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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 4  |  Page : 184-186

Poor obstetrics outcome in an undiagnosed sub-septate uterus


1 Department of Radiology, Olabisi Onabanjo University, Ilorin, Nigeria
2 Department of Radiology, University of Ilorin, Ilorin, Nigeria

Date of Submission19-Aug-2015
Date of Acceptance07-Feb-2015
Date of Web Publication22-Dec-2015

Correspondence Address:
Mutiu Oladapo Atobatele
Department of Radiology, Olabisi Onabanjo University, Ilorin
Nigeria
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DOI: 10.4103/2384-5147.172450

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  Abstract 

This is a case of a 22-year-old woman who has had a second-trimester abortion and two preterm deliveries incidentally diagnosed of sub-septate uterus on hysterosalpingography (HSG). The case is presented to emphasize on the value of HSG in the management of recurrent pregnancy loss due to suspected Mullerian duct anomaly (MDA). The degree of intercornual angle distinguishes between the types of MDAs and angles of <75° that have a high diagnostic accuracy for the septate uterus variety.

Keywords: Hysterosalpingography, obstetrics, septate, uterus


How to cite this article:
Atobatele MO, Oyinloye OI, Akande HJ. Poor obstetrics outcome in an undiagnosed sub-septate uterus. Sub-Saharan Afr J Med 2015;2:184-6

How to cite this URL:
Atobatele MO, Oyinloye OI, Akande HJ. Poor obstetrics outcome in an undiagnosed sub-septate uterus. Sub-Saharan Afr J Med [serial online] 2015 [cited 2019 Nov 14];2:184-6. Available from: http://www.ssajm.org/text.asp?2015/2/4/184/172450


  Introduction Top


Septate uterus is the most common Mullerian duct anomaly (MDA) constituting about 55%. [1],[2],[3] It results from partial or complete failure of resorption of the uterovaginal septum after fusion of the paramesonephric duct. [3],[4] The septum which arises in the midline fundus is considered to be complete when it extends to the internal cervical os or even further downward. [3],[5] The overall frequency of uterine malformations is estimated to occur in 3-4% of the general population. [1],[2],[5] This anomaly has been associated with subfertility, recurrent spontaneous abortion, preterm deliveries, fetal intrauterine growth development, fetal malposition, and retained placenta. However, fertility does not appear to be substantially compromised in patients with septate uterus type of this anomaly, [1],[6],[7] but is associated with the poorest reproductive outcome and the overall premature birth rates range from 9% to 33%. [3],[8]

Unless the woman has a vaginal septum or double cervix which is visualized on speculum examination, septate uterus is usually not diagnosed until a woman has had some pregnancy failure. [2],[9]


  Case Report Top


A.Z. is a 32-year-old P2 +1 (nonalive) woman who presented with a history of miscarriage and two preterm deliveries. Her first pregnancy resulted in spontaneous abortion at about 20 weeks' gestation. Her second and third pregnancies resulted in premature deliveries at 28 weeks and 30 weeks, respectively. The first baby died <24 h after delivery whereas the second baby died 3 days after delivery. She is not a known hypertensive or diabetes. Her blood pressure was 120/85 mmHg whereas her fasting blood sugar was 3.5 mmol/L.

On examination, no physical abnormality was present. On account of the obstetric history, the gynecologist requested for hysterosalpingography (HSG), which revealed a partially divided uterine cavity with intercornual distance of 2.2 cm and intercornual angle of 58° [Figure 1]. The right  Fallopian tube More Details was normal in caliber and showed free intraperitoneal spillage of contrast medium whereas the left tube showed abrupt termination of contrast at the cornual end suggestive of tubal blockage.
Figure 1: A hysterosalpingogram (anteroposterior view) showing partially divided uterine cavity with an intercornual angle of 580 suggestive of a sub-septate uterus. The left fallopian tubal blockage is also noted

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A diagnosis of sub-septate uterus with the left tubal blockage was made and was confirmed during metroplasty. The patient did well = after surgery and was discharged home.


  Discussion Top


Septate uterus is one of the Mullerian duct anomalies (MDAs) and it is classified as class V by American Society of Reproductive Medicine. [5],[6],[7]

During embryogenesis, two Mullerian ducts fuse together to form a single uterus. In one of the final events of uterine formation, the wall where the ducts fuse dissolves forming a single endometrial cavity. It is the failure of this last process that produces a septate uterus with two endometrial canals. [7]

This anomaly has been related with subfertility, recurrent pregnancy loss, prematurity, and other obstetrics complications. [1],[8] Most studies reported an approximate frequency of 25% for associated reproductive problems compared with 10% in the general population. [3] Of all the obstetrics problems, early spontaneous abortions and preterm deliveries were found to be quite common as in the case presented. [1] Uterine septum is poorly vascularized, thus abortion in women with septate uterus is related to septal implantation. [8] The pregnancy outcome is extremely poor with septal implantation whereas it is good with uterine wall lateral implantation. [8]

The role of imaging is to detect, diagnose, and distinguish surgically correctable forms of MDAs from those that may not require surgery. Prior to the advent of newer imaging modalities, HSG was the primary imaging method for the evaluation of uterine anomalies. Other radiological investigations that may reveal septate uterus include ultrasonography (2D, three-dimensional [3D], and sonohysterography) and MRI.

