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Recurrent Transverse Lie in an Arcuate Uterus: a Case Report and Literature Review

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Recurrent Transverse Lie in an Arcuate Uterus: a Case Report and Literature Review CASE REPORT Recurrent transverse lie in an Arcuate Uterus: A Case Report and Literature Review Okonkwo Susan Gana SUMMARY Arcuate uterus is a mild form of uterine anomaly that may go unnoticed during a reproductive life of a woman. While it is shrouded in controversy in categorization and diagnosis, studies have shown that arcuate uterus is associated with Endometriosis. Arcuate uterus is rarely associated with reproductive failure. However, malpresentation, preterm birth and miscarriages have been found to be associated with arcuate uterus. Transverse lie is a presentation commonly associated with uterine anomalies. The uterine cavity distortion and reduction in capacity seen in arcuate uterus may explain the increase incidence of Transverse lie as demonstrated in the case report. Key words: Arcuate uterus, Miscarriages, Malpresentation, Transverse lie Department of Obstetrics and Gynaecology, common defects of the female reproductive State Specialist Hospital, Maiduguri system. In the general population of women, they occur with an incidence rate of Corresponding Author approximately 4% 2. The anomaly can be a Dr. Susan Gana Okonkwo, physical abnormal formation of the uterus or Department of Obstetrics and Gynaecology, could be a more subtle abnormalities within State Specialist Hospital, Maiduguri. Borno the uterine cavity. Some of these anomalies State. Email: [email protected] have been found to be associated with such conditions as pelvic pain, infertility, and Introduction endometriosis3. Others are increased risk of The uterus is responsible for many of the most miscarriage and preterm delivery 2, 4, 5. For crucial steps in the process of reproduction. some that may carry the pregnancy to age of Sperm migration, embryo implantation, fetal viability may have operative delivery. As nourishment, development and growth, and experienced by the case reported. finally, the process of labor and delivery are all reliant on the existence of a structurally Case Summary normal and functionally competent A 34year old female G 3 P2 + 0 who presented uterus1.Congenital uterine anomalies are to Antenatal clinic for prenatal care at 20 strongly associated with adverse effect on weeks gestation of pregnancy at State fertility and pregnancy outcome. Specialist Hospital Maiduguri. Her Malformations of the uterus are the most pregnancy has been uneventful. She had Access this article online cesarean deliveries in her 2previous QuickResponse Code pregnancies due to transverse lie. All her website:www.bornomedicaljournal.com routine ANC investigation were within normal limits. Her blood group was O rhesus DOI: 10.31173/bomj.bomj_182_17 positive and her genotype was AA. She was Borno Medical Journal January - June 2020 Vol. 17 Issue 1 Page 1 This work is licensed under a Creative Commons Attribution 4.0 International License Okonkwo S G regular on her routine prenatal medication. these anomalies with a patient’s fertility is an The only abnormal finding found during her interestingphenomena but also a debatable entire prenatal care were on abdominal issue. Proper management of infertile examination. The lie of the baby remained women with many forms of these anomalies transverse throughout the pregnancy period. remains controversial1.Congenital uterine Her first ultrasound scan was at 32 weeks anomalies may affect some or all of these gestation that revealed a live intrauterine uterine functions, precluding a successful fetus at 32 weeks gestation in transverse lie, pregnancy. Several studies have shown that placenta was posterior but not previa. uterine congenital anomalies are found Estimated fetal weight was 2.0 kg. The liquor present in 1-10% of unselected population, 2- was adequate for the gestational age. She was 8% of infertile women and 5-10 % of women scheduled for elective cesarean section at 39 with the history of miscarriage 7, 9, 10, 12. The weeks because of 2 previuos cesarean wide range of difference in the prevalence sections. She had uneventful antenatal period rate is presumably because of use of different a repeat ultrasound scan upheld the previous classification systems and non-uniformity in findings. She was booked for elective diagnostic tests11, 12. cesarean section at 39 weeks gestation. The Normal development of the female preoperative investigations were PCV 36%, reproductive tract involves a series of Urinalysis negative for protein and Glucose, complex processes which includes her electrolytes were within Normal limits. differentiation, migration, fusion and The operation findings were: Uterus in canalization of the Mullerian system11 12. The dextrorotation with well-formed lower interruption of these processes results to segment. The tubes and ovaries were grossly uterine anomaly. normal. The fetus was transverse lie, in right The reported incidence of congenital uterine acromion anterior position. Delivery was anomalies varies from 1.8 - 3.76% 13. The wide conducted by internal Podalic version and range reflects the differences in the criteria, breach extraction. A live male baby that the population studied and the techniques weighed 3.8 Kg with Apgar sores 7 in first used for the diagnosis. Saravelos, Cocksedge minute and 9