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Ashkar A, Shah S, Yousuf F, Siddiqui FZ, Yousuf H. Case report: Elective management of a bicornuate uterus with hematometra, incidentally found submucosal fibroids, rectus sheath hematoma, and hydronephrosis in a resource limited setting. Int J Surg Case Rep 2024; 120:109889. [PMID: 38852567 PMCID: PMC11220550 DOI: 10.1016/j.ijscr.2024.109889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/11/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Bicornuate uterus is a rare type of congenital mullerian anomaly, presenting as a diagnostic challenge. Metroplasty either via an open approach or laparoscopically can be performed to definitively diagnose and treat the defect. CASE PRESENTATION A 26-year-old female, with no known comorbids and past surgical history of endometriotic cyst excision presented with acute symptoms of left lower abdominal pain, burning micturition, and relative constipation. After clinical and radiologic investigations, the diagnosis of bicornuate was suspected. An elective exploratory laparotomy was then performed due to limited resources and skilled surgical techniques. Intra-operatively it was found that she had a bicornuate uterus with a single cervix and vagina, with the left cornuate being non-communicating with fluid suggesting hematometra. Dense adhesions were reported with drainage of 150-200 ml of free fluid upon opening the rectus sheath. Postoperatively she remained vitally stable and was discharged home. CLINICAL DISCUSSION We report a rare case of a bicornuate uterus with double horns along with submucosal fibroids, rectus sheath hematoma, and left sided hydronephrosis. Diagnosis of bicornuate uterus is associated with diagnostic uncertainty mainly due to its rarity and nonspecific presentation. CONCLUSION Although bicornuate is rare, it may result in complications if not attended to timely. Early diagnosis and management are necessary to minimize associated morbidity and mortality that can occur as a consequence of associated unattended pressure symptoms.
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Affiliation(s)
- Anusha Ashkar
- Dow University of Health Sciences, Karachi, Pakistan.
| | - Saba Shah
- Dow University of Health Sciences, Karachi, Pakistan
| | - Fizza Yousuf
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Hamza Yousuf
- Dow University of Health Sciences, Karachi, Pakistan
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Mbwambo OJ, Anthony J, Mremi A, Ngowi NB, Mvunta DH. A case report on rare co-occurrence of invasive ovarian mucinous adenocarcinoma, unilateral renal agenesis, and bicornuate uterus: is it a new triad? BMC Womens Health 2024; 24:300. [PMID: 38769573 PMCID: PMC11103989 DOI: 10.1186/s12905-024-03130-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 05/06/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Concomitant invasive ovarian mucinous adenocarcinoma, unilateral renal agenesis and bicornuate uterus is a rare combination. Unilateral renal agenesis has been associated with genital anomalies, such as unicornuate and bicornuate uterus. Furthermore, a wealth of studies has reported the association between unicornuate uterus and ovarian anomalies, such as the absence of an ovary or ectopic ovaries, but rarely has there been a combination of the three to the best of our knowledge. The present case report is the first case presentation with a combination of the three syndromes: ovarian mucinous tumor, unilateral renal agenesis, and bicornuate uterus. CASE PRESENTATION We report the case of a 17-year-old who presented with abdominal distension. On examination, a CT scan revealed a large multicystic abdominal mass on the right side, with an absence of the right kidney while the left kidney was normal in size, appearance, and position. Intraoperatively, massive blood-stained ascitic fluid was evacuated. Additionally, a large whitish polycystic intra-abdominal mass with mucus-like materials and solid areas was attached to the midpoint of the colon and the right ovary, with visible metastasis to the omentum. The uterus was bicornuate. The mass and omentum were taken for histopathology and a diagnosis of invasive ovarian mucinous cystadenocarcinoma with metastasis to the colon and omentum was made after a pathological report. CONCLUSIONS The presence of these conditions in the same individual could potentially complicate medical management and fertility considerations. Thus, a need for a multidisciplinary medical team, including gynecologists, urologists, and oncologists, to address their unique needs and provide appropriate treatment and guidance. Further research and case studies are needed to better understand the possible association and implications of these rare co-occurring conditions.
