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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 4  |  Page : 233-236

Complete uterine didelphys: An incidental finding at emergency cesarean section


Department of Obstetrics and Gynecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication8-Dec-2017

Correspondence Address:
Dr. F Bakari
Department of Obstetrics and Gynecology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_46_16

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  Abstract 

Uterine didelphys is a rare form of Mullerian duct abnormality. Women with this developmental anomaly are often asymptomatic although pregnancy complications are common. We present a 23-year-old para 0+1 that registered for antenatal care at 31 weeks gestation and in whom an ultrasound scan revealed a suspected huge cervical mass that turned out to be an undiagnosed ipsilateral nonpregnant half of a double uterus at emergency cesarean section, which was indicated because of preterm labor and a coexisting suspected huge cervical mass.

Keywords: Cesarean section, didelphys uterus, preterm labor


How to cite this article:
Bakari F, Adesiyun A G, Ochogwu E P, Umar-Sulayman H, Ameh N, Bawa U S. Complete uterine didelphys: An incidental finding at emergency cesarean section. Arch Int Surg 2016;6:233-6

How to cite this URL:
Bakari F, Adesiyun A G, Ochogwu E P, Umar-Sulayman H, Ameh N, Bawa U S. Complete uterine didelphys: An incidental finding at emergency cesarean section. Arch Int Surg [serial online] 2016 [cited 2020 Jul 11];6:233-6. Available from: http://www.archintsurg.org/text.asp?2016/6/4/233/220330


  Introduction Top


Developmental anomalies of the female internal genitalia are sometimes encountered incidentally by Obstetricians and Gynecologists during surgery. It is fascinating when it is encountered during a procedure that was indicated for an unsuspected case of the condition.

Didelphys uterus also known as double uterus is a congenital malformation resulting from complete failure of fusion of the ipsilateral paramesonephric ducts during embryonic development. The paramesonephric ducts are the primordial anlage of the female reproductive tract that differentiates to form the fallopian tubes, uterus, cervix, and the upper part of the vagina. Variable malformations can occur when this system is disrupted. Complete uterine and vaginal duplication (didelphys uterus) is one of such malformations. Uterine didelphys accounts for about 11% of all uterine abnormalities and it is characterized by 2 hemi uteri, 2 endocervical canals with cervices fused at the lower uterine segment.[1] A complete longitudinal vaginal septum is found in 75% of cases of uterine didelphys.[2]

The majority of patients with didelphys uterus are usually asymptomatic and fertility is usually not affected in them, but those who are pregnant have higher incidences of complications during pregnancy and delivery.[3],[4]

This is a reported case of a nullipara, who had an emergency cesarean section because of preterm labor with a suspected coexisting huge cervical mass, but in whom a complete uterine and vaginal duplication was found incidentally intraoperatively.


  Case Presentation Top


Mrs AM was a 23-year-old gravida 2 para 0+1 who registered for antenatal care at 31 weeks gestation. Her height was 1.62 m and weight at booking was 80 kg. Her blood pressure, urinalysis, retro-viral screening, venereal disease research labouratory (VDRL), hepatitis B & C screening were all within normal limits. Routine obstetric ultrasonography done revealed a singleton viable normal intrauterine gestation at 31 weeks, 2 days gestational age with an anterior placenta. There was a huge mass attached to the cervix posteriorly measuring about 10 × 8 cm on ultrasonography. Digital vaginal examination that was done following the ultrasound findings revealed a huge hard mobile mass occupying the pouch of Douglas. Her pregnancy was desired and had remained uneventful at the time she registered.

She had a spontaneous miscarriage of an 8 weeks pregnancy a year earlier. She attained menarche at 13 years and had normal menstrual duration and flow. She had no history of dysmenorrhea, but reported occasional discomfort during coital penetration by her spouse.

The findings of ultrasonography were explained to her and she was counseled for a possibility of an elective cesarean section at term. She continued with her routine antenatal care that had remained essentially uneventful.

