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Martinez-Peñuela CRE, et al., J Reprod Med Gynecol Obstet 2019, 4: 025 DOI: 10.24966/RMGO-2574/100025 HSOA Journal of Reproductive , &

Case Report A Successful Pregnancy Outcome in a Complete Septate Uterus

Catalina Renata Elizalde Martinez-Peñuela*, Jesus Zabaleta, Gema Campo, Francisco Javier Elizalde and Beatriz Pérez

Department of Gynecology, Hospital Virgen del Camino, Pamplona, Spain

Figure 1: Classification of congenital uterine anomalies as described by the American Abstract Fertility Society (1988). The incidence of congenital uterine malformation is estimated to be 3-5% in general population. Abnormal fusion of Mullerian duct in embryonic life results in variety of malformations. Here, we report a Case Report

case of successful pregnancy outcome in a complete septate uterus nd with pregnancy in the right horn. An emergency lower segment cae- A 26 yr old 2 gravida, presented to the OBG dept of Navarra with sarean was performed instead of delivery because of a non reassur- 2months amenorrhoea. She had a first trimester abortion in first preg- ing foetal heart rate. The diagnosis was confirmed intra operatively. nancy. She had no complaints, but an early ultrasound done at 7 wks A septoplasty prior to a new gestation was performed. of gestational age detected a complete septate uterus with pregnancy in the right horn (Figure 2). Per speculum examination showed one Keywords: MRI; Mullarian ducts; Preterm labour; Septate uterus; cérvix and vulva, urethra and vagina were normal. She had regular an- Ultrasound tenatal visits which are uneventful till 8 month. At 32 wks of gestation she was admitted with complain of abdominal pain. Tocolysis given Introduction and patient steroided for lung maturity. USG done revealed cervical shortening. Doppler was normal. Tocolysis stopped 48 hrs after giv- Uterine anomalies can lead to infertility and problems with re- ing corticosteroids. production among women. A lot of uterine malformation like septate uterus, unicornuate uterus and bicornuate uterus result from abnor- mal development of paramesonephric (mullarian) duct fusion during uterus development. The prevalence of uterine anomalies in the gen- eral population is about 0.5% [1]. Acien, in a review study, found a mean incidence for septate uterus 22% (complete septate 9%, partial septate 13%) among the all other types of mullarian defects [2]. In 1988 American Fertility society described congenital uterine anoma- lies relateted to mullarian ducts according to figure 1. Septate uterus is the most frequent uterine malformation [3,4] and characterized by a muscular or fibrous wall, called the septum. The septum affects only the cranial part of the uterus (partial septate uterus) or it may reach as far as the cervix (complete septate uterus) figure 1. It is diagnosed by medical image techniques, i.e., ultrasound or an MRI. *Corresponding author: Catalina Renata Elizalde Martinez-Peñuela, Depart- ment of Gynecology, Hospital Virgen del Camino, Irunlarrea st 31008. Pamplona, Figure 2: Three dimensional ultrasound: complete uterine sept. Spain, Tel: +34 660825639; E-mail: [email protected] Citation: Martinez-Peñuela CRE, Zabaleta J, Campo G, Elizalde FJ, Pérez B At 34 wks of gestation the patient presented with prelabour pre- (2019) A Successful Pregnancy Outcome in a Complete Septate Uterus. J Re- mature rupture of membranes. In view of non-reassuring foetal heart prod Med Gynecol Obstet 4: 025. rate, an emergency lower segment caesarean section was done with Received: July 15, 2019; Accepted: August 01, 2019; Published: August 08, the following intra operative findings: A complete uterine septus with 2019 pregnancy in the right horn seen. A live male child in right occipito Copyright: © 2019 Martinez-Peñuela, et al. This is an open-access article posterior position weighing 1.7 kg was delivered. Placenta is located distributed under the terms of the Creative Commons Attribution License, which anteriorly in the upper segment. By exteriorizing the uterus, findings permits unrestricted use, distribution, and reproduction in any medium, provided are confirmed. She had uneventful post operative period and was dis- the original author and source are credited. charged on 8th post operative day. Citation: Martinez-Peñuela CRE, Zabaleta J, Campo G, Elizalde FJ, Pérez B (2019) A Successful Pregnancy Outcome in a Complete Septate Uterus. J Reprod Med Gynecol Obstet 4: 025.