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Affiliation(s)
- Orgeness Jasper Mbwambo
- Department of Urology, Kilimanjaro Christian Medical University College (KCMUCO), P. O Box 2240, Moshi, Tanzania
- Department of Urology, Kilimanjaro Christian Medical Centre (KCMC), P. O Box 3010, Moshi, Tanzania
| | - Jonaviva Anthony
- Department of Urology, Kilimanjaro Christian Medical University College (KCMUCO), P. O Box 2240, Moshi, Tanzania
| | - Alex Mremi
- Department of Pathology, Kilimanjaro Christian Medical Centre (KCMC), P. O Box 3010, Moshi, Tanzania
- Department of Pathology, Kilimanjaro Christian Medical University College (KCMUCO), P. O Box 2240, Moshi, Tanzania
| | - Nicholas B Ngowi
- Department of Urology, Kilimanjaro Christian Medical University College (KCMUCO), P. O Box 2240, Moshi, Tanzania
- Department of Urology, Kilimanjaro Christian Medical Centre (KCMC), P. O Box 3010, Moshi, Tanzania
| | - David H Mvunta
- Department of Clinical Oncology, Ocean Road Cancer Institute (ORCI), Barack Obama Drive, P. O Box 3592, Dar es Salaam, Tanzania.
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, 9 United Nations Road, Upanga West, P. O Box 65017, Dar es Salaam, Tanzania.
- Department of Obstetrics and Gynecology, St. Joseph College of Health and Allied Sciences, P. O Box 11007, Dar es Salaam, Tanzania.
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Feghali E, Etrusco A, Haydamous J, Ayed A, Laganà AS, Chiantera V, Vitale SG, Angioni S, Stabile G, Sleiman Z. Concurrent Diagnosis of Adenomyosis and Congenital Uterine Anomalies: A Review. J Pers Med 2023; 13:jpm13050716. [PMID: 37240886 DOI: 10.3390/jpm13050716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/21/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Background: Adenomyosis and congenital uterine anomalies (CUAs) can compromise reproductive potential and may coexist in the same patient, especially in cases of infertility. This review (CRD42022382850) aims to evaluate the published cases of concurrent adenomyosis and syndromic and nonsyndromic CUAs. Methods: A literature search for suitable articles published in the English language was performed using the following databases from inception to 30 November 2022: MEDLINE, EMBASE, Global Health, the Cochrane Library, Health Technology Assessment Database, and Web of Science. Articles including both CUAs and adenomyosis, with data about their potential relationship, were included. Results: The literature search retrieved 14 articles that met the purpose of this review and summarized the most recent findings regarding the concurrent diagnosis of adenomyosis and CUAs. Conclusions: Adenomyosis can be found in both syndromic and nonsyndromic CUAs, and may arise from several etiologies. The hypothesis that obstructions in CUAs increase uterine pressure and promote the development of adenomyosis remains to be further elucidated, and additional findings may also play a role. The patient's genetic, epigenetic, and hormonal patterns, as well as normal physiological processes, such as pregnancy, may influence the growth of adenomyosis.
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Affiliation(s)
- Edwin Feghali
- Department of Obstetrics and Gynecology, Lebanese American University Medical Center, Beirut 1100, Lebanon
| | - Andrea Etrusco
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Joe Haydamous
- Department of Obstetrics and Gynecology, University of Balamand, Beirut 1100, Lebanon
| | - Amal Ayed
- Department of Obstetrics and Gynecology, Farwaniah Hospital, Ministry of Health, Kuwait City 085700, Kuwait
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Vito Chiantera
- Unit of Gynecologic Oncology, ARNAS "Civico-Di Cristina-Benfratelli", Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy
| | - Guglielmo Stabile
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137 Trieste, Italy
| | - Zaki Sleiman
- Department of Obstetrics and Gynecology, Lebanese American University Medical Center, Beirut 1100, Lebanon
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Wang S, Wang K, Hu Q, Liao H, Wang X, Yu H. Perinatal outcomes of women with Müllerian anomalies. Arch Gynecol Obstet 2023; 307:1209-1216. [PMID: 35426514 PMCID: PMC10023634 DOI: 10.1007/s00404-022-06557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 03/30/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the perinatal outcomes of singleton pregnant women with Müllerian anomalies (MuAs). METHODS A retrospective cohort study was conducted on singleton pregnant women with MuAs who delivered at the West China Second University Hospital between January 1, 2009 and December 31, 2020. RESULTS Four hundred fifty-seven cases of MuAs were identified, with an incidence of 0.40%. The most common anomaly was a septate uterus (38.7%). Compared to the control group, the MuAs group had significantly higher incidences of perinatal complications, including preterm deliveries (PTDs) (27.4 vs. 9.8%, P < 0.001), preterm