The obstetric consequences of uterovaginal anomalies

Reproductive performance after hysteroscopic metroplasty in the hypoplastic uterus: a study of 29 cases

OBJECTIVE

To evaluate the reproductive performance after hysteroscopic metroplasty performed for hypoplastic uterus.

DESIGN

Crossover study (15 patients) and descriptive analysis (14 patients).

SETTING

Tertiary care university hospital.

POPULATION

Twenty-nine women (mean age: 31.4 years; range: 27-38.5 years) with a hypoplastic malformed uterus and a history of primary infertility and/or recurrent abortion and/or preterm delivery were included in this study. Fourteen women suffered from primary infertility and 15 women had previous pregnancies. Twenty-three women had been exposed to diethylstilboestrol in utero.

METHODS

Women underwent hysteroscopic metroplasty between January 1996 and May 1999.

MAIN OUTCOME MEASURES

Rate of pregnancies and live births, anatomical results.

RESULTS

The mean follow up was 40 months (range: 13-67 months). Twenty-one women (72.4%) experienced 30 pregnancies. Thirteen women gave birth to 16 live infants. At the time of the follow up, four women were pregnant in the second trimester. Compared with previous pregnancies, the rate of deliveries increased from 3.8% to 63.2%. No complications occurred during metroplasty. The hysteroscopic anatomical results were good in all cases.

CONCLUSIONS

Our results suggest that hysteroscopic metroplasty, with its simplicity and minimal post-operative sequelae, seems to be an operation of choice in women with a hypoplastic malformed uterus and a history of severe infertility and/or recurrent pregnancy loss.

Female genital anomalies affecting reproduction

OBJECTIVE

A multitude of female congenital anomalies are uncommon. However, their impact on reproduction can be profound. The aim of this review is to remind the practicing physician of the clinically relevant embryology and summarize the studies that look at the impact of such various anomalies on a woman's fecundity. We review particular surgical therapies that possibly may improve fertility in such women.

DESIGN

Review and critique of available studies in which particular surgical therapies were done and whether they truly improved fertility in these women with congenital reproductive anomalies.

RESULTS

Clear evidence demonstrates that uterine septum resection is effective in women with demonstrated recurrent pregnancy losses. Arcuate uterus has little impact on reproduction. Other studies fail to definitively show that surgical correction will improve pregnancy retention or fertility except for specifically indicated clinical scenarios.

CONCLUSIONS

The practicing reproductive specialist should have working knowledge of evidence-based therapeutic options for women with reproductive congenital anomalies. A summary chart has been devised to clearly associate embryologic structures with normal adult derivative as well as anomalous structures.

Pulmonary endometriosis in a patient with unicornuate uterus and noncommunicating rudimentary horn

OBJECTIVE

To report a rare case of a patient with catamenial hemoptysis, secondary infertility, and endometriosis associated with a unicornuate uterus and noncommunicating rudimentary horn.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 29-year-old woman who developed progressive catamenial hemoptysis and secondary infertility was evaluated at the University Hospital of Crete.

INTERVENTION(S)

The complete history, laboratory data, laparoscopic findings, and chest magnetic resonance image of this patient were analyzed. A GnRH agonist, leuprolide acetate, was successfully administered.

MAIN OUTCOME MEASURE(S)

Diagnosis and appropriate treatment of pulmonary endometriosis in a patient with rudimentary uterine horn.

RESULT(S)

Treatment with a GnRH agonist achieved suppression of both menstruation and hemoptysis. After 6 months of normal menstrual activity, the symptoms reappeared. The patient was again treated with leuprolide acetate (3.75 mg/mo IM) for 6 months and remained asymptomatic. In fact, the patient became pregnant after cessation of therapy. Finally, the patient was treated successfully with removal of the rudimentary uterine horn during cesarean section. Three-year follow-up showed disappearance of the chest symptoms.

