Uterine malformation

This presentation of Uterine malformation is easy to understand read and very precise.

1. Uterine malformation

2. INTRODUCTION Congenital malformations are anomalies, which may be either hereditary or occuring during gestation and evident at the time of birth. Development of the female genital tract is a complex process depend upon a series of event involving cellular differentiation , migration, fusion and canalization. Failure of any one these processes result in a congenital anomaly.

3. Definition A Uterine malformation is the result of an abnormal development of the Mullerian ducts during embryogenesis. The most common types of uterine abnormalities are caused by incomplete fusion of mullerian ducts. Uterine anomalies are often associated with vaginal maldevelopment.

4. Classification American Fertility society (AFS) classification of mullerian anomalies are : Class 1: Mullerian agenesis / hypoplasia-segmental ( a. vaginal, b. cervical, c. uterine, d. tubal, e. combined). Class 2 : Unicornuate with or without a rudimentary horn. Class 3 : Uterus didelphys. Class 4 : Bicornuate utrerus (a.complete to internal os, b.partial).

5. Class 5: Septate uterus (complete \incomplete ) Class 6: Arcuate uterus. Class 7: Diethylstilbesterol (DES) –related anomalies. INCIDENCE It varies between 3 and 4%.The incidence is found to be high in women suffering from recurrent miscarriage or pre term deliveries (5-20%).

6. CAUSES Failure of development of one or both mullerian ducts : The absence of both ducts leads to absence of uterus , including oviducts . There is absence of vagina as well . Primary amenorrhea is the chief complaint. Failure of recanalization of the Mullerian ducts : Agenesis of the upper vagina or of the cervix – this may lead to hematometra as the uterus is functioning.

7. Failure of fusion of mullerian ducts: In majority , the presence of deformity escapes attention. In some , the detection is made accidently during investigation of infertility or repeated pregnancy wastage . In others, the diagnosis is made during D & E operation , manual removal of placenta or during cesarean section .

8. TYPES OF FUSION ANOMALIES: ARCUATE (18%): The cornual parts of the uterus remains separated . The uterine fundus looks concave with heart shaped cavity outline . UTERINE DIDELHYS (8%): There is complete lack of fusion of the mullerian ducts with a double uterus, double cervix and a double vagina.

9. UTERUS BICORNIS (26%): There is varying degree of fusion of the muscle walls of the two ducts . Uterus bicornis bicollis – There are two uterine cavities with double cervix with or without vaginal septum. Uterus bicornis unicollis – There are two uterine cavities with one cervix . The horns may be equal or one horn may be rudimentary and have no communication with the developed horns

10. SEPTATE UTERUS (35%): The two Mullerian ducts are fused together but there is persistence of septum in between the two partially or completely . UNICORNUATE UTERUS OR UTERUS UNICORNIS(10%): There is a failure of development of one Mullerian duct . Only one side of the Mullerian ducts forms and there is a single uterine cavity with a cervix and one fallopian tube coming out of the uterus.

11. ABSENT UTERUS OR UTERINE AGENESIS: This is the most severe kind of uterine malformation . There is failure of uterus , cervix and vagina to develop. A girl with this malformation will experience puberty with the absence of menstruation . The women will have a small dimple in the place where the vagina should be at. DES – RELATED ABNORMALITY: It is due to DES exposure during intrauterine life . Varieties of malformation are included . Eg: Vagina –adenocarcinoma , adenosis. Cervix – cockscomb cervix , cervical collar. Uterus- hypoplasia , T-shaped cavity. Fallopian tube – cornual budding , abnormal fimbrae .

12. CLINICAL FEATURES: The condition may not produce any clinical manifestation. Gynecological: Infertility and dyspareunia are often related in association with vaginal septum. Dysmenorrhea in Bicornuate uterus or due to cryptomenorrhea. Menstrual disorders (menorrhagia , cryptomenorrhea) are seen. Menorrhagia is due to increased surface area in Bicornuat e uterus .

13. Obstetrical: Midtrimister miscarriage which may be recurrent . Rudimentary horn pregnancy may occur due to transperitoneal migration of sperm or ovum from the opposite side. Cervical incompetence. Increased incidence of malpresentation : tansverse lie in arcuate or subseptate, breech in bicornuate,unicornuate or complete septate uterus. Preterm labor,IUGR,IUD. Prolonged labor – Due to incordinate uterine action. Obstructed labor – obstruction by the non-gravid horn of the bicornuate uterus or rudimentary horn. Retained placenta and postpartum hemorrhage where the placenta is implanted over the uterine septum.

14. DIAGNOSIS Ultrasonography. Hysterosalpingography which allows evaluation of the uterine cavity and tubal pregnancy. MRI Scan. Hysteroscopy.

15. COMPLICATIONS Dysmenorrhea. Hematometra. Complications during pregnancy and labor – late miscarriage, preterm labor, ssuterine rupture, malpresentation, obstructed labor. Fertility is uneffected except for uterine agenesis.

16. MANAGEMENT Surgical intervention depending on the type of abnormality or enabling a viable pregnancy. Rudimentary horn should be excised to reduce the risk of ectopic pregnancy. Unification operation (bicornuate or septate uterus) is,therefore,indicated in unexplained cases with uterine malformation. Abdominal metroplasty could be done either by excising or incising the septum. Hysteroscopic metroplasty is more commonly done.Resection of the septum can be done either by resectoscope or by laser.

17. contd….. Advantages are- High success rate(80-89%) Short hospital stay. Reduced postoperative morbidity. Subsequent chance of vaginal delivery is high compared to abdominal metroplasty where C-section is mandatory. Unicornuate uterus has very poor outcome for pregnancy (40%).No treatment is generally effective. Uterus didelphys has best possibility of successful pregnancy(64%).

18. NURSING MANAGEMENT Assess the condition of the women by collecting health history , menstrual history and obstetrical history . Based on the severity of the condition plan for interventions. Educate the couple about the best possible treatment of uterine malformation. Assure the couple about chances of fertility or pregnancy except for the case of uterine agenesis.

19. Allow the client exploring all possible options for family. Help the couples in overcoming delimmas , deciding the right fertility treatment. Counsel and encourage the couple for child adoption in case of infertility. Help the couple to deal with emotional stress. Advice the mother to avoid fertility impairing medication. To relieve dysmenorrhea , provide hot application. Administer analgesics to relieve pain. Educate the woman to practice light exercise and maintain nutritious diet such as fibre diet after surgical treatment .