premature rupture of membranes (PPROM) (29.1 vs. 22.5%, P = 0.001), malpresentation (34.4 vs. 5.6%, P < 0.001), abruptio placentae (4.6 vs. 1.2%, P < 0.001), placental accreta/increta (19.7 vs. 11.8%, P < 0.001), and uterine rupture (2.8 vs. 1.6%, P = 0.035). The rates of in vitro fertilization and embryo transfer (IVF-ET), foetal growth restriction (FGR), and low birth weight were also significantly higher in the MuAs group (8.3 vs. 4.5%, P < 0.001; 2.6 vs. 0.9%, P = 0.001; 3.1 vs. 1.7%, P = 0.033, respectively). In the MuAs group, the incidence of PPROM was high in cases with unicornuate uterus (31.5%), and malpresentation was as high as 42.4 and 37.0% in cases with septate and didelphys uteri, respectively. CONCLUSION The data suggest that pregnancy with MuAs may increase adverse perinatal outcomes, which calls for intensive supervision during pregnancy and delivery to reduce maternal and foetal complications. Individualized considerations should be emphasized according to the different categories of MuAs in pregnancies.
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Affiliation(s)
- Si Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Kana Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Qing Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Hua Liao
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Haiyan Yu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Chengdu, 610041, Sichuan, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.
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Qiu J, Du T, Chen C, Lyu Q, Mol BW, Zhao M, Kuang Y. Impact of uterine malformations on pregnancy and neonatal outcomes of IVF/ICSI–frozen embryo transfer. Hum Reprod 2022; 37:428-446. [PMID: 35048124 DOI: 10.1093/humrep/deac003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 12/08/2021] [Indexed: 11/12/2022] Open
Abstract
Abstract
STUDY QUESTION
What is the impact of uterine malformations on reproductive and neonatal outcomes of IVF/ICSI–frozen embryo transfer?
SUMMARY ANSWER
Unification defective uteri are associated with poorer neonatal outcomes including higher preterm delivery rate and lower birthweight, and septate uteri are associated with worse fertility outcomes including higher miscarriage and lower live birth rates (LBRs).
WHAT IS KNOWN ALREADY
Several studies have investigated the negative effects of uterine malformations on pregnancy outcomes. However, an all-round and definitive conclusion has not been reached yet owing to the relatively low incidence of the disease and the heterogeneity of study populations, especially among women undergoing ART.
STUDY DESIGN, SIZE, DURATION
This was a retrospective cohort study including 411 women with congenital uterine anomalies and 14 936 women with a normal uterus who underwent first frozen-thawed embryo transfer cycles of IVF/ICSI from July 2008 to August 2019. We compared reproductive outcomes.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Reproductive outcomes of women with uterine malformations were studied through three propensity score-matched comparisons (patients with bicorporeal uterus, septate uterus and hemi-uterus [bicorporeal, septate and hemi-uterus groups, respectively] along with corresponding control groups without uterine malformations). We also compared pregnancy and neonatal outcomes, and performed subgroup analysis addressing didelphus, bicornuate uteri and septate uteri before and after surgery independently.
MAIN RESULTS AND THE ROLE OF CHANCE
Compared to the matched control group, women with a bicorporeal uterus had a significantly lower LBR (24.4% versus 34.8%, odds ratio (OR) 0.61 [95% CI: 0.37, 1.00], P = 0.048). The incidence of miscarriage and preterm delivery was higher but not statistically significant (29.0% versus 18.1%, OR 1.85 [95% CI: 0.82, 4.19], P = 0.135; 22.6% versus 9.9%, OR 2.64 [95% CI: 1.07, 6.52], P = 0.063, respectively). In addition, the bicorporeal group had a significantly lower gestational age, higher caesarean rate and lower birthweight than bicorporeal control. Women with a septate uterus had comparable clinical pregnancy rates to controls (43.3% versus 49.9%, OR 0.77 [95% CI: 0.57, 1.04], P = 0.091), increased miscarriage rates (23.5% versus 13.0%, OR 2.05 [95% CI: 1.18, 3.58], P = 0.010) and lower LBRs (29.4% versus 42.2%, OR 0.57 [95% CI: 0.41, 0.79], P = 0.001). In both singleton and twins pregnancies, pregnancy and neonatal outcomes were comparable between women with a septate uterus and control. Women with a hemi-uterus had a tendency for lower clinical pregnancy rate (36.8% versus 42.3%, OR 0.80 [95% CI: 0.52, 1.21], P = 0.287) and LBR (29.8% versus 33.1%, OR 0.86 [95% CI: 0.55, 1.34], P = 0.502), compared to women without malformations. The incidences of miscarriage and preterm delivery, respectively, were 16.7% versus 16.6% (OR 1.01 [95% CI: 0.41, 2.47], P = 0.989), and 9.5% versus 11.4% (OR 0.82 [95% CI: 0.27, 2.51], P = 1) in women with a hemi-uterus as compared to control.