CONCLUSION(S)

Pulmonary endometriosis and unicornuate uteri are rare. To our knowledge, this is the first case of catamenial hemoptysis with a congenital müllerian anomaly. We describe successful management using a combination of GnRH agonist and surgical resection of the rudimentary uterine horn.

Prevalence of Müllerian duct anomalies detected at ultrasound

The true prevalence of müllerian duct abnormalities is not well established. We used standard ultrasound examinations to establish the prevalence of müllerian duct abnormalities in girls and women who were evaluated for reasons unrelated to the presence of uterine anomalies. Prospective ultrasound examinations for nonobstetric indications in 2,065 consecutive girls and women (aged 8-93) showed that 8 had anomalies, including bicornuate uterus, septate uterus, and double uterus. In this first attempt to determine the prevalence of uterine anomalies in the general population, using noninvasive methodology, the rate of anomalies was 3.87 per 1,000 women (exact 95% confidence interval: 1.67-7.62), or approximately 1 in 250 women. This prevalence estimate may be greater than the true rate if selection biases are strong, or less than the true prevalence if ultrasound detection rates are low. As a first attempt to establish the prevalence by pelvic ultrasound in a consecutive series, these data may serve as a baseline estimate.

Hysteroscopic treatment of the uterine septum: a clinician's experience

OBJECTIVE

I reviewed my experience with the diagnosis and hysteroscopic treatment of uterine septa.

STUDY DESIGN

This article is a retrospective review of cases from 1992-1999. A septate uterus was diagnosed in a total of 40 patients, and all were treated by hysteroscopic resection.

RESULTS

The rate of preoperative pregnancy loss was 77.4%, and the uncomplicated delivery rate was 6.5%. After hysteroscopic septum resection 21 patients reported a total of 22 pregnancies with an 18.2% miscarriage rate and a 77.3% uncomplicated delivery rate.

CONCLUSION

Hysteroscopic treatment of uterine septa is a safe, simple, and effective procedure. It can be used for all types of uterine septa, it attains optimal obstetric outcomes, and it should be undertaken whenever a uterine septum is diagnosed.

Incidence of uterine rupture among women with müllerian duct anomalies who attempt vaginal birth after cesarean delivery

OBJECTIVE

The purpose of this study was to determine and compare the incidences of uterine rupture among women with and without müllerian duct anomalies who were attempting vaginal birth after cesarean delivery.

STUDY DESIGN

There were 1813 attempts at vaginal birth after cesarean delivery between 1992 and 1997 at the Foothills Hospital in Calgary, Alberta, Canada. Of the patients 25 had known müllerian duct anomalies and 1788 did not. The records of these 1813 women were reviewed with respect to uterine rupture, other complications, mode of delivery, and characteristics of the trial of labor. Comparisons were made with the Fisher exact test.

RESULTS

The rates of uterine rupture were 8% (2/25) in the group with müllerian duct anomalies and 0.61% (11/1788) in the group without müllerian duct anomalies (P =.013). The cesarean delivery rates were 20% (5/25) and 25.1% (448/1788), respectively. All cesarean deliveries among women with müllerian duct anomalies were performed urgently in response to severe fetal heart rate abnormalities. The rates of fetal heart rate abnormalities necessitating immediate delivery (60% vs 14.1%, P =.013), operative vaginal delivery (40% vs 19.6%, P =.02), and cord prolapse (8% vs 0.45%, P =.0076) were significantly greater in the group with müllerian duct anomalies.

CONCLUSIONS

Vaginal delivery is common among women with müllerian duct anomalies who attempt vaginal birth after cesarean delivery, but the rates of uterine rupture and other complications are high.

