Pregnancy and Uterus Didelphys: Case Report

Aicha Bennani* ^1,2, Hanaa Lazhar ^1&2, Aziz Slaoui ^1&2, Najia Zeraidi ¹, Amina Lakhdar ¹,
Aicha Kharbach ²,  Aziz Baydada ¹

1. Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco.

2. Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco.

Corresponding Author: Aicha Bennani, University Hospital Center IBN SINA of Rabat, Gynaecology-Obstetrics and Endoscopy Department & Gynaecology-Obstetrics and Endocrinology Department, Mohammed V of Rabat University, Morocco.

Copy Right: © 2023 Aicha Bennani, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: March 16, 2023

Published Date: April 01, 2023

Abstract

Uterus didelphys is a rare congenital abnormality of the reproductive tract in which there is a complete failure of fusion of the paramesonephric ducts, resulting in a completely divided uterine body with two cervices and sometimes a double vagina. Uterus didelphys has a good reproductive prognosis. There is a clear association of the presence of uterus didelphys and adverse obstetric outcome. In our case report, the patient with â history of two abortions, had a labor dystocia and a baby at term weighing 2100 grams (third percentile). The uterus didelphys was discovered intra operatively.

Introduction

Uterus didelphys is a rare congenital uterine malformation with various reproductive and obstetrics outcomes.

In this study we reported a case of uterus didelphys discovered intraoperatively. The reproductive outcomes in this case report were two abortions and the obstetrics outcomes were a labour dystocia and a baby at term, weighing less than 2500 without anomaly of the doppler on ultrasound.

Case Report

A 25-year-old primigravida patient, with a history of two abortions, presented to the emergency room with a 37-week spontaneously conceived pregnancy for uterine contractions. The patient had no prenatal follow-up.

The clinical examination did not show a vaginal septum.

Ultrasound showed an evolving mono foetal pregnancy with cephalic presentation and foetal growth estimation of 2200 grams.

The fetal heart tracing showed a fetal heart rate of 140 per minute at baseline, with accelerations and repetitive late decelerations and stagnation of the dilatation of the cervix in the active phase of labor.

The patient underwent a caesarean in emergency for labour dystocia and foetal distress. 

Intraopertaively, after extraction of the newborn, a didelphys uterus was discovered: two uteri with one fallopian tube and ovary one on each side with two services, the baby was a female weighing 2100 g, Apgar 10/10.

The postoperative course was uncomplicated, and the mother and the baby were discharged home on the second postoperative day.

There were no renal anomalies on subsequent USG.

Discussion

The ASRM Mullerian Anomalies Classification 2021 classifies mullerian anomalies into the nine categories. Because mullerian anomalies represent a continuum of development and many have combined elements, some anomalies appear in more than one category.

1. Mullerian agenesis
2. Cervical agenesis
3. Unicornuate uterus
4. Uterus didelphys +/- longitudinal septum or obstructed hemi vagina
5. Bicornuate uterus
6. Septate uterus
7. Transverse vaginal septum
8. Longitudinal vaginam septum
9. Complex anomalies [1]

The prevalence of congenital uterine anomalies in the general population is 5.5%, 8.0% in women with infertility, 13.3% of the population with abortions, and reaches 24.5% in patients with abortions and infertility. [2]

There is a clear association of the presence of CUA and adverse obstetric outcome. [3]

Unification defects, such as the bicornuate, unicornuate and didelphic uterus, do not appear to reduce fertility unlike canalization defects but are associated with aberrant outcomes throughout the course of pregnancy. Unification defects have double risk of second trimester miscarriage,  malpresentation at delivery compared to females without congenital uterus anomaly. Women  with uterus didelphys seem to have only a modestly increased risk of preterm labour compared to others CUA. [2]

Uterus didelphys is a rare congenital abnormality of the reproductive tract in which there is a complete failure of fusion of the paramesonephric ducts, resulting in a completely divided uterine body with two cervices and sometimes a double vagina.