LIMITATIONS, REASONS FOR CAUTION
This was a single-centre, retrospective study in which neonatal data were extracted from parental questionnaires. The information on uteri septum type and surgery methods was poorly presented, with limited detail. In patients with uterine malformations, the number of babies with birth defects and twin pregnancies was relatively small, limiting the power of the study.
WIDER IMPLICATIONS OF THE FINDINGS
Compared to patients with a normal uterus, women with uterine malformation have poorer reproductive outcomes. Pregnant women with a uterine anomaly need to be managed as high-risk pregnancies and followed with appropriate obstetric review.
STUDY FUNDING/COMPETING INTEREST(S)
This work was supported by the National Ministry of Technology (2018YFC1003000), the Elite Team Project of Ninth People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JY201801), Shanghai Sailing Program (21YF1423200) and the Fundamental Research Program Funding of Ninth People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JYZZ117). B.W.M. is supported by an NHMRC Investigatorgrant (GNT1176437). B.W.M. reports consultancy (with stock options) for ObsEva. B.W.M. has received research funding from Ferring and Merck. The authors declare no other competing interests.
TRIAL REGISTRATION NUMBER
N/A.
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Affiliation(s)
- Jiaxin Qiu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Tong Du
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Chen Chen
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Qifeng Lyu
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Ming Zhao
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- The Shanghai Towako Hospital, Shanghai, People's Republic of China
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Zhang C, Wang X, Jiang H, Hou L, Zou L. Placenta percreta after Strassman metroplasty of complete bicornuate uterus: a case report. BMC Pregnancy Childbirth 2021; 21:95. [PMID: 33514327 PMCID: PMC7844894 DOI: 10.1186/s12884-021-03540-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/02/2021] [Indexed: 12/03/2022] Open
Abstract
Background A bicornuate uterus often results in infertility. While reconstructive procedures may facilitate pregnancy, spontaneous abortion or serious pregnancy complications may occur. We present a case of a bicornuate uterus with spontaneous conception after Strassman metroplasty; however, life-threatening complications during pregnancy occurred. Case presentation : A 38-year-old woman with a history of infertility presented for prenatal care at 6 weeks of gestation. She had conceived spontaneously after four failed in vitro fertilization and embryo transfer (IVF-ET) procedures, Strassman metroplasty for a complete bicornuate uterus, and two postoperative IVF-ET pregnancies that ended in embryo arrest. This pregnancy was uneventful until the patient presented with massive vaginal bleeding at 28 weeks of gestation and was diagnosed with placenta previa and placenta percreta. Bleeding was controlled after emergency Caesarean section and delivery of a healthy neonate. However, severe adhesions were noted as well as a rupture along the metroplasty scar. Two days later, on removal of the intrauterine gauze packing, severe hemorrhage resumed, and the uterus did not respond to oxytocin, hemabate, or carbetocin. Emergency hysterectomy was required. Conclusions Reconstructive surgical procedures for complete bicornuate uterus may allow patients to achieve spontaneous pregnancies. However, potential intrapartum complications include placenta implantation and postpartum hemorrhage, and the latter may be exacerbated as the uterus does not contract or respond to oxytocin or prostaglandin drugs. Patients should be counseled on the risks associated with pregnancy after Strassman metroplasty, and clinicians must be aware of potential severe complications.
