Uterine anomalies are present in 1 to 10% of the unselected population and presents with various gynaecological obstetric and even renal problems. Although the reproductive outcome of women with unicornuate uterus is poor, a successful pregnancy is possible. We report a case of a 29 years old women having a successful pregnancy after 7 spontaneous abortions.
Congenital Mullerian malformations, Congenital uterine anomalies, Recurrent Pregnancy Loss
Uterine anomalies are present in 1 to 10% of the unselected population, 2 to 8% of infertile women and 5 to 30% of women with a history of miscarriages.
A unicornuate uterus is a type II AFS classification with unilateral hypoplasia or agenesis that can be further subclassified into communicating, non communicating, no cavity and no horn.
It accounts for 2.5 to 3% of all Mullerian Anomalies, and presents at different stages of life starting with dysmenorrhoea, hematometra, endometriosis. It causes infertility due to abnormal genital tract, recurrent pregnancy loss due to faulty implantation, ectopic pregnancy. Obstetric outcome in case of unicornuate uterus is also poor as it causes intra uterine growth restrictions, malpresentations, preterm delivery, stillborn, uterine rupture. These can be explained by mechanical factors (decreased and distorted uterine space), and reduced blood flow (absent or abnormal uterine artery). The reproductive performance of women with unicornuate uterus is poor, with a live birth rate of only 29.2%, prematurity rate of 44%, and an ectopic pregnancy rate of 4%. Moreover, women with this anomaly, present rates of 24.3% first trimester abortion, 9.7% second trimester abortion and 10.5% intrauterine fetal demise.
Associated Renal anomalies like renal agenesis, Horseshoe kidney and pelvic kidney may be present in 44% of cases. (In the presence of obstructed horn)
We present a case report of a successful pregnancy in a P0+7 woman with unicornuate uterus.
Case Presentation :
A 30 years old G8P0+7 visited our antenatal OPD for the first time at 13 weeks period of gestation with an USG report that showed a single live fetus with good decidual reaction, and gestational age corresponding to that of last menstrual period, the pregnancy was in the Left horn of the uterus.
Detailed history was elicited and routine antenatal investigations were done. Serial obstetric ultrasounds were done at 2nd and 3rd trimester and revealed no gross anomaly of the fetus, cervical length of around 4 cm. and normal growth pattern with a breech presentation.
She was admitted at 35 weeks 6 days period of gestation for monitoring when she was given a course of steroid to ensure fetal maturity. An USG at 36 weeks POG was done to see the growth pattern and liquor volume of the fetus, and an elective Caesarean Section was planned at 37 weeks period of gestation.
She delivered a healthy male baby of 2.8 kg birth weight, APGAR score 9/10 at 1 and 5 mins of birth with no structural anomaly.
Figure 1. The gravid uterus prior to uterine incision. Note - rt fallopian tube is absent.
Figure 2. Well developed left horn with tube and ovary.
Figure 3. Unicornuate uterus after delivery of the baby showing the non communicating cavities.
Past History :
The patient had pain during menstruation from her menarche but didnot seek medical help. She was married at 18 years of age after which conceived for the first time within 8 months of regular intercourse, but she had a spontaneous complete abortion at 8 weeks period of gestation. The second pregnancy also had the same course (i.e., first trimester abortion).
Then she went for medical help where a battery of tests was done and she was diagnosed to have a unicornuate uterus.
Her USG (2D,TVS) could not pick up any gross anomaly.
Laparoscopic dye test result :
- - Unicornuate uterus
- - Well developed left horn
- - Presence of left tube and ovary ill developed right horn
- - Mid portion of the right fallopian tube was absent
- - Right ovary was visualised.
- - USG KUB found no abnormality.
- - Menstrual history
Menarche 14 years
Cycle -regular 28 days
Duration-4 to 5 days
Associated with pain lower abdomen
Family history -nothing significant
|Month, Year||Type of abortion||Period of gestation||?D&E needed|
|Feb, 2004||spontaneous||8 wks||No|
|Jan, 2005||spontaneous||8 wks||No|
|Jan, 2008||spontaneous||10 wks||Yes|
|Nov, 2009||spontaneous||12 wks||No|
|Oct, 2010||spontaneous||8 wks||Yes|
|Feb, 2012||spontaneous||14 wks||Yes|
|June, 2013||spontaneous||12 wks||No|
Past Medical History-Nothing Significant.
Women with unicornuate uterus have an increased incidence of gynecologic and obstetric problems and tend to present, at menarche or later in their life, with symptoms such as dysmenorrhea and chronic pelvic pain, infertility, recurrent pregnancy loss, etc.
The primary investigation to these problems is therefore an USG of pelvis. Nevertheless ultrasound diagnosis can be missed, particularly in inexperienced hands.
A unicornuate uterus is often associated with ectopic pregnancies and with rupture of the rudimentary horn and, although it is unclear whether or not to remove the rudimentary horn before conception or early in pregnancy, its resection may improve the obstetrical outcome.
Patients with a unicornuate uterus present a higher risk of obstetrical complications, such as first trimester abortion, second trimester abortion, intrauterine growth restriction, preterm delivery and intrauterine fetal demise, and only a few obstetrical risks can be reduced by a particular pregnancy follow up and specific interventions.
As for the risk of preterm labor, there are no consistent data that any intervention can delay delivery in women for longer than 24 to 48 hours once they present a preterm labor. For this reason, much attention has been focused on preventive strategies rather than on intervention strategies. Although several strategies have been proposed, the prevention of preterm birth has been largely unsuccessful.
The utility of ultrasound cervix length measurement for assessing the risk of preterm birth has been well documented, with an accepted cut off value for cervix length of < 25mm before the 24th week of gestational age.
The predictive value of a negative test is high (92%); this implies that pregnant women who do not have a shortened cervix can be reassured, and unnecessary therapeutic measures can be avoided.
By contrast, cervical cerclage is the best treatment for women with a short cervix (< 25mm), and particularly for women with a history of prior midtrimester pregnancy losses due to cervical insufficiency, Therefore, in our case report, a cervical cerclage was considered unnecessary. Whether progesterone acts by attenuating further cervical shortening is not clear yet.
Accumulating evidence suggests that the myometrial activity associated with preterm labor results primarily from a release of the inhibitory effects of pregnancy on the myometrium rather than an active process mediated through the release of uterine stimulants, and progesterone appears to play a central role.
Nevertheless, the optimal management approach cannot be clearly stated. Further large observational and prospective studies are essential to investigate the treatments needed during pregnancies in this uterine anomaly.