Diagnosis of Mullerian anomalies in adults: evaluation of practice

An Uncommon Encounter: Obstetric Management of a Bicornuate Bicollis Uterus With a Longitudinal Vaginal Septum

This case report describes a rare presentation of a bicornuate bicollis uterus with a longitudinal vaginal septum in a 25-year-old woman presenting with a ruptured ectopic pregnancy. The patient's obstetric history revealed a previous cesarean section due to oligohydramnios. The diagnosis was confirmed through intraoperative assessment and MRI findings. Despite successful management of the ectopic pregnancy, the case underscores the importance of early detection and tailored management of Mullerian anomalies to optimize pregnancy outcomes. This report highlights the need for continued research to improve diagnostic accuracy and therapeutic approaches for such complex anatomical variations.

Vaginal bleeding in a newborn as initial presentation of uterus didelphys

Vaginal bleeding of the newborn is described as a normal phenomenon, occurring physiologically in a subset of baby girls as a response to decreased oestrogen levels in the postnatal period compared with in utero exposure. Here, we present the case of heavy vaginal bleeding prompting an evaluation via transabdominal ultrasound, which was ultimately diagnostic for uterus didelphys. We suggest that neonates with uterus didelphys are predisposed to heavy bleeding due to relatively larger amount of the endometrial tissue in two cavities. While diagnosis of Müllerian anomalies is typically made in adulthood, an earlier diagnosis facilitates timely medical and surgical intervention and prompts screening for concurrent and associated conditions. In summary, we recommend routine consideration of transabdominal ultrasound to investigate abnormal vaginal bleeding in the newborn.

Müllerian Anomalies Prevalence Diagnosed by Hysteroscopy and Laparoscopy in Mexican Infertile Women: Results from a Cohort Study

Background: To evaluate the prevalence of Müllerian anomalies (MAs) in a cohort of infertile Mexican women candidates for infertility treatments (intrauterine insemination or IVF (In vitro fertilization) cycles). Methods: We performed a retrospective observational study on a cohort of consecutive women, who underwent hysteroscopy and laparoscopy as part of the basic infertility workup from 2002 to 2014, at our center. Our aim was to calculate the prevalence of MAs and each subtype. Results: A total of 4005 women were included in the study. The MA prevalence was 4.4% (95% CI; 3.8–5.1; n = 177). Among women with MAs, the prevalence of different MA types was: septate uterus 54.2% (n = 96), arcuate uterus 15.8% (n = 28), bicornuate uterus 10.7% (n = 19), unicornuate uterus 8.5% (n = 15), didelphys uterus 6.2% (n = 11) and hypoplasia/agenesis 3.4% (n = 6), unclassifiable 1.1% (n = 2). Women with MAs who achieved pregnancy were: 33.3% (n = 59). The MA associated with the highest pregnancy rate was septate uterus after hysteroscopic correction, at 38.5% (37/96). Conclusions: The prevalence of MAs among infertile Mexican women can be considered as low, but not negligible. The septate uterus is the most common MA in women with infertility.

Maternal müllerian anomalies and future health of the offspring

OBJECTIVE

To evaluate whether offspring of women with müllerian anomalies are at an increased risk for long-term pediatric morbidity.

STUDY DESIGN

A population-based cohort study compared the incidence of long-term (up to the age of 18 years for offspring) hospitalizations due to cardiovascular, endocrine, neurological, hematological, respiratory and urinary morbidity of offspring to mothers diagnosed with uterine anomalies. Deliveries occurred between the years 1991 and 2013 in a tertiary medical center. Multiple pregnancies, unknown gestational age, gestational age of less than 24 weeks, perinatal mortality, and fetuses with congenital malformations were excluded. Kaplan-Meier survival curves were used to compare cumulative morbidity incidence. Survival analysis for clustered data was performed for each major-system pediatric hospitalization.

RESULTS

During the study period 253,808 deliveries met the inclusion criteria; 0.48% (n=1230) of which occurred in women diagnosed with müllerian anomalies. In the Kaplan-Meier survival curve, children born to mothers with müllerian anomalies did not have a significantly different cumulative incidence of any of the long-term pediatric morbidities, compared with the comparison group. In the multivariable survival analysis for clustered data, after adjustment of maternal clusters, maternal age, gestational age and birthweight, müllerian anomalies did not exhibit an independent association with long-term morbidities of the offspring.

CONCLUSION

Müllerian anomalies do not appear to have an independent impact on long-term morbidity of the offspring.

The comprehensiveness of the ESHRE/ESGE classification of female genital tract congenital anomalies: a systematic review of cases not classified by the AFS system

STUDY QUESTION

How comprehensive is the recently published European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) classification system of female genital anomalies?

SUMMARY ANSWER

The ESHRE/ESGE classification provides a comprehensive description and categorization of almost all of the currently known anomalies that could not be classified properly with the American Fertility Society (AFS) system.