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Affiliation(s)
- Chengyan Zhang
- Beijing Obstetrics & Gynecology Hospital, Capital Medical University, 100026, Beijing, PR China
| | - Xiaoxin Wang
- Beijing Obstetrics & Gynecology Hospital, Capital Medical University, 100026, Beijing, PR China
| | - Haili Jiang
- Beijing Obstetrics & Gynecology Hospital, Capital Medical University, 100026, Beijing, PR China
| | - Lei Hou
- Beijing Obstetrics & Gynecology Hospital, Capital Medical University, 100026, Beijing, PR China
| | - Liying Zou
- Beijing Obstetrics & Gynecology Hospital, Capital Medical University, 100026, Beijing, PR China.
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Passos IDMPE, Britto RL. Diagnosis and treatment of müllerian malformations. Taiwan J Obstet Gynecol 2020; 59:183-188. [PMID: 32127135 DOI: 10.1016/j.tjog.2020.01.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2019] [Indexed: 11/27/2022] Open
Abstract
Anomalies in the müllerian ducts are congenital alterations with more prevalence than it is imagined, varying from 0.5 to 6.7% in the general population and up to 16.7% in women with recurrent miscarriage. The main findings are primary amenorrhea, dysmenorrhea, pelvic pain, endometriosis, sexual difficulties and low self-esteem. The major impact on the quality of life in women stricken by these problems justifies this study, whose objective is to analyze their most important aspects such as etiopathogeny, classification, diagnostic methods and proposed treatments. The research was performed on the Medline-PubMed database from 1904 to 2018. The American Fertility Society, European Society of Human Reproduction and Embryology, and the European Society of Gynaecological Endoscopy classify malformations as: Class 1/U5bC4V4: agenesis or hypoplasia of uterus and vagina; Class 1/U5aC4V4: cervical hypoplasia, associated with total or partial vaginal agenesis; Class 2/U4: unicornuate uterus; Class 3/U3bC2V1 or Class3/U3bC2V2: uterus didelphys; Class 4/U3C0: bicornuate uterus; Class 5/U2: septate uterus; Class 6: arcuate uterus; Class 7/U1: induced by diethylstilbestrol, represented by a T-shaped uterus; and V3: transverse vaginal septum. The diagnostic methods are the two-dimensional or three-dimensional ultrasound, MRI, hysterosalpingo-contrast-sonography, X-ray hysterosalpingography, hysteroscopy and laparoscopy. Some müllerian malformations are healed with surgery and/or self-dilatation. For vaginal agenesis, dilatation by Frank technique shows good results while malformations with obstruction of the menstrual flow need to be rapidly treated by surgery.
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Affiliation(s)
- Itana de Mattos Pinto E Passos
- Center for Women's Health, University Hospital Professor Edgard Santos, Federal University of Bahia (UFBA), Salvador, Bahia, Brazil.
| | - Renata Lopes Britto
- Center for Women's Health, University Hospital Professor Edgard Santos, Federal University of Bahia (UFBA), Salvador, Bahia, Brazil; Department of Gynecology and Obstetrics, Faculty of Medicine, Federal University of Bahia (UFBA), Salvador, Bahia, Brazil
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Akhtar MA, Saravelos SH, Li TC, Jayaprakasan K. Reproductive Implications and Management of Congenital Uterine Anomalies: Scientific Impact Paper No. 62 November 2019. BJOG 2019; 127:e1-e13. [PMID: 31749334 DOI: 10.1111/1471-0528.15968] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congenital uterine anomalies (CUAs) are malformations of the womb that develop during fetal life. When a baby girl is in her mother's womb, her womb develops as two separate halves from two tubular structures called 'müllerian ducts', which fuse together before she is born. Abnormalities that occur during the baby's development can be variable from complete absence of a womb through to more subtle anomalies, which are classified into specific categories. While conventional ultrasound is good in screening for CUAs, 3D ultrasound is used to confirm a diagnosis. If a complex womb abnormality is suspected, MRI scanning may also be used, with a combination of laparoscopy in which a camera is inserted into the cavity of the abdomen, and hysteroscopy, when the camera is placed in the womb cavity. As there can be a link between CUAs and abnormalities of the kidney and bladder, scans of these organs are also usually requested. Although CUAs are present at birth, adult women typically do not have any symptoms, although some may experience painful periods. Most cases of CUA do not cause a woman to have difficulty in becoming pregnant and the outcome of pregnancy is good. However, these womb anomalies are often discovered during investigations for infertility or miscarriage. Moreover, depending upon the type and severity of CUA, there may be increased risk of first and second trimester miscarriages, preterm birth, poor growth of the baby in the mother's womb (fetal growth restriction), pre-eclampsia and difficult positioning of the baby for birth (fetal malpresentation). Surgical treatment is only recommended to a woman who has had recurrent miscarriages and has a septate uterus, i.e., the womb cavity is divided by a partition. In this case, surgery may improve her chances for a successful pregnancy, although the risks of surgery, especially scarring of the womb should be considered. However, further evidence from randomised controlled trials are required to provide conclusive evidence-based recommendations for surgical treatment for septate uterus. Surgical treatment for other types of CUAs is not usually recommended as the risks outweigh potential benefits, and evidence for any benefits is lacking. Women with CUAs may be at an increased risk of preterm birth even after surgical treatment for a septate uterus. These women, if suspected to be at an increased risk of preterm birth based on the severity of CUA, should be followed up using an appropriate protocol for preterm birth as outlined in UK Preterm Birth Clinical Network Guidance.1 >.