Laparoscopic management of a unicornuate uterus with two cavitated, non-communicating rudimentary horns: case report

An 18 year old nulligravid woman presented with severe dysmenorrhoea secondary to stage IV (revised American Fertility Society) endometriosis, right haematosalpinx, right endometrioma, unicornuate uterus and two cavitated, non-communicating rudimentary uterine horns. To our knowledge, this is the first reported case of a unicornuate uterus accompanied by two rudimentary horns. Operative video-laparoscopy proved a successful approach for treating this previously unreported variant of congenital Müllerian anomaly. A review of the world literature confirms the uniqueness of this case while demonstrating laparoscopy to be a viable alternative to laparotomy for management of congenital Müllerian anomalies. The case presented may help to elucidate Müllerian duct embryology further.

Gynecologic concerns in the treatment of teenagers with cloaca

BACKGROUND/PURPOSE

Gynecologic anomalies are common in patients with persistent cloaca, but, except for hydrocolpos, these patients remain asymptomatic in the neonatal period. Anatomic abnormalities may become manifest in puberty when menses occurs. The authors sought to describe the sequelae of these anatomic defects in the teenage cloaca patient and to determine recommendations for prevention and treatment in the neonatal period.

METHODS

From a series of 198 patients operated on for persistent cloaca, the authors report a group of 22 patients who have reached puberty.

RESULTS

Seven patients are menstruating normally. Six patients have primary amenorrhea because of absent or atretic uteri. Nine patients presented with abdominal pain and cystic abdominal masses and required surgical resection of inflamed collections of old blood in uteri, hemiuteri, tubes, blind vaginas, hemivaginas, or in the peritoneum. The common denominator of this last group was an obstruction of one or more Mullerian structure that interfered with the drainage of menstrual blood. Asymmetric gynecologic anatomy or a vaginal atresia in the neonatal period seemed to correlate with future obstruction to menstrual flow.

CONCLUSIONS

To prevent future problems, the management of the neonatal cloaca must include the early clarification of the gynecologic anatomy, specifically the patency of Mullerian structures. Unilateral atretic structures and tubes connected to atretic uteri should be resected. Also, clinicians must be suspicious of menstrual problems in teenagers operated on early in life for persistent cloaca.

Unicornuate uterus and rudimentary horn

OBJECTIVE

To evaluate clinical implications of the unicornuate uterus and rudimentary horn.

DESIGN

A retrospective study.

SETTING

A university hospital.

PATIENT(S)

Forty-two women who had a unicornuate uterus with or without rudimentary horn.

INTERVENTION(S)

The rudimentary horn was removed in 21 cases.

MAIN OUTCOME MEASURE(S)

Presence of other anomalies, fertility, and outcome of pregnancies were studied.

RESULT(S)

A right unicornuate uterus with noncommunicating rudimentary horn was the most common type of uterine anomaly. Unilateral renal agenesis was found in 13 (38%) of 34 cases. Six (14%) of the 42 patients had primary infertility. Thirty-four women produced 93 pregnancies; ectopic pregnancy (EP; rudimentary horn, tubal) occurred in 20 of these cases (22%). The pregnant uterine horn ruptured in 3 of 7 cases. Eight (57%) of the 14 women with infertility underwent treatment by IVF-ET; 4 of them conceived, and 2 had term delivery. The fetal survival rate was 61%, prematurity 17%, fetal growth retardation 5%, and the spontaneous intrauterine (IU) abortion rate was 16%. Pregnancy-induced hypertension (PIH) was more common in women lacking a kidney than in those with two kidneys.

CONCLUSION(S)

The high number of EPs indicates removal of rudimentary horn and its tube when diagnosed. The prognosis of IU pregnancy is not impaired in the unicornuate uterus although prematurity threatens. Unilateral renal agenesis is associated with PIH.