WHAT IS KNOWN ALREADY

Until now, the more accepted classification system, namely that of the AFS, is associated with serious limitations in effective categorization of female genital anomalies. Many cases published in the literature could not be properly classified using the AFS system, yet a clear and accurate classification is a prerequisite for treatment.

STUDY DESIGN, SIZE AND DURATION

The CONUTA (CONgenital UTerine Anomalies) ESHRE/ESGE group conducted a systematic review of the literature to examine if those types of anomalies that could not be properly classified with the AFS system could be effectively classified with the use of the new ESHRE/ESGE system. An electronic literature search through Medline, Embase and Cochrane library was carried out from January 1988 to January 2014. Three participants independently screened, selected articles of potential interest and finally extracted data from all the included studies. Any disagreement was discussed and resolved after consultation with a fourth reviewer and the results were assessed independently and approved by all members of the CONUTA group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Among the 143 articles assessed in detail, 120 were finally selected reporting 140 cases that could not properly fit into a specific class of the AFS system. Those 140 cases were clustered in 39 different types of anomalies.

MAIN RESULTS AND THE ROLE OF CHANCE

The congenital anomaly involved a single organ in 12 (30.8%) out of the 39 types of anomalies, while multiple organs and/or segments of Müllerian ducts (complex anomaly) were involved in 27 (69.2%) types. Uterus was the organ most frequently involved (30/39: 76.9%), followed by cervix (26/39: 66.7%) and vagina (23/39: 59%). In all 39 types, the ESHRE/ESGE classification system provided a comprehensive description of each single or complex anomaly. A precise categorization was reached in 38 out of 39 types studied. Only one case of a bizarre uterine anomaly, with no clear embryological defect, could not be categorized and thus was placed in Class 6 (un-classified) of the ESHRE/ESGE system.

LIMITATIONS, REASONS FOR CAUTION

The review of the literature was thorough but we cannot rule out the possibility that other defects exist which will also require testing in the new ESHRE/ESGE system. These anomalies, however, must be rare.

WIDER IMPLICATIONS OF THE FINDINGS

The comprehensiveness of the ESHRE/ESGE classification adds objective scientific validity to its use. This may, therefore, promote its further dissemination and acceptance, which will have a positive outcome in clinical care and research.

STUDY FUNDING/COMPETING INTERESTS

None.

Is magnetic resonance imaging sufficient to diagnose rudimentary uterine horn? A case report and review of the literature

Imaging is often part of the evaluation of gynecologic disorders, with transvaginal ultrasound being the most frequently used imaging modality. Although laparoscopy, hysterosalpingography, and hysteroscopy can add diagnostic accuracy, they are invasive and costly. Magnetic resonance imaging (MRI) has been increasingly used because it is both noninvasive and highly accurate. Although MRI is more expensive than ultrasound, it is less so than surgery. Given the demonstrated accuracy of MRI in assessing müllerian anomalies, additional imaging is not often sought once an MRI diagnosis is made. However, when imaging findings are not pathognomonic via MRI or otherwise, inaccurate diagnoses and their consequences may occur. We describe the case of a 21-year-old woman with unilateral dysmenorrhea whose MRI features suggested a unicornuate uterus with a hematometrous noncommunicating horn although laparoscopy ultimately revealed a necrotic myoma without an accompanying müllerian anomaly.

Unilateral uterine segmentary aplasia, papillary endometrial hyperplasia and ipsilateral renal agenesis in a cat

A 1-year-old, female, previously spayed domestic shorthair cat presented with abnormal behavior characterized by rubbing up against objects, vocalization and abnormal body posture. A diagnostic laparoscopy was performed and a dilated segment of the left uterus and ovary was found in association with ipsilateral renal agenesis. Papillary hyperplasia of the endometrium of the dilated segment was found on histopathology. The occurrence and findings of this condition are reviewed.

Müllerian duct anomalies and their effect on the radiotherapeutic management of cervical cancer

Radiotherapy plays a major role in the treatment of cervical cancer. A successful radiotherapy program integrates both external beam and brachytherapy components. The principles of radiotherapy are strongly based on the anatomy of the organ and patterns of local and nodal spread. However, in patients with distorted anatomy, several practical issues arise in the delivery of optimal radiotherapy, especially with brachytherapy. Müllerian duct anomalies result in congenital malformations of the female genital tract. Though being very commonly studied for their deleterious effects on fertility and pregnancy, they have not been recognized for their potential to interfere with the delivery of radiotherapy among patients with cervical cancer. Here, we discuss the management of cervical cancer among patients with Müllerian duct anomalies and review the very sparse amount of published literature on this topic.