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One year later, she cames to the hospital for gestational desire and Ultrasonography is a simple, quick, and non invasive technique after the hysterosalpingography (Figure 3) we recommend the possi- for detecting and diagnosing uterine anomalies. Despite the notable bility of performing a septoplasty prior to a new gestation (Figure 4). advantages of this technique, unfortunately the obstetric ultrasound 6 months later she got pregnant and had a eutocic deivery without any scan done on our patient in her first pregnancy could not detect the problem during pregnancy. septate uterus as anomalies accordance with uterus exactly and it could be probably as a result of lack of experience and poor ultra- sound quality. However, our MRI images diagnosed this problem accuracy. Grimbizis et al., reported that 12 (26.1%) out of their 46 infertile patients with septate uterus had laparascopic finding of endo- metriosis [7]. Fayez also found endometriosis in three (43%) out of seven similar patients [3]. It seems possible that septate uterus may be involved in the pathogenesis of endometriosis and thereby plays an important role in indirect relationship within fertility. Therefore, it seems that any finding about endometriosis should be followed by careful investigation for uterine malformation especially in women affected by septate uterus. Hysteroscopy remains the standard for evaluation of intracavitary abnormalities. Its use is especially practical, as it offers the oppor- tunity for treatment at the time of diagnosis. The septum incision is Figure 3: Hysterosalpingography. performed with a hysteroscopic resectoscope and it may be controlled under laparoscopic supervisión. Hysteroscopy without damaging the intact hymen is feasible and helpful for the diagnosis in the treatment of pathologic endometrial changes in women [8,9]. Although hysteroscopy is now the preferred method for treatment of the septate uterus, a report of two cases de- scribed successful removal of the septum at the time of cesarean sec- tion. The difficulty in achieving complete uterine septum caesarean has been reported [10,11], however in the in present case we didn’t found any trouble. Conclusion The reported prevalence of the septate uterus in different popula- tions, including women with normal fertility, infertility, and repeated pregnancy loss, varies widely, partly because the methods used for diagnosis differ between investigators. The pooled data suggest that Figure 4: Histeroscopy after septoplasty. the prevalence in women with normal fertility and infertility is similar (approximately 1%). The prevalence in women with repeated preg- Discussion nancy loss is significantly higher (mean, 3.3%) [4]. Early diagnosis and proper antenatal care is required to suc- Uterine anomalies are related to an increased risk of infertility, cessfully manage a pregnancy with bicornuate uterus. Patient with miscarriage, premature birth, fetal loss and cesarean delivery [5,6]. mullerian duct anamolies are known to have a higher incidence of In present case, according to the patient history, septate uterus has infertility, repeated first, second trimester spontaneous abortions in- influenced her fertility and there was a previous history of abortion. trauterine growth retardation, fetal malpositions, preterm labor, prela- Other than a miscarriage or recurrent miscarriage, there aren’t any bour preterm rupture of membranes & retained placenta. Anticipation symptoms of a septate uterus. It’s often only diagnosed after an inves- and preparedness to deal with these known complications will ensure tigation into the cause of miscarriages. Sometimes it can be picked up positive outcome for the mother and baby. during a routine pelvic exam if the septum extends beyond the uterus to include the cervix and vagina as well. The finding of a septate uterus perse is not an indication for surgi- cal intervention because it is not always associated with poor obstetric Most of the uterine septi are diagnosed by fertility subspecialists, performance. However, when a septate uterus is found in association after the patient presents with recurrent pregnancy loss. It is import- with adverse reproductive outcome, surgical intervention ought to be ant that fertility specialists make the correct diagnosis of the uterine considered [4]. Hysteroscopic septal incision is the best method for septum versus a bicornuate uterus. The uterine septum contains a sep- the preservation of the hymen and it can be performed using the aration in the uterine cavity, however the outer appearance of the uter- microscissors, electrosurgery, or fiber optic light laser energy. us is normal. A bicornuate uterus at the other hand has a completely separated upper end both internally and externally. Diagnosing this In conclusion, the diagnosis of septate uterus as a congenital properly is very important since an attempted resection of the bicor- anomaly can be achieved easily with MRI. It can be corrected by nuate uterus, that is improperly diagnosed as a uterine septum might hysteroscopic and thereby decreases the rate of abortion for create a uterine perforation. women greatly.

Volume 4 • Issue 3 • 100025 J Reprod Med Gynecol Obstet ISSN: 2574-2574, Open Access Journal DOI: 10.24966/RMGO-2574/100025

Citation: Martinez-Peñuela CRE, Zabaleta J, Campo G, Elizalde FJ, Pérez B (2019) A Successful Pregnancy Outcome in a Complete Septate Uterus. J Reprod Med

Gynecol Obstet 4: 025.

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References 7. Grimbizis G, Camus M, Clasen K, Tournaye H, De Munck L, et al. (1998) Hysteroscopic septum resection in patients with recurrent abortions or in- 1. Nahum GG (1998) Uterine anomalies. How common are they, and what is fertility. Hum Reprod 13: 1188-1193. their distribution among subtypes? J Reprod Med 43: 877-887. 8. Xu D, Xue M, Cheng C, Wan Y (2006) Hysteroscopy for the diagnosis and 2. Acien P (1997) Incidence of Müllerian defects in fertile and infertile wom- treatment of pathologic changes in the uterine cavity in women with an en. Hum Reprod 12: 1372-1376. intact hymen. J Minim Invasive Gynecol 13: 222-224. 3. Fayez JA (1986) Comparison between abdominal and hysteroscopic 9. Cheong ML (2010) Minihysteroscopy for examination and management metroplasty. Obstet Gynecol 68: 399-403. of pathologic lesions of virginal reproductive tracts: Can we preserve the hymen intact? Arch Gynecol Obstet 281: 375-376. 4. Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simón C, et al. (1997) Reproductive impact of congenital Müllerian anomalies. Hum Reprod 12: 10. Lipitz S, Shalev J, Kokia E, Kushnir O, Serr DM, et al. (1990) Success- 2277-2281. ful outcome of pregnancy following complete removal of uterine septum during cesarean section. Gynecol Obstet Invest 29: 78-80. 5. Rock JA, Schlaff WD (1985) The obstetric consequences of uterovaginal anomalies. Fertil Steril 43: 681-692. 11. Green LK, Harris RE (1976) Uterine anomalies. Frequency of diagnosis and associated obstetric complications. Obstet Gynecol 47: 427-429. 6. Ludmir J, Samuels P, Brooks S, Mennuti MT (1990) Pregnancy outcome of patients with uncorrected uterine anomalies managed in a high-risk ob- stetric setting. Obstet Gynecol 75: 906-910.

Volume 4 • Issue 3 • 100025 J Reprod Med Gynecol Obstet ISSN: 2574-2574, Open Access Journal DOI: 10.24966/RMGO-2574/100025

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