Uterine surgery by operative hysteroscopy

Uterine anomalies are found in 10-15% of women with repeated pregnancy loss. Uterine malformations and benign tumors are common causes of abortions, premature labour and abnormal fetal presentation in some cases. One-third of patients with habitual abortion have a septated or subseptated uterus, and two-thirds of pregnancies in women with duplicated uterus progress to term. Müllerian fusion defects and submucous fibroid may cause poor implantation or ineffective maternal blood supply to the placental site of the developing pregnancy. When these abnormalities were evaluated in infertile patients or in habitual abortions, traditionally the abdominal correction (Jones, Strassman, Tompkins etc.) were used traditionally. These procedures require incision of abdominal and uterine walls in general anesthesia with relative long hospitalization and recovery. The new endoscopic procedure; hysteroscopy is used not only to evaluate the type and size of Müllerian fusion defects but also to treat this malformation. The uterine septum is transsectable, via this elegant method, without injury of abdominal wall and healthy uterine wall musculature. After a traditional abdominal metroplasty there is no other-choice other than the cesarean section to prevent rupture of the uterus, but after hysteroscopic septotomy the vaginal delivery is possible and the uterine rupture rarity.

Reproductive outcome after metroplasty

OBJECTIVE

To evaluate the impact of abdominal metroplasty for symmetric uterine anomalies on reproductive performance.

METHOD

A retrospective analysis of 24 patients who conceived following metroplasty for symmetric congenital anomalies during a 5-year period.

RESULTS

In patients with poor obstetric histories before surgery, the overall fetal survival rate increased from 2.5%, before treatment to 73.3% after treatment and 90.5% of women gave birth to a surviving infant. The remaining three patients suffering from infertility delivered a full-term infant after metroplasty. Antenatal complications occurred in 56.7% of the pregnancies.

CONCLUSION

Abdominal metroplasty clearly improves fetal survival particularly in women suffering from a history of poor obstetric outcome associated with symmetric malformations.

Hematometra in an unattached rudimentary uterine horn and ipsilateral renal agenesis

This report describes an adolescent female with a functioning unattached rudimentary blind uterine horn who presented with dysmenorrhea, severe lower abdominal pain and a pelvic mass. She had been unsuccessfully treated with prostaglandin inhibitors, and in her past history several episodes of urinary tract infections were reported. Removal of the uterine horn afforded complete relief of symptoms.

Reproductive performance after conventional metroplasty: an evaluation of 102 cases

OBJECTIVE

To evaluate the influence of conventional metroplasty on reproductive performance of symmetric uterine anomalies and determine the complications of these procedures.

DESIGN

A retrospective clinical analysis of consequently operated 102 women.

SETTING

Institutional.

PATIENTS AND PARTICIPANTS

One hundred two patients with bicornuate and septate uterus and a history of late recurrent abortion and/or preterm delivery were included in this study.

INTERVENTIONS

Jones, Strassman, and Tompkins procedures for metroplasty and McDonald operation for cervical cerclage.

MAIN OUTCOME MEASURE

The fetal survival rate has increased from 3.7% before operation to 75.0% afterwards. In only two patients uterine rupture was observed.

RESULTS

Conventional metroplasty improves the fetal survival rate in women with symmetric uterine anomalies.

CONCLUSIONS

Our results confirm the view that conventional metroplasty seems to be an operation of choice in women with symmetric uterine anomalies and a history of recurrent late abortion and preterm delivery. However, uterine rupture and postoperative infertility may be potential complications.

Evidence of embryo- and trophoblast-toxic cellular immune response(s) in women with recurrent spontaneous abortion

OBJECTIVE

The purpose of this study was to determine whether reproductive antigens stimulate lymphocytes and macrophages from women with recurrent abortion to secrete factors that are toxic to preimplantation embryos or trophoblast cells in vitro.

STUDY DESIGN

Mononuclear cells were isolated from 30 fertile controls and 300 nonpregnant women being evaluated for recurrent abortion. Supernatants generated from these cells after separate culture with sperm and trophoblast antigen extracts were added to two-cell mouse embryo cultures and trophoblast proliferation assays. Toxicity was assumed when the median percentage of embryos developing to blastocysts or trophoblast proliferation was less than or equal to 50% of control values. Both parametric and nonparametric statistical methods were used where appropriate.