Bilateral ectopic hypoplastic uteri attached to bilateral pelvic sidewalls in a 21-year-old patient with primary amenorrhea: the first published report

Müllerian duct anomalies (MDAs) encompass a group of anatomical malformations resulting from defective development, fusion, migration, or resorption of Müllerian (paramesonephric) ducts during embryonic life. Herein, we report the first case of an exceedingly uncommon MDA (bilateral ectopic hypoplastic uteri attached to bilateral pelvic sidewalls) in a 21-year-old woman who was referred to our tertiary care center as a case of primary amenorrhea for workup and further management.

Clinical approach for the classification of congenital uterine malformations

A more objective, accurate and non-invasive estimation of uterine morphology is nowadays feasible based on the use of modern imaging techniques. The validity of the current classification systems in effective categorization of the female genital malformations has been already challenged. A new clinical approach for the classification of uterine anomalies is proposed. Deviation from normal uterine anatomy is the basic characteristic used in analogy to the American Fertility Society classification. The embryological origin of the anomalies is used as a secondary parameter. Uterine anomalies are classified into the following classes: 0, normal uterus; I, dysmorphic uterus; II, septate uterus (absorption defect); III, dysfused uterus (fusion defect); IV, unilateral formed uterus (formation defect); V, aplastic or dysplastic uterus (formation defect); VI, for still unclassified cases. A subdivision of these main classes to further anatomical varieties with clinical significance is also presented. The new proposal has been designed taking into account the experience gained from the use of the currently available classification systems and intending to be as simple as possible, clear enough and accurate as well as open for further development. This proposal could be used as a starting point for a working group of experts in the field.

The Effect of Didelphys Uterus on the Outcome of Pregnancy

Congenital anomalies of the uterus are often asymptomatic and unrecognized but they may affect a woman's obstetric and gynecological health. A woman with uterus didelphys and a past history of two abortions, two abnormal fetal lie and two previous cesarean sections was admitted in labor to our Obstetrics department. Delivery was smooth and successful without complications. We review briefly the literature on diagnostic methods and complications of uterine anomalies.

Congenital malformations of the female genital tract: the need for a new classification system

Current proposals for classifying female genital anomalies seem to be associated with limitations in effective categorization, creating the need for a new classification system that is as simple as possible, clear and accurate in its definitions, comprehensive, and correlated with patients' clinical presentation, prognosis, and treatment on an evidence-based foundation. Although creating a new classification system is not an easy task, it is feasible when taking into account the experience gained from applying the existing classification systems, mainly that of the American Fertility Society.

Diagnostic accuracy of real-time 3D sonography in the diagnosis of congenital Mullerian anomalies in high-risk patients with respect to the phase of the menstrual cycle

PURPOSE

To compare the diagnostic accuracy of 2-dimensional sonography (2DUS) and real-time 3-dimensional sonography (3DUS) in the diagnosis of congenital mullerian defects (CMD) with respect to the phase of the menstrual endometrium.

METHOD

The accuracy of sonography was examined on 108 women by 2 gynecologists during the 1st 5 days after cessation of menstrual flow and then re-examined at the cycle days 20-24. Entrance criteria for the patients enrolled in the study were as follows: women who were referred to our center with a suspected Mullerian anomaly at hysterosalpingography, and women who were suspected to have a uterine anomaly at our hospital during infertility, dysmenorrhea, and recurrent abortion workup. First, 1 of the gynecologists performed the 2DUS, and afterwards the 2nd gynecologist performed the real-time 3DUS. Results from both examiners were compared and correlated with the definitive diagnosis obtained by MRI, laparoscopy, or hysteroscopy. The sensitivity and specificity values of 2DUS and real-time 3DUS for the diagnosis of CMD were calculated at follicular and luteal phases.

RESULT

Among the 108 cases suspected to have CMD, the sensitivity and specificity values of real-time 3DUS were significantly higher in the follicular sensitivity, 94.7%, specificity, 75.0%, and luteal phases (sensitivity, 100%, specificity, 93.7%) when compared with 2DUS values (sensitivity of 30.2% and specificity of 78.1% in the follicular phase and sensitivity of 42.1% and specificity of 81.2% in the luteal phase).

CONCLUSION

Real-time 3DUS is an accurate method that can be used for the diagnosis of congenital mullerian defects.

Müllerian duct anomalies: review of current management

The aim of this paper was to discuss the embryological aspects of Müllerian duct anomalies and to analyze the current diagnostic methods and therapy. Müllerian anomalies are congenital defects of the female reproductive tract resulting from failure in the development of the Müllerian ducts and their associated structures. Their cause has yet to be fully clarified, and it is currently believed to be multifactorial. Symptoms appear principally during adolescence or early adulthood, and affect the reproductive capacity of these women. When clinically suspected, investigations leading to diagnosis include imaging methods such as hysterosalpingography, ultrasonography and magnetic resonance. The classification of these malformations relates to their embryogenesis, and defines the therapy and prognosis. Müllerian anomalies consist of a wide range of defects that may vary from patient to patient. Therefore, their management must also be individual, taking anatomical and clinical characteristics into consideration, as well as the patient's wishes.