Congenital Uterine Anomalies and Uterine Rupture

Applicability and Suitability of the Embryological-Clinical Classification of Female Genital Malformations: A Systematic Review

Complex urogenital malformations are clinically highly relevant; thus, they must be appropriately diagnosed and classified before initiating treatment. Background/Objectives: This study aimed to evaluate the applicability and suitability of the embryological-clinical classification of female genital malformations. Methods: A systematic review of cases of genital malformations reported in the literature from 2000 to 2020 was conducted. Case reports and series with the following combinations: "female genital tract" AND (malformation OR anomaly OR müllerian anomaly OR uterine anomaly OR cervical anomaly OR vaginal anomaly OR cloacal anomaly OR urogenital sinus); and "female genital tract" AND (renal agenesis OR ectopic ureter) were searched. A total of 3124 articles were identified, of which 824 cases of genital malformation were extracted. The characteristics of each malformation were included in a database for further analyses. Results: Using the embryological-clinical classification, 89.9% of the published cases and 86.5% of the 52 cases defined as unclassifiable by their authors have been classified in this review. In 73 cases (72.2%), the classification of the malformation using the AFS system was incomplete because although the type of uterine anomaly of the AFS classification matched that of the embryological-clinical classification, characteristics of the urinary system or the vagina were overlooked when using the AFS system. Following a dispersion matrix, we have been able to show that the embryological-clinical classification system is able to classify and subclassify the genitourinary malformations more accurately. Conclusions: The applicability of the embryological-clinical classification has been confirmed after classifying most of the cases of genital malformation previously published. This system also provides a more complete and accurate classification than other classifying systems exclusively based on Müllerian duct development or uterovaginal parameters, demonstrating its suitability.

Spontaneous Rupture of the Unscarred Uterus: A Review of the Literature

Importance

Uterine rupture is defined as a nonsurgical disruption of all layers of the uterus. Most ruptures occur in the presence of a scar, usually secondary to a previous cesarean delivery. Rupture of an unscarred uterus is rare and is associated with severe maternal and neonatal outcomes.

Objective

To outline the literature on potential predisposing factors, clinical findings, and maternal and fetal outcomes of a rupture of an unscarred uterus.

Evidence Acquisition

PubMed was searched for the phrases "uterine rupture," "unscarred," and "spontaneous." Individual case reports, retrospective case series, and review articles in English between 1983 and 2020 were included.

Results

We found 84 case reports in 79 articles. The mean maternal age was 29.3 (SD, 5.7) years; 38 women (45.2%) were nulliparous. Uterine rupture occurred in 37% of the women at term; in 9.9%, the gestational age was ≤12 weeks. The most common clinical presentations were abdominal pain (77.4%), signs of hypovolemic shock (36.9%), fetal distress (31%), and vaginal bleeding (22.6%). The most common risk factors were the use of uterotonic drugs for induction or augmentation of labor and a prior curettage procedure. The most frequently ruptured site was the body of the uterus. Hysterectomy managed 36.9% of the ruptures. Four women died (4.8%). Perinatal mortality was 50.6%. Perinatal death was higher in developing than developed countries.

Conclusions and relevance

Although rare, spontaneous rupture of the unscarred uterus has serious consequences to the mother and the fetus and should be included in the differential diagnosis of acute abdomen in pregnancy.

Undiagnosed uterine anomalies revealed by breech on ultrasound prior to external cephalic version - A chance to take a closer look

OBJECTIVE

Uterine anomalies (UA) occur in up to 6.7% of women. Breech is eight times more likely to occur with UA which may not be diagnosed prior to pregnancy and may only be found in the third trimester with breech. The objective of the study is to assess the prevalence of both already known and newly sonographically diagnosed UA in breech from 36 weeks of gestation and its impact on external cephalic version (ECV), delivery options and perinatal outcomes.

STUDY DESIGN

We recruited 469 women with breech at 36 weeks of gestation over a 2-year period at the Charité University Hospital, Berlin. Ultrasound examination was performed to rule out UA. Patients with known and newly 'de novo' diagnosed anomalies were identified and delivery options and perinatal outcomes analyzed.

RESULTS

The 'de novo' diagnosis of UA at 36-37 weeks of pregnancy with breech was found to be significantly higher compared to the diagnosis prior to pregnancy with 4.5% vs 1.5% (p < 0.001 and odds ratio 4 with 95% confidence interval 2.12-7.69). Anomalies found included 53.6% bicornis unicollis, 39.3% subseptus, 3.6% unicornis and 3.6% didelphys. A trial of vaginal breech delivery was successful in 55.5% of cases when attempted. There were no successful ECVs.

CONCLUSION

Breech is a marker for uterine malformation. Diagnosis of UA with breech can be up to four times improved with focused ultrasound screening in pregnancy even from 36 weeks of gestation prior to ECV to identify missed anomalies. Timely diagnosis aids antenatal care and delivery planning. Importantly, definitive diagnosis and treatment can be planned postpartum to improve outcomes in future pregnancies. ECV plays a limited role in selected cases.

UTERINE RUPTURE IN THIRD TRIMESTER OF PREGNANCY FOLLOWING CORNUAL RESECTION DUE TO ECTOPIC PREGNANCY

Uterine rupture during pregnancy is a critical obstetric complication associated with maternal and fetal mortality and morbidity. The risk is increased in patients with a history of previous uterine surgery including cesarean section, myomectomy, salpingectomy, as well as uterine and placental anomalies and polyhydramnios. It can also occur spontaneously. We present a case of uterine rupture in the early third trimester in a woman who had undergone previous laparoscopic removal of the left fallopian tube due to sactosalpinx and laparotomic removal of left uterine horn due to ectopic pregnancy.

Diagnosis and Management of Congenital Uterine Anomalies in Pregnancy

Importance

Congenital uterine anomalies (CUAs) are strongly associated with adverse fertility and pregnancy outcomes. Health care providers must be able to diagnose these anomalies, understand their impact, and counsel women on interventions that might improve rates of pregnancy and live birth.

Objectives

The aims of this study were to characterize CUAs and their effects on adverse fertility and pregnancy outcomes, to describe the best imaging modalities to diagnose specific uterine anomalies, and to learn about interventions that may improve the reproductive outcomes of infertile and pregnant women.

Evidence Acquisition

A search of the PubMed database revealed 56 relevant studies, 49 of which were referenced in this comprehensive summary of the literature.

Results

Congenital uterine anomalies are strongly associated with recurrent pregnancy loss, low birth weight, preterm birth, hypertensive disorders of pregnancy, malpresentation, and cesarean delivery. Transvaginal 3-dimensional ultrasonography appears to be the best initial test for uterine anomaly evaluation. Prior to conception, women who undergo hysteroscopic metroplasty may have better fertility and pregnancy outcomes.

Conclusions and Relevance

Congenital uterine anomalies, although rare in the general population, pose significant challenges to women and their clinicians with regard to fertility and pregnancy management. Accurate diagnosis, preconception counseling and metroplasty, and antenatal monitoring may improve reproductive outcomes for women with CUAs.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to (1) characterize congenital uterine anomalies and their potential effects on adverse fertility and pregnancy outcomes, (2) determine the best imaging modalities to diagnose specific uterine anomalies, and (3) counsel both infertile and pregnant patients about interventions that may improve their reproductive outcomes.