RESULTS

Mouse embryo development and/or trophoblast proliferation were significantly inhibited by supernatants from trophoblast and/or sperm antigen-activated peripheral blood leukocyte cultures from a majority of 300 women with recurrent abortion but not from 30 women with normal reproductive histories. The mouse blastocyst development assay was more sensitive than the trophoblast proliferation assay in determining toxic factor production. Embryo-toxic factors were produced by activated leukocyte cultures from 90% of 180 women with a history of recurrent abortion of unexplained etiology, whereas trophoblast-inhibitory factors were detected in 50% of women from the same group. The embryo-toxic factor(s) was heat labile, had a molecular weight(s) between 10 and 30 kd, and was absorbed out by passage through affinity columns containing anti-interferon gamma beads.

CONCLUSION

We conclude that recurrent abortion in some women is associated with embryo- and/or trophoblast-toxic factor production in response to stimulation by sperm or trophoblast antigens and that the principal factor may involve the 18 kd, heat-labile, T-lymphocyte cytokine interferon gamma. This study suggests a new cause of recurrent abortion.

Outcome of pregnancy in women with uterine malformation: evaluation of 62 cases

A retrospective analysis of the outcome of pregnancy in 62 women seen between 1971 and 1988, with a uterine malformation was carried out. Fifty-seven out of 62 cases with a uterine malformation conceived and there was a total of 127 pregnancies. On the other hand five women have an unexplained infertility of more than 2 years duration. The abortion rate among these 127 pregnancies was 36% premature delivery rate 22% and term delivery rate 42%. Cases with a complete septate uterus had the higher abortion rate. Metroplasty was done in three patients with a uterus bicornis and in six cases with a septate uterus. Cervical cerclage was done in 23 cases. Breech presentation was very frequent (46%). The cesarean section rate in the 81 cases whose pregnancy continued beyond the 28th week of pregnancy was 63%. Perinatal mortality rate was 37% and fetal survival rate 61%.

Strassman procedure for correction of a class II müllerian anomaly in an adolescent

A logical approach to the diagnosis of pelvic pain in an adolescent with a suspected uterine anomaly is necessary for optimal care. A 16-year-old female born with an imperforate anus and a Class II müllerian anomaly is presented. A Strassman procedure resulted in unification of uterine horns, correction of pelvic pain, and potential fertility.

Transvaginal ultrasound for diagnosis of uterine malformations

Uterine malformations were detected in 8 of 300 patients (3%) referred for transvaginal ultrasound scan (TVS) for different indications. Six of them had a partially septate uterus and two had a uterus didelphys. As uterine malformations can be associated with both sterility and reproductive failure, we suggest that the study of uterine morphology and structure could be a part of routine TVS examination.

Reproductive prognosis after abdominal metroplasty in bicornuate or septate uterus: a life table analysis

Reproductive prognosis after abdominal metroplasty was assessed in 73 women with a septate and 71 with a bicornuate uterus who underwent metroplasty at the First Obstetric and Gynecologic Clinic of the University of Milan between 1972 and 1985. The overall cumulative 5-year delivery rates were respectively 70% and 73% in women with septate and bicornuate uterus, rising constantly with time. The number of previous miscarriages did not affect the reproductive prognosis: the 5-year probability of giving birth was 64% and 75% in the women with septate uterus and respectively fewer than two or more previous miscarriages, and the corresponding values were 66% and 73% in the bicornuate uterus subgroup. The miscarriage rate (about 20%) was similar with both types of malformation.

Single ectopic ureter opening into blind vagina, with renal dysplasia and associated utero-vaginal duplication

A rare case of single ectopic ureter opening into a blind vagina with renal dysplasia and associated uterovaginal duplication is reported. The findings are interesting from the clinical diagnostic viewpoint and also contribute to our knowledge of the embryology of the female genitourinary system, especially concerning the origin of the vagina.