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de Ziegler D, Pirtea P, Galliano D, Cicinelli E, Meldrum D. Optimal uterine anatomy and physiology necessary for normal implantation and placentation. Fertil Steril 2016; 105:844-54. [PMID: 26926252 DOI: 10.1016/j.fertnstert.2016.02.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 02/02/2016] [Accepted: 02/11/2016] [Indexed: 12/11/2022]
Abstract
The authors review aberrations of uterine anatomy and physiology affecting pregnancy outcomes with IVF. In the case of endometriosis and hydrosalpinx, pathologies outside of the uterus alter the uterine endometrium. In the case of endometriosis, Dominique de Ziegler outlines the numerous changes in gene expression and the central role of inflammation in causing progesterone resistance. With endometriosis, the absence of ovarian function inherent in deferred transfer, with or without a more lengthy suppression of ovarian function, appears to be sufficient to restore normal function of eutopic endometrium. Because laparoscopy is no longer routine in the evaluation of infertility, unrecognized endometriosis then becomes irrelevant in the context of assisted reproductive technology. With hydrosalpinx and submucus myomas, the implantation factor HOXA-10 is suppressed in the endometrium and, with myomas, even in areas of the uterus not directly affected. Daniela Galliano reviews various uterine pathologies, the most enigmatic being adenomyosis, where the endometrium also manifests many of the changes seen in endometriosis and deferred transfer with extended suppression appears to provide the best outcomes. Ettore Cicinelli's group has extensively studied the diagnosis and treatment of endometritis, and although more definitive diagnosis and care of this covert disorder may await techniques such as sequencing of the endometrial microbiome, it undoubtedly is an important factor in implantation failure, deserving our attention and treatment.
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Affiliation(s)
- Dominique de Ziegler
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Université Paris Descartes, Paris Sorbonne Cité-Assistance Publique Hôpitaux de Paris, CHU Cochin, Paris, France.
