management of an abortion) should be explained in detail to the couple and sufficient informed consent should be obtained before starting IVF-ET procedures.

Uterocervicoplasty with a bladder mucosa layer for the treatment of complete cervical agenesis

OBJECTIVE

To create an endocervical canal in a patient with a complete cervical agenesis.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 12-year-old girl presented with lower abdominal pain. On examination, complete vaginal agenesis was noted, with a 2-cm vaginal dimple. A pelvic magnetic resonance imaging scan disclosed an hematometra and absence of the cervix and vagina.

INTERVENTION(S)

Initial surgical therapy consisted of a vaginoplasty with a sigmoid bowel segment and opening of the uterus by puncture and stenting. The cervical permeation failed, with immediate complete stenosis. A new attempt was made through a low sagittal hysterotomy by removing a central muscular cylinder and lining the channel with a free tubularized bladder mucosa graft. A stent was left in place.

MAIN OUTCOME MEASURE(S)

Hysteroscopy, hysterography, and clinical follow-up evaluation.

RESULT(S)

The cervical stent was removed after 5 months. A hysterography and hysteroscopy confirmed the permeability of the cervix, which was lined by a well-vascularized longitudinally folded mucosa. Regular menses had been noted for more than 3 years as of this report.

CONCLUSION(S)

Cervicoplasty with mucosal lining permits the creation of a patent cervical canal, even in the reputedly unfavorable forms of congenital cervical agenesis.

[Congenital agenesis of vagina and cervix]

A case of vaginal and cervical agenesis was presented. The mode of therapeutic procedure consisting of several stages was shown. Menstruation to abdominal cavity was stopped, using pharmacological agent. At the first step diagnostic laparoscopy was performed and artificial vagina was formed. During the second operation a junction of uterus with vagina was carried out. At present, the patient menstruates through vagina. The normal sexual function was achieved.

Findings in female offspring of women exposed in utero to diethylstilbestrol

OBJECTIVE

To examine a group of women (third-generation daughters) whose mothers were exposed in utero to diethylstilbestrol (DES) and compare their findings on pelvic examination with those noted in their mothers.

METHODS

Letters were mailed to women documented to have been exposed in utero to DES who had given birth to a female offspring, inviting them to have their daughters come in for a detailed history and pelvic examination. Records of the mothers whose daughters appeared for examination were reviewed, and findings noted at the time of their initial examination were recorded. Detailed pelvic examination of the third-generation daughters included colposcopic examination and iodine staining of the vagina and cervix and Papanicolaou smear. The findings observed in these women were compared with those noted in their mothers at the time of their mothers' first examination.

RESULTS

Twenty-eight third-generation daughters were examined. Three of the daughters were delivered from one mother. Review of the mothers' records indicated that 16 (61.5%) of the mothers exposed to DES during their pregnancy demonstrated structural changes of the cervix, upper vagina, or vaginal epithelial changes consisting of adenosis, nonstaining vaginal epithelium after application of iodine solution, or white epithelium within the vagina. None of the daughters were found to have changes usually associated with DES exposure.

CONCLUSION

The absence of abnormalities in the lower genital tract in third-generation women compared with the high frequency of these abnormalities in their mothers suggests that third-generation carryover effects of in utero DES exposure are unlikely.

Primary infertility associated with isolated cervical collecting diverticulum

OBJECTIVE

To describe a previously unreported isolated congenital cervical diverticulum and its gynecologic, reproductive, and obstetrical implications.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT

A 31-year-old woman presenting with menometrorrhagia and primary infertility. Investigation revealed an isolated collecting cervical diverticulum causing prolonged postmenstrual spotting, possibly interfering with sperm capacitation and access to the uterine cavity.

INTERVENTION(S)

The examination included hysterosalpingography and magnetic resonance imaging. The combined hysteroscopy and laparoscopy revealed a 5 x 5 cm cervical diverticulum, around 1 cm from the external cervical os, leading to a short cervical canal connected to a normal uterine cavity. The patient achieved a pregnancy after controlled ovarian hyperstimulation and ultrasonographically guided intrauterine insemination. MAIN OTUCOME MEASURE(S): Pregnancy and obstetrical outcome.