Congenital anomalies of the müllerian system

Congenital anomalies of the müllerian system, the most common of which are uterine malformations, are associated with fertility problems. Multifactorial polygenic and familial factors are involved in their formation. The result may be deficient development (agenesis, rudimentary horn, unicornuate uterus), nonfusion (didelphys or bicornuate uterus), or defective canalization of the müllerian ducts (septate uterus). The principal diagnostic procedures include HSG, laparoscopy, hysteroscopy, and US. The clinical presentation varies from symptoms of obstruction of the menstrual flow in adolescence to hypomenorrhea and fertility problems in adult life. Repeated fetal loss, after excluding other reasons, is usually the indication for surgical intervention. Uterine septa should be resected hysteroscopically. A prophylactic cerclage has been suggested by various authors, including those of this work, in cases of symmetric uterine anomalies, especially bicornuate uteri, as a simple and effective treatment to be tried before embarking on major surgery such as metroplasty.

Reproductive problems and birth defects in survivors of Wilms' tumor and their relatives

In a retrospective cohort study of 47 Wilms' tumor survivors and their 77 sibling controls, female survivors had a fourfold excess risk (risk ratio, 4.1; 95% confidence interval, 1.7-10.1) for any adverse livebirth outcome, including birth defects, compared with their sibling controls. Wives of male survivors had no apparent excess risk for problem pregnancies. The families had a number of severe reproductive problems and major birth defects, such as primary amenorrhea in two survivors, bicornuate uterus in two survivors and one control, and mental retardation in one male survivor and a male control. The son of a female survivor died after bilateral Wilms' tumors. Birth defects in the offspring of female survivors are compatible either with intrauterine constraint, possibly due to radiation-induced fibrosis or with the complex of malformations associated with Wilms' tumor. Female survivors of Wilms' tumor appear to be at increased risk for a variety of reproductive problems, from sterility to fetal loss, early delivery, and birth defects in offspring. Furthermore, relatives of survivors of Wilms' tumor may be at risk of having associated birth defects, with clinically significant consequences.

Obstetric implications of minor müllerian anomalies in oligomenorrheic women

The obstetric performance of 50 consecutive women with minor müllerian anomalies was compared with that of 141 subjects having a normal uterine cavity on hysterosalpingography. All 191 patients had a history of some years' infertility. Spontaneous abortion was the outcome of the first pregnancy in 27.8% of women with müllerian anomalies (not statistically different from the outcome of the control group). However, the evidence of a greater risk of variously complicated first pregnancies and labors (30.3% versus 12.9%, p less than 0.05) and of emergency cesarean sections (21.2% versus 7.1%, p less than 0.05) in the group of minor müllerian anomalies than in the group with normal uteri confirmed the innate pathologic condition and clinical significance of these mild to moderate malformations present in about 40% to 50% of oligomenorrheic women. The most frequent complications were threatened abortion and abnormal fetal lie. Even the very mildest müllerian anomalies seemed to have gynecologic and obstetric implications, but the clinical impact in this group still remains uncertain. It is concluded that a genital tract anomaly of a certain obstetric significance (ratio between distance from nadir of fundal indentation to line connecting summits of uterine horns and length of this line or H/L ratio greater than 0.15) must be suspected in about one third of women with oligomenorrhea. Consequently a high risk in the event of a future pregnancy is evident, and about half the pregnancies (42.1%) in this group will be complicated in one or more ways.

Can ultrasound be used to screen uterine malformations?

Eighty-nine patients were examined by ultrasound during the second phase of the menstrual cycle. The operators were not aware of the patients' history or results of previous ultrasonographic or radiologic investigations. The operators' aim was to diagnose uterine malformations graded as normal, suspected, or abnormal. Ultrasound identified 7 of 9 patients with a didelphic or complete septate uterus and 2 out of 3 with a bicornuate or partial septate uterus. Two other cases were suspected (one with a unicornuate, the other with a didelphic uterus). One false-positive case occurred, and 10 patients were not identified as having a malformed uterus (sensitivity, 42.9%; specificity, 97.8%). False-negatives involved mainly minor malformations.