Uterus didelphys accounts for 8% of the congenital anomalies of the female reproductive tract. [4]

The clinical significance of this congenital uterine anomaly is associated with various reproductive issues:  spontaneous abortion rates are reported to range from 32% to 52%, premature birth rates range from 20% to 45% and foetal survival rates, from 41% to 64%. [5]

Venetis et al found that women with a didelphys had a significantly higher probability of giving birth to a neonate weighing less than 2500 g  when compared with women without a CUA and higher risk of intrauterine growth restriction. Didelphys uterus was not associated with placenta abruption, breech presentation, premature membrane rupture compared to the others CUA and the relative risk for perinatal mortality was increased; however, this increase was not statistically significant.  [6,7]

The didelphys uterus is a highly unusual Mullerian duct aberration with varied reproductive and gestational consequences and decreased likelihood of carrying a pregnancy to term (45 percent). [7]

It has a good reproductive prognosis and only needs intervention in cases of HWW syndrome, since one of the vaginas is obliterated and the septum between them needs to be resected to drain the hematocolpos and hematometra, as well as it allows for the outflow of normal menstrual flow. [8]

The use of 3D ultrasound is becoming more commonly used for diagnosis as it is not only noninvasive, but it also overcomes the limitation of 2D ultrasound by providing a coronal view that enables examination of both the endometrial cavity and uterine fundus, thus giving all the information needed for morphological classification. [9]

Although MRI may be a useful adjunct if the ultrasound or clinical examinations are incomplete or inconclusive.[10]

Women with a recently diagnosed CUA also require evaluation of the kidneys, as the urinary tract forms in conjunction with the uterus. Overall, 31% will have associated renal abnormalities. [3]

In a recent study that showcased three cases of uterus didelphys and full-term pregnancy, which resulted in favourable birth outcomes of live-born, full-term infants. Two of the patients had an emergency c-section due to failure of the labour to progress. Authors in this study believe that labour dystocia in women with uterus didelphys may result from mechanical impediment, the question arises as to whether abnormal embryonic development of the reproductive organs is not a cause for the impaired function of the myometrium. Also, they believe that surgical delivery is a safer method for this Müllerian anomaly.  [5]

The authors Rajshree Dayanand Katke of a study reported a case of retained product and perforation in left horn of uterus didelphys after vaginal delivery which was managed by obstetric hysterectomy. Second case, a patient with diagnosed uterus didelphys after her second abortion. Patient was followed with routine antenatal checkup and elective c-section at 37 weeks for a precious pregnancy. Both mother and baby were healthy.

The authors concluded that clinicians should have a high index of suspicion of uterine anomaly to make early diagnosis of uterus Didelphys especially while handling obstetric complications. [11]

Another study, they reported a case of uterus didelphys with breech presentation and premature rupture of the membranes. During the c-section, uterus didelphys was discovered.  [12]

Pathan ZH et al. reported a case of c-section at 34.2 weeks of gestation for foetal distress and doppler anomalies. Intraoperatively, an uterus didelphys was revealed. A female foetus of 1790 g was delivered with apgar 9/10.

Reza et al. reported a case of a patient with a history of spontaneous abortion who successfully conceived, carried her pregnancy to term, and delivered vaginally without any complications with uterus didelphys with complete destruction of the vaginal septum as the foetal head was delivered. [9]

Ross et al. reported the case of a woman with uterus didelphys who spontaneously conceived two singleton pregnancies, one in each uterus, and was delivered in both instances of a healthy breech infant at term by elective caesarean section. [13]

Deswal V et al. reported a rare case of Herlyn-Werner-Wunderlich syndrome-with pregnancy. A female patient referred to the hospital with retention of urine revealed uterus didelphys with 8 weeks gestation sac in the left moiety and hematometra and hematocolpos in the right moiety with absent right kidney. Follow-up sonography showed us 2 cervical canals with 2 different uterine cavities and single live healthy foetus in the left moiety. [10]

Conclusion

Uterus didelphys, which constitutes approximately 5% of mullerian duct anomalies.

Pregnancy in a uterus Didelphys deserves early diagnosis of the anomaly, and careful monitoring in pregnancy and delivery to avoid the associated adverse outcomes.

References

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