RESULT(S)

Extensive evaluation revealed the patient's condition to be a previously undescribed congenital cervical anomaly. The patient's infertility was corrected by ovulation induction and sonographically guided intrauterine insemination, which resulted in a twin pregnancy. After 27 weeks of gestation, preterm labor complicated the delivery.

CONCLUSION(S)

The diagnosis and management of this unusual congenital cervical diverticulum present a particular challenge, as this congenital abnormality has not been previously described or reported.

[Congenital absence of the vagina--its diagnostic-therapeutic implications--case report]

Issues relating to diagnosis and reconstructive therapy for developmental anomalies of female genital tract are controversial. The teratogenic influence during the 6th week of intrauterine life, the time for the development of structures such as fallopian tube, uterus and cervix from the Müllerian duct may lead to their defective formation. In a 14 year old girl congenital absence of vagina, cervix developed right half of uterus (rudimentary horn?) and a pelvic kidney was diagnosed by laparoscopy and laparotomy. The attempt to connect uterus with the artificial vagina during the laparotomy was unfortunately not successful, the main reason being prolonged distance between the apex of artificial passage and the rudimentary uterus. In our opinion ultrasound is a superior diagnostic tool for diagnosis of developmental anomalies in comparison to the palpatory methods. The corrective and reconstructive surgery for the developmental anomalies of the female genital tract should be the domain of a specialized center. Increased awareness of the parents and the public, increase in environmental pollution has led to more frequent and earlier diagnosis of these malformations, which in turn has led to the shift in age for therapeutic interventions.

Successful pregnancy in an adolescent woman with a communicating double uterine anomaly

BACKGROUND

Women with communicating double uterine anomalies are at increased risk for obstetric complications, including early pregnancy loss, preterm delivery, and breech presentation. We present the pregnancy of a woman with a previously diagnosed communicating double uterine anomaly.

CASE

An 18-yr-old white female with a previous diagnosis at age 11 of a communicating double uterus, double cervix, and obstructed left hemivagina was followed during the course of her pregnancy. She experienced no complications until 36 6/7 weeks, when she was found to have signs and symptoms of mild preeclampsia. The fetus was in a breech presentation and a cesarean section was performed. Two hemiuteri were identified intraoperatively. The communication was not visualized. A viable male infant was delivered without complications.

CONCLUSION

This patient represents only the sixth report of successful pregnancy in a woman with a Toaff type 5A communicating uterine anomaly.

Double cervix and vagina with septate uterus: an uncommon müllerian malformation

BACKGROUND

The case of an unusual müllerian anomaly is described.

CASE

A nulligravida was found to have a septate uterus with double cervix and a vagina with partial longitudinal vaginal septum. The anomaly presented symptomatically, was suggested by clinical examination, and confirmed by magnetic resonance imaging and intraoperative visualization. Visualization of the anomaly was enhanced by magnetic resonance-based three-dimensional reconstruction techniques.

CONCLUSION

Description of double cervix and vagina in the setting of an anatomically normal or simple septate uterus is uncommon. This anomaly is inconsistent with the generally accepted understanding of müllerian development but fits with an alternative hypothesis. Magnetic resonance imaging and magnetic resonance-based three-dimensional reconstruction was useful in aiding visualization of the anomaly.

Cervico-isthmic pregnancy: an extremely rare case diagnosed during labour

This case report describes a cervico-isthmic pregnancy ending in a live vaginal birth at 37+2 weeks' gestation. The case remained undiagnosed throughout pregnancy when after a fairly normal labour a massive haemorrhage occurred. After an unsuccessful effort to control the bleeding conservatively, a total abdominal hysterectomy was carried out. During the operation the diagnosis of cervico-isthmic pregnancy was confirmed, which was in accordance with the pathology report.

Utero-vaginal anastomosis in women with uterine cervix atresia: long-term follow-up and reproductive performance. A study of 18 cases

BACKGROUND

Atresia of the uterine cervix is an uncommon Müllerian anomaly. Total hysterectomy remains the classical treatment of this malformation. The purpose of this study was to evaluate functional results and reproductive performance of women who had conservative surgical procedure.

