Issuu on Google+

JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 5 | NUMBER 1 | January 2010

46

CASE REPORTS

Uterus didelphys having single pregnancy in her right horn:a case report Mohd Suhail ,Hina Khan ,Safia Suhail 1,2

[Abstract]  In a female fetus,the uterus starts out as two small tubes.As the fetus develops,the tubes normally join to create one larger,hollow organ唱 the uterus. Fusion of the two Mullerian ducts and the establishment of the va唱 ginal canal are usually completed between the 10th and 17th week of intra唱 uterine development. Sometimes,howev唱 er,the Mullerian ducts don摧 t join completely. Several degrees of duplication of the uterus are possible,ranging from a complete duplication of the uterus,cervix and vaginal canal. Instead,each one develops into a separate cavity.This condition is called double uterus (uterus didelphys). Each cavity in a double uterus often leads to its own cervix. Some women with a double uterus also have a duplicate or divided vagina.Uterus didelphys is rare and sometimes not even diagnosed. It is a rare uterine anomaly and according to one estimate,it occurs in 0畅 1% ~0畅 5% healthy fertile population. A 24 years old pregnant woman was admitted on 12th June 2007 in our hospital with full term pregnancy & labor pain. Her previous delivery was done 2 years ago in some other nursing home by caesarian sec唱 tion.On examination,she was found to have pregnancy of 34 weeks with breech presentation,thick muconium dis唱 charge per vagina. Cervix was taken up and 2 cm dilated with fetal distress ++. She was advised emergency cae唱 sarian section.Abdomen was opened by transverse incision in layers and we observed two uteri with intervening thick connective fibrous band in between them. On the left side was a non唱 pregnant uterus,which was lying anterior and to the left side of the pregnant uterus. A live female baby presenting as frank breech,weighing 2,500 gms was extracted out from the right uterus by lower segment caesarean section and bilateral tubal ligation was done.At the end of surgery during the time of vaginal toileting,a single vagina was seen. [Key words]  uterus didelphys;single pregnancy;cytoplasmic receptor;estrogen and progesterone receptors INTRODUCTION In a female fetus, the uterus starts out as two small tubes. As the fetus develops,the tubes normally join to

create one larger,hollow organ唱 the uterus. Fusion of the two Mullerian ducts and the establishment of the vagi唱 nal canal are usually completed between the 10th and 17th week of intra唱 uterine development.Sometimes, however, the Mullerian ducts don摧 t join completely. Several degrees of duplication of the uterus are possi唱 ble,ranging from a complete duplication of the uterus, cervix and vaginal canal. Instead,each one develops in唱 to a separate cavity. This condition is called double ute唱

rus (uterus didelphys). Each cavity in a double uterus often leads to its own cervix. Some women with a doub唱 le uterus also have a duplicate or divided vagina.Ute唱 rus didelphys is rare and sometimes not even diag唱 nosed. It is a rare uterine anomaly and according to one estimate, it occurs in 0畅 1% ~0畅 5% healthy fertile population.The percentage may be higher in women with a history of miscarriage or premature birth.Treat唱 ment is needed only if a double uterus causes symptoms or complications,such as pelvic pain or repeated mis唱 carriages. Some women have a double uterus and never realize it,even during pregnancy and childbirth. Possible

1 Department of Biochemistry,University of Allahabad,Allahabad唱 211002,India

2 City Nursing & Maternity Home Research Center,21,Minhajpur,Allahabad唱 211003,India

Correspondence to Prof.Mohd Suhail,Honorary Director,City Nursing & Maternity Home Research Center,21,Minhajpur唱 211003,India E唱 mail:profmsuhail@gmail.com

signs and symptoms may include:a mass in the pelvis,

unusual pain before or during a menstrual period,ab唱


JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 5 | NUMBER 1 | January 2010

47

normal bleeding during a period,such as blood flow de唱 spite the use of a tampon.Researchers do not know what causes double uterus.The condition is associated with kidney abnormalities, which suggests that some唱 thing may influence the development of these related tubes before birth.Many women with a double uterus have normal sex lives, pregnancies and deliveries.In

breech presentation and thick muconium discharge per vagina. Cervix was taken up and 2 cm dilated with fetal distress + +.She was advised emergency caesarian section.Her hemoglobin concentration was 10 gm % and blood group was ‘ A’ positive.She had average blood pressure 130 / 80 mm Hg.Her urine sample showed absence of albumin & sugar.