She presented at 36 weeks gestational age with 3 h history of abdominal pain and passage of “Show.” She had a tonically contracted uterus and fetal heart rate abnormality was evident on auscultation. Cervical changes were not well appreciated because of severe lower abdominal pain. A diagnosis of preterm labor to rule out abruptio placenta in a nullipara at 36 weeks gestation with a coexisting huge cervical fibroid was made. She was counseled for an emergency cesarean section and an informed consent was obtained. The intraoperative findings were that of a clean peritoneal cavity, poorly formed lower uterine segment, blood stained liquor, anterior placenta with some retro-placental clots, and a live male infant with good Apgar score that weighted 2.1 kg was delivered. The uterus was discovered to be didelphys following exteriorization [Figure 1] and [Figure 2]. The right half of the didelphys uterus was the pregnant half, while the other half was found impacted in the pelvis, postero-inferiorly to the pregnant half. Each half has its single round ligament and fallopian tube. The ovaries were grossly normal without mal-positioning. She had one grossly normal urinary bladder. At vulval toileting, following closure of the uterus and the abdominal cavity, a longitudinal vaginal septum was noted and digital exploration into the vaginal canal revealed double vagina and cervix. The right cervix was dilated to about 4 cm, while the left cervix was soft, closed, and uneffaced. The longitudinal septum divided the vagina into two capacious equal halves from the cervix up to the introital opening [Figure 3]. The total estimated blood loss was 400 ml. The baby was examined and found to be grossly normal except for the low birth weight.
Figure 1: Right and left half of a didelphys uterus and the placenta (green armitage forceps is attarched to the pregnant half)

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Figure 2: Right and left half of a didelphys uterus after suturing

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Figure 3: Longitudinal vaginal septum that divides the vagina into two equal halves

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She had an uneventful postoperative care. She was properly counseled on the intraoperative findings and its likely implications in her subsequent pregnancies and deliveries. She was discharged on the third postoperative day and asked to present with an intravenous pyelography (IVP) report at the postnatal clinic in 6 weeks in order to rule out an associated renal anomaly.

At 6 weeks postpartum, she presented with a normal IVP findings with no duplication of the urinary tract. She and her baby were in a good state of health.


  Discussion Top


Congenital uterine anomalies in this modern day contemporary practice ought to have been diagnosed at puberty with pelvic and radiological examination in adolescent girls that are presenting with complaints of obstructing outflow features of amenorrhea, severe dysmenorrhea, or dyspareunia in the presence of varying degrees of gynatresia that may have also led to the development of hematometrocolpos, hematometra, and hematosalpinx. However, many cases of women with a didelphys uterus may not present with any reproductive challenges.[4]

In resource-constraint settings and where patients have poor health-seeking behaviors, diagnosis of uterine abnormalities might be delayed until pregnancy or during childbirth when patients present with recurrent pregnancy losses, mal-presentation, or an obstructed labor. An unsuspected half of a didelphys uterus may present as a space occupying previa barrier in advanced pregnancy around the cervix or the lower segment of the pregnant half of the uterus on ultrasonography and thereby mimicking a cervical or a lower segment fibroid or mass. On the contrary, if such a mass is not detected antenatally, the patient may develop an obstructed labor during delivery because of the previa barrier caused by the mass or because of a longitudinal vaginal septum that is usually present in 75% of cases of uterine didelphys. This was the scenario in this particular patient who booked for antenatal care at 31 weeks gestation and in whom a two-dimensional (2D) ultrasonography showed features consistent with a huge cervical fibroid that turned out to be a misdiagnosed left half of a didelphys uterus intraoperatively.

Women with uterine didelphys, although constituting a smaller proportion of all uterine anomalies, have a higher proportion of preterm birth at 34–37 weeks than any other subgroup of any uterine anomaly.[5]

Some who have found an association between uterine anomalies, preterm birth, and low birth weight theorized that diminished muscle mass and abnormal uterine blood flow plays an important role in the mechanism of both.[5],[2]