METHODS AND RESULTS

The medical records of 18 patients admitted to our centre between 1969 and 1998 for the treatment of uterine cervix atresia, were reviewed. Seven women had an associated high vaginal aplasia. Fifteen women had a history of abdominal or pelvic surgery before referral, with an unsuccessful attempt at canalization in five cases. Associated pelvic endometriosis or adhesions were observed in 12 cases. The utero-vaginal anastomosis procedure was performed successfully in all cases. A secondary stenosis of the anastomosis occurred in one case and this required canalization. Median follow-up after surgery was 4.5 years. Sexual intercourse was satisfactory for the 12 patients who began sexual activity. Ten patients had a pregnancy, four of which resulted in a total of six successful spontaneous pregnancies. Of the six remaining women, five had an evident cause of infertility.

CONCLUSIONS

Utero-vaginal anastomosis should be proposed in women with congenital atresia of the uterine cervix, even when it is associated with vaginal aplasia. Early diagnosis and surgery appear necessary to avoid the development of pelvic associated lesions.

Classification for endoscopic treatment of mullerian anomalies with an obstructive cervix

STUDY OBJECTIVE

To describe our classification according to severity of developmental mullerian anomalies with obstructed cervix.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-based, tertiary-level center for endoscopic surgery.

PATIENTS

Ten women with developmental mullerian anomalies with obstructed cervix.

INTERVENTION

Patients with didelphic uterus with a rudimentary nonfunctional horn and hypoplastic cervix (type 1) underwent hemihysterectomy or diagnostic endoscopy. Those with agenesis of cervix with normal uterus (type 2) had uterovaginal canalization or neocervix with full-thickness skin graft. Women with identical didelphic uteri and hypoplastic cervix (type 3) underwent uterovaginal canalization with or without endometrial ablation or hemihysterectomy. Patients with didelphic uterus with a rudimentary horn and hypoplastic cervix (type 4) had laparoscopic hemihysterectomy. Those with agenesis of the vagina and cervix but with functional endometrium (type 5) had laparoscopic-assisted full-thickness skin graft.

MEASUREMENTS AND MAIN RESULTS

Average duration of surgery was 60 to 210 minutes. There were no intraoperative complications. Patients with type 1 anomaly are continuing infertility treatment. All three patients in type 2 continue to have regular menses without dysmenorrhea. In those with type 3 conditions, hemihysterectomy was performed in one woman and uterovaginal canalization was performed on the hypoplastic cervix in another. After the neocervix was created, endometrial ablation was performed. No evidence of cervical obstruction or hematometra was found in either patient. The patient with type 4 anomaly continues to have regular menstrual periods without dysmenorrhea. Women with type 5 disorder had good healing of vaginal skin grafts.

CONCLUSION

This classification helps identify mullerian anomalies in relation to obstructive cervix. It is useful in categorizing the disorders and determines management strategies and prognosis.

Septate uterus with double cervix and longitudinal vaginal septum. A case report

BACKGROUND

Congenital uterine anomalies in the general population are estimated to have an incidence of 0.001-10%. The septate uterus, the most common form of structural uterine anomaly, has the highest reproductive failure rate. A rare developmental variant is a septate uterus with cervical duplication and a complete longitudinal vaginal septum. The existence of this anomaly challenges classical müllerian developmental theory. Traditional transabdominal metroplasty has been replaced by operative hysteroscopy in the surgical correction of a septate uterus, with laparoscopy aiding in the diagnosis and contributing to the safety and efficiency of the procedure.

CASE

A 28-year-old, nulliparous woman with a septate uterus with cervical duplication and complete longitudinal vaginal septum was diagnosed by combined laparoscopy and hysteroscopy. Excision of the complete longitudinal vaginal septum followed by hysteroscopic partial resection of a thick uterine septum with laparoscopic assistance was performed. However, because of the septum's broad base and the rigidity of the operative resectoscope, we opted to proceed with transabdominal metroplasty.