| | - Paul Pirtea
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Université Paris Descartes, Paris Sorbonne Cité-Assistance Publique Hôpitaux de Paris, CHU Cochin, Paris, France
| | - Daniela Galliano
- Instituto Valenciano de Infertilidad (IVI), Rome, Italy and Barcelona, Spain; IVI Foundation, Valencia, Spain
| | - Ettore Cicinelli
- 2nd Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncologic Science, University of Bari, Bari, Italy
| | - David Meldrum
- Reproductive Partners San Diego, Division of Reproductive Endocrinology, University of California, San Diego, California
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Acién P, Acién M. The presentation and management of complex female genital malformations. Hum Reprod Update 2015; 22:48-69. [DOI: 10.1093/humupd/dmv048] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 10/14/2015] [Indexed: 11/13/2022] Open
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Galliano D, Bellver J, Díaz-García C, Simón C, Pellicer A. ART and uterine pathology: how relevant is the maternal side for implantation? Hum Reprod Update 2014; 21:13-38. [PMID: 25155826 DOI: 10.1093/humupd/dmu047] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Assisted reproduction technology (ART) has become a standard treatment for infertile couples. Increased success rates obtained over the years have resulted primarily from improved embryo quality, but implantation rates still remain lower than expected. The uterus, an important player in implantation, has been frequently neglected. While a number of uterine pathologies have been associated with decreased natural fertility, less information exists regarding the impact of these pathologies in ART. This report reviews the evidence to help clinicians advise ART patients. METHODS An electronic search of PubMed and EMBASE was performed to identify articles in the English, French or Spanish language published until May 2014 which addressed uterine pathology and ART. Data from natural conception were used only in the absence of data from ART. Studies were classified in decreasing categories: RCTs, prospective controlled trials, prospective non-controlled trials, retrospective studies and experimental studies. Studies included in lower categories were only used if insufficient evidence was available. Pooled data were obtained from systematic reviews with meta-analyses when available. The summary of the evidence for the different outcomes and the degree of the recommendation for interventions were based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) statement recommendations. RESULTS There is strong evidence that surrogacy is effective for uterine agenesia. For the remaining pathologies, however, there is very little evidence that the established treatments improve outcomes, or that these pathologies have a negative effect on ART. In the presence of an apparently normal uterus, assessing endometrial receptivity (ER) is the goal; however diagnostic tests are still under development. CONCLUSIONS The real effect of different uterine/endometrial integrity pathologies on ART is not known. Moreover, currently proposed treatments are not based on solid evidence, and little can be done to assess ER in normal or abnormal conditions. No strong recommendations can be given based on the published experience, bringing an urgent need for well-designed studies. In this context, we propose algorithms to study the uterus in ART.
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Affiliation(s)
- Daniela Galliano
- Department of Reproduction, Instituto Valenciano de Infertilidad, Barcelona 08017, Spain
| | - José Bellver
- Department of Reproduction, Instituto Valenciano de Infertilidad (IVI), Valencia 46015, Spain
| | - César Díaz-García
- Woman's Health Department, Hospital Politécnico y Universitario La Fe, Valencia 46026, Spain
| | - Carlos Simón
- Department of Reproduction, Instituto Valenciano de Infertilidad (IVI), Valencia 46015, Spain IVI Foundation, Valencia 46015, Spain
| | - Antonio Pellicer
- Department of Reproduction, Instituto Valenciano de Infertilidad (IVI), Valencia 46015, Spain Woman's Health Department, Hospital Politécnico y Universitario La Fe, Valencia 46026, Spain IVI Foundation, Valencia 46015, Spain
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Hirschelmann A, De Wilde RL. Plastic and reconstructive uterus operations by minimally invasive surgery? A review on myomectomy. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2012; 1:Doc09. [PMID: 26504693 PMCID: PMC4582479 DOI: 10.3205/iprs000009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Plastic and reconstructive uterus operations are performed in congenital uterine anomalies or benign uterine conditions. Congenital uterine anomalies are relatively rare diseases with various approaches for surgical treatment. Therefore, to address the question of the usefulness of a minimally invasive approach in plastic uterus operations, the most common uterine condition which requires reconstructive surgery, namely myomectomy, is discussed. METHOD Searches were conducted in PubMed and The Cochrane Library to identify relevant literature. FINDINGS Compared with myomectomy by laparotomy and minilaparotomy, laparoscopic myomectomy is associated with improved short-term outcomes. Laparoscopy is further associated with less adhesion formation. Pregnancy rates after myomectomy in symptomatic patients might be higher after laparoscopy than after laparotomy. Although uterine ruptures following laparoscopic myomectomy are described in the literature, it seems to be a rare event. Concerning the recurrence, there is evidence that rates are similar after laparoscopy and laparotomy. CONCLUSION Myomectomy by laparoscopy has several advantages over abdominal myomectomy (by conventional laparotomy and minilaparotomy) and should be the standard procedure. Despite the advantages of laparoscopy, abdominal myomectomy is still a frequently performed procedure. Lack of training in advanced laparoscopic procedures hampers the wide-spread use of laparoscopic myomectomy. Due to the advantages of laparoscopic surgery, efforts should be made to implement this procedure into daily practice. To provide the best care, physicians should offer patients the opportunity of a laparoscopic treatment of myomas.
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Affiliation(s)
- Anja Hirschelmann
- Pius-Hospital Oldenburg, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische Onkologie, Oldenburg, Germany
| | - Rudy Leon De Wilde
- Pius-Hospital Oldenburg, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische Onkologie, Oldenburg, Germany
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