with uterus didelphys , the usual history is one of abortion or premature labor.Patients with uterus didel唱 phys belong to a high唱 risk group and deserve a parti唱 cular prenatal care.Therefore it is of great importance for the clinical management of these cases that abnor唱 malities of the reproductive tract are detected in an early stage.In the study of uterine anomalies, ultra唱 sound is used which is as reliable as laparoscopy or [ 4] hysterosalpingography . But,sometimes a double uterus leads to infertility or miscarriage.A double uterus may also cause prema唱

managed by oxytocic infusion and two units of blood transfusion.Baby suction done, cried immediately. Uterus cleaned & closed in layers.After closing right uterus,we snapped both the uteri having separate fal唱 lopian tube & ovary on right side and other uterus of normal size with fallopian tube & ovary on left side which are shown in Figures 1 ~4 .At the end of sur唱 gery during the time of vaginal toileting,a single va唱 gina was seen. This is the second case of congenital uterine a唱 nomaly being communicated by our group of the hospi唱

fact,the more complete the duplication,the less likely complications are to arise.Uterine malformations have clinical importance because of the many obstetrical complications that can take place in the pregnant pa唱 [1] [ 1] tient .According to them pregnancies in a func唱 tional hemi唱 uterus originating from a single Mullerian duct ( one horn of a uterus didelphys,unicornuate uni唱 collis) have a better prognosis with regard to the fetal wastage rate than a pregnancy in a uterus bicornuate, septate or arcuatus.Though the delivery of a normal infant,and very rarely twins, is possible in a patient [ 2 ,3 ]

ture birth or unusual positions of the baby in the ute唱 rus,such as bottom down ( breech presentation) . CASE REPORT In present case a 24 years old pregnant woman was ad唱 mitted on 12th June 2007 in our hospital with full term pregnancy & labor pain.She had been seeking care in other hospitals in previous pregnancy and delivery;and had for the first time attended our hospital.There was one scar in lower midline caesarean section. Her previ唱 ous delivery was done two years ago in some other Nursing Home by caesarian section.On examination, she was found to have pregnancy of 34 weeks with

Abdomen was opened by transverse incision in layers and we observed two uteri with intervening thick connective fibrous band in between them.On the left side was a non唱 pregnant uterus, which was lying anterior and to the left side of the pregnant ute唱 rus.A live female baby presenting as frank breech, weighing 2 , 500 g was extracted out by lower seg唱 ment caesarean section and bilateral tubal ligation was done.There was atonicity of the uterus leading to primary postpartum hemorrhage resulting in excessive blood loss amounting to more than 750 ml which was

tal,the other one we have reported earlier . When the mother of present baby was asked about her pevious operation唱 caesarian section, and if the doctor told her that she is having two uteri. She answered in negative. On investigation, we found that, this woman had her previous pregnancy in her right uterus even at that time too.And during her second pregnancy this time again she had pregnancy in her right uterus only. Her progno唱 sis was good and she was discharged on the 10th day. Thus,this woman had her pregnancy both the times in唱 her right uterus.This tempted us to go through litera唱 ture on uterus didelphys & we have gone through the literature of last forty years. [5]


48

JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 5 | NUMBER 1 | January 2010

Figure 1 Both separate uteri withhold with hands after caesarian section Figure 2  Fallopian tubes of

both uteri clearly visible Figure 3 Both uteri clearly visible after caesarian section Figure 4 Both sep唱 arate uteri with suture on right uterus after caesarian section

DISCUSSION Reports are available on double uterus with a pregnan唱 [6唱 11] cy in each half . In case of single pregnancy in ute唱 rus didelphys literature shows the right uterus having [12] pregnancy predominantly.Tsibris et al. carried in唱 vestigation on a 23唱 year唱 old woman with a uterus didel唱 phys and a totally occluded left tube had a hysterecto唱 my one year after having a child.Endometrial estrogen and progesterone receptors, both cytoplasmic and nu唱 clear,were determined in five longitudinal sections of each horn.The amount and distribution of these recep唱 tors were normal but the receptor content of the right horn was higher than that of the left. Cytoplasmic recep唱 tor values were in the expected normal range, and in general descended from the fundus to the cervix as in normal uteri.Nuclear receptor values were also in the expected range for secretary nuclei and their distribution was as seen in normal uteri. Both receptors (estrogen + progesterone; cytoplasmic + nuclear ) however, were higher in the right horn vs.the left horn;this difference is ascribed to the woman摧 s earlier pregnancy.