CONCLUSION

Only six cases of septate uterus with cervical duplication and complete longitudinal vaginal septum have been reported. Although its counterpart, the septate uterus, has effects on preterm labor, fetal presentation, infertility and spontaneous abortion, its reproductive outcome has not been assessed. Review of the literature suggests that surgical correction in the setting of poor reproductive outcome has been beneficial. Laparoscopically assisted hysteroscopic resection of the uterine septum is a safe, effective surgical technique of uterine reunification and is preferable to transabdominal methods. However, in certain cases, conventional transabdominal metroplasty may still be required.

Uterovaginal canalization and endometrial ablation of the obstructed uterine horn with hypoplastic cervix in the didelphic uterus

Maldevelopment of the mullerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix. Two women with this anomaly experienced symptoms including recurrent lower abdominal pain off and on of 1 to 2 years' duration. Magnetic resonance imaging revealed a double uterus with right hematometrium both patients. After hysteroscopic identification of hypoplasia of right uterine cervix, laparoscopic resection of the hematosalpinx, followed by uterovaginal canalization and prophylactic endometrial ablation of the right uterus was successfully performed by resectoscope. Normal menstruation ensued during follow-up of 18 and 24 months, respectively. Our experience suggests that uterovaginal canalization with prophylactic endometrial ablation may be an efficacious alternative to hysterectomy for management of didelphic uterus with a hypoplastic cervix. (J Am Assoc Gynecol Laparosc 8(1):151-153, 2001)

Successful pregnancy by transmyometrial and transtubal embryo transfer after IVF in a patient with congenital cervical atresia who underwent uterovaginal canalization during Caesarean section: case report

Successful pregnancy in a patient with congenital cervical atresia is a great challenge for assisted reproductive techniques and reproductive medicine. We report a case of successful pregnancy by transmyometrial and transtubal embryo transfer simultaneously after in-vitro fertilization (IVF) in a 33 year-old patient with congenital cervical atresia diagnosed at the age of 18 years. The patient had experienced cyclic abdominal pain and amenorrhoea since she was 13 years old. She had had two unsuccessful attempts to create a new uterovaginal canal in another hospital. At the age of 32 years, she was referred to our unit and had a successful pregnancy after transmyometrial and transtubal embryo transfer. Caesarean section was performed at 36 weeks gestation due to progressive pre-eclampsia and gestational diabetes. A healthy male baby weighing 2812 g was safely delivered. Uterovaginal canalization with amniotic membrane for the covering of the neo-endocervical wall was performed during Caesarean section. Normal menstrual outflow and symptomatic relief have continued for 5 months after the operation. To the best of our knowledge, this is the first reported case of successful pregnancy by transmyometrial and transtubal embryo transfer as well as uterovaginal canalization performed during Caesarean section in a patient with congenital cervical atresia.

Intrauterine exposure to diethylstilbestrol: long-term effects in humans

DES is the most carefully scrutinized EDC and its history provides valuable insights into the current evaluation of less well-studied EDCs. This review summarizes the health effects of prenatal exposure to diethylstilbestrol (DES) and emphasizes the role of DES as the first endocrine disrupting chemical (EDC). Vaginal clear cell adenocarcinoma (CCAC), the most severe consequence of prenatal exposure to DES, affected only 0.1% of exposed females, while the far more prevalent teratogenic and reproductive effects of DES were only discovered when DES daughter were screened for CCAC. Initial studies, conducted before most DES daughters had tried to conceive, examined vaginal cancer and vaginal, cervical and uterine abnormalities. Subsequently, several controlled studies demonstrated the increased risk of adverse reproductive outcomes in DES daughters. While most DES daughters can eventually experience a live birth, this is less likely in women with genital tract abnormalities, in whom there is a two-thirds chance that each pregnancy will be unsuccessful. In DES sons, who have been far less studied, results suggest male reproductive toxicity, but are less consistent. The importance of dose and gestational age at initial exposure are discussed, and the implications of DES findings for the evaluation of risks from current EDCs emphasized.