Our patient was scheduled for an elective abdominal delivery at 38 weeks because of a suspected cervical fibroid but developed preterm labor at 36 weeks, which necessitated an emergency cesarean delivery. She had an associated tonically contracted uterus and fetal heart rate abnormalities that was suggestive of an abruptio placenta, which further influenced our decision for an emergency cesarean section for her. At cesarean section, the liquor was noticed to be slightly blood stained and the placenta was partially separated with retro-placental blood clots. The baby's weight was 2.1 kg, which was low for the gestational age of 36 weeks. Development of an abruptio placenta and placenta previa in association with uterine anomalies has also been reported. The delivery of a low birth weight (<2500 g) infant was significantly associated with a didelphys, bicornuate, and unicornuate uterus.[6]

Heinonen [3]et al. reported higher cesarean section rate of 82% in women with didelphys uterus because of obstetric reasons. Despite the relatively higher prevalence of preterm birth and low birth weight infants in pregnant women with didelphys uterus, a rare case of a didelphys uterus with full-term pregnancy in each horn has been reported.[7]

A 2D ultrasonography is usually the first kind of imaging study done for antenatal clients and it is usually inadequate in making a diagnosis of uterine anomalies. More recently, a 3D ultrasonography has been advocated as an excellent noninvasive method to evaluate uterine malformations, as it is not only noninvasive but also overcomes the limitation of 2D ultrasound by providing a coronal view.[8]

A 2D ultrasound was used in evaluating this patient when she presented at 31 weeks for booking because that was what was available in our antenatal care unit of the hospital. A coronal view which is necessary to distinguish a cervical mass from a hemi didelphic uterus could not have been possible with a 2D ultrasound and also coupled with the fact that it was an obstetrician and not a trained radiologist that did the ultrasound. Generally, however, diagnosis of uterine anomalies is best achieved with the gold standard, magnetic resonance imaging (MRI).[7]

Miscarriages, preterm labor, and increase in cesarean birth as recorded in this case are known pregnancy complications. In 75% of cases of uterine didelphys, a longitudinal vaginal septum is found in association. MRI or a 3D/4D ultrasonography if employed in selected antenatal cases like the index patient with pelvic mass of unconfirmed origin would have been helpful in the management. Findings can be used to counsel women and to help guide appropriate antenatal surveillance of such pregnancies so as to reduce the chances of adverse pregnancy outcome like preterm birth, low birth weight, and abruptio placenta to the barest minimum. Cesarean section in uterus didelphys achieves a favorable outcome by reducing complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nahum GG. Uterine anomalies. How common are they, and what is their distribution among subtypes? J Reprod Med.1998;43:877-87.  Back to cited text no. 1
    
2.
Venetis CA, Papadopoulos SP, Campo R, Gordts S, Tarlatzis BC, Grimbizis GF. Clinical implications of congenital uterine anomalies: A meta-analysis of comparative studies. Reprod Biomed 2014;29:665-83.  Back to cited text no. 2
[PUBMED]    
3.
Heinonen PK. Uterus didelphys: A report of 26 cases. Eur J Obstet Gynecol Reprod Biol 1984;17:345-50.  Back to cited text no. 3
[PUBMED]    
4.
Rezai S, Bisram P, Alcantara IL, Upadhyay R, Lara C, Elmadjian M. Didelphys uterus: A case report and review of the literature. Case Rep Obstet Gynecol 2015;2015:865821.  Back to cited text no. 4
    
5.
Moutos D, Damewood M, Schlaff W, Rock JA. A comparison of the reproductive outcome between women with a unicornuate uterus and women with a didelphic uterus. Fertil Steril 1992;58:88-93.  Back to cited text no. 5
    
6.
Garg R, Kwatra A, Bangal V. Rare case of uterus didelphys with full term pregnancy in each horn. Pravara Med Rev 2010;2: 22-4  Back to cited text no. 6
    
7.
Moyle P, Mannelli L, Shafi M, Sala E. Magnetic resonance imaging of uterine abnormalities. The Obstetrician & Gynaecologist 2012;14:1-8.  Back to cited text no. 7
    
8.
Woelfer B, Salim R, Banerjee S, Elson J, Regan L, Jurkovic D. Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening. Obstet Gynecol 2001;98:1099-103.  Back to cited text no. 8
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  [Figure 1], [Figure 2], [Figure 3]



 

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