The present case reports the woman with uterus didelphys having single pregnancy in her right uterus. This is interesting as it corroborates to the observation on estrogen and progesterone receptors in the case of u唱 [12] terus didelphys women .In present case,the women with a uterus didelphys do not have a duplicate or di唱 vided vagina. Uterus didelphys (UD),as is the case in the present report,should not be confused with uterus bicornis bicollis (UBB). Although both have two sepa唱 rate uterine cavities, the walls of the UBB are still slightly joined together,but not just by a thin septate but rather by a thick uterus wall.In a UD these are completely separate,the two uterus cavities are not e唱 ven partially joined,as was the situation in the present case. [ 13] Heinonen P.K. carried studies on forty唱 nine didelphys women to evaluate their reproductive per唱 formance and possible long唱 term consequences associ唱 ated with this uterine anomaly.He reported that five ( 13%) patients had primary infertility.Thirty唱 four (94%) out of thirty唱 six women who wanted to conceive


JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 5 | NUMBER 1 | January 2010 had at least one pregnancy,and they produced seventy唱 one pregnancies;21% miscarried,and ectopic pregnan唱 cy occurred in 2%.The fetal survival rate was 75%, prematurity 24%,fetal growth retardation 11%,perina唱 tal mortality 5畅 3%, and cesarean section rate 84%. Pregnancy located more commonly (76%) in the right uterus than in the left. During the follow唱 up period en唱 dometriosis was observed in seven (16%) out of forty唱 five cases. Ovarian neoplasm was found in four (9%) cases,one of them had ovarian cancer.On the basis of his findings he concluded that fertility in women with didelphic uterus is not notably impaired.The prognosis of pregnancy is comparatively good, while prematurity and fetal growth retardation indicate meticulous prena唱 tal care. Long唱 term follow唱 up did not reveal that didel唱 phic uterus is associated with increased frequency of endometriosis or genital neoplasm. Interestingly, in our present case report, this woman had single pregnancy in her right uterus only and gave birth to a baby by caesarian section which corroborates with the findings of studies earlier repor唱 ted. However,the mother of the present case report did not have a history of miscarriage or premature birth but she used to have unusual pain before or during a men唱 strual period. Conclusively,we may also state that patients with uterus did���lphys belong to a high唱 risk group and de唱 serve a particular prenatal care.Therefore it is of great importance for the clinical management of these cases that abnormalities of the reproductive tract are detected in an early stage. In the study of uterine anomalies,ul唱 trasound is used which is as reliable as laparoscopy or hysterosalpingography.

49

REFERENCES 1畅Green LK, Harris RE.Uterine anomalies; frequency of diagnosis and associated obstetric complications.Obstet Gynecol,1976,47 ( 4 ) :427 -429. 2畅Brody S.Double uterus with double pregnancy.Am J Obstet Gynecol, 1954,67(1) :161 -167. 3畅Getts JS.Double pregnancy in a uterus duplex unicollis.Am J Obstet Gynecol,1967,97(2) :277 -278.

4畅Fedele L,Ferrazzi E,Dorta M,Vercellini P,Candiani G.Ultrasonogra唱 phy in the differential diagnosis of ‘ double’ uteri.Fertil Steril,1988,

50(2) :361 -364. 5畅Suhail MF,Khan H, Suhail S.Congenital uterine anomaly: Pregnancy in a woman with bicornis bicollis uterus.Ind J Pract Doctors,2008,5 (1) :58 -62. 6畅Tortora JM.Uterus didelphys;pregnancies in alternate uteri.N Y State J Med,1971,71(17) :2089 -2092.

7畅Clarke GC.Uterus didelphys with a pregnancy in each horn.Case re唱 port.Br J Obstet Gynaecol,1977,84(9) :720.

8畅Brown DC,Nelson RF.Uterus didelphys and double vagina with deliv唱 ery of a normal infant from each uterus.Can Med Assoc J,1967,96 (11) :675 -677. 9畅Kekkonen R,Nuutila M,Laatikainen T.Twin pregnancy with a fetus in each half of a uterus didelphys.Acta Obstet Gynecol Scand,1991,70 (4 -5) :373 -374. 10畅Kanakas N,Boos R,Schmidt W.Twin pregnancy in the right horn of a

uterus didelphys:a case report.Eur J Obstet Gynecol Reprod Biol,

1989,32(3) :287 -292. 11畅Nh备 n VQ,Huisjes HJ.Double uterus with a pregnancy in each half. Obstet Gynecol,1983,61(1) :115 -117.

12畅Tsibris JC,Fort FL,Cantor B,Gelman SR,Riggall FC,Spellacy WN.

Endometrial estrogen and progesterone receptors in a uterus didel唱 phys.J Reprod Med,1980,24(4) :182 -184.

13畅Heinonen PK.Clinical implications of the didelphic uterus :long唱 term follow唱 up of 49 cases.Eur J Obstet Gynecol Reprod Biol,2000,91 (2) :183 -190.

(Editor LEE)


Uterus didelphys having single pregnancy in her right horn: a case report