Most of the anomalies would be diagnosed initially by HSG or US, further imaging with MRI will often be required for a definitive diagnosis. [3] MRI was not done in this case because of financial constraints. The suspicion of a congenital uterine abnormality is high during HSG examination, if the typical trigone configuration of the uterine cavity is not demonstrated. [6] A divided uterine cavity on HSG may result from septate, bicornuate, or didelphys uterus.

Where the intercornual distance is <2 cm, the likelihood of a septate uterus is increased, whereas when the distance is >4 cm, the likelihood of didelphys uterus is increased. [6] HSG alone is not always adequate to make the distinction between a septated and a bicornuate uterus unless the intercornual angle is 75° or less which indicate a septated uterus as in the case presented. [6] However, if the angle is ≥105°, a bicornuate uterus is probably present. [6] Angles between 75° and 105° are more likely to be due to septate uterus. [3] The major limitation of HSG is its inability to evaluate external uterine contour. [3]

MRI is the imaging study of choice because of its high accuracy and detailed elaboration of uterovaginal anatomy as a result of its excellent soft tissue contrast resolution and multiplanar imaging capability. [3] The configuration of the external uterine contour is crucial for the differentiation of a septate from a bicornuate uterus. The outer fundal contour is convex, flat, or mildly concave (<1.0 cm) in septate uterus whereas the concavity is >1.0 cm in bicornuate uterus. [3]

3D US had also been found to show a sensitivity of 93% and specificity of 100% in distinguishing between a septate and a bicornuate uterus. [3]

Differentiation between a septate and a bicornuate uterus is important because septate uterus is treated with transvaginal hysteroscopic resection of the septum, whereas if surgery is indicated for the bicornuate uterus, an abdominal approach is required for metroplasty. [3],[6]

In conclusion, a case of a 22-year-old woman with septate uterus diagnosed by HSG has been presented. Diagnostic accuracy of HSG in identifying septate uterus, especially in those with intercornual angle <75° has been highlighted. This may be of value in a resource-poor setting where MRI if available may not be affordable for definitive diagnosis.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simón C, Pellicer A. Reproductive impact of congenital müllerian anomalies. Hum Reprod 1997;12:2277-81.  Back to cited text no. 1
    
2.
Kupesic S, Kurjak A. Septate uterus: Detection and prediction of obstetrical complications by different forms of ultrasonography. J Ultrasound Med 1998;17:631-6.  Back to cited text no. 2
    
3.
Troiano RN, McCarthy SM. Mullerian duct anomalies: Imaging and clinical issues. Radiology 2004;233:19-34.  Back to cited text no. 3
    
4.
Nouri K, Ott J, Huber JC, Fischer EM, Stögbauer L, Tempfer CB. Reproductive outcome after hysteroscopic septoplasty in patients with septate uterus - A retrospective cohort study and systematic review of the literature. Reprod Biol Endocrinol 2010;8:52.  Back to cited text no. 4
    
5.
Braun P, Grau FV, Pons RM, Enguix DP. Is hysterosalpingography able to diagnose all uterine malformations correctly? A retrospective study. Eur J Radiol 2005;53:274-9.  Back to cited text no. 5
    
6.
Syed I, Hussain HK, Weadock, Ellis J, Atobatele MO, Oyinloye OI, et al. Mullerian Duct Abnormality. Available from: http://www.emedicine.medscape.com/article/imaging. [Last accessed on 2011 May 13].  Back to cited text no. 6
    
7.
Salle B, Sergeant P, Gaucherand P, Guimont I, de Saint Hilaire P, Rudigoz RC. Transvaginal hysterosonographic evaluation of septate uteri: A preliminary report. Hum Reprod 1996;11:1004-7.  Back to cited text no. 7
    
8.
Fedele L, Dorta M, Brioschi D, Giudici MN, Candiani GB. Pregnancies in septate uteri: Outcome in relation to site of uterine implantation as determined by sonography. AJR Am J Roentgenol 1989;152:781-4.  Back to cited text no. 8
    
9.
Nwankwo NC, Maduforo CO. Mullerian duct anomaly in a Nigerian woman with recurrent pregnancy loss. Niger J Clin Pract 2011;14:109-11.  Back to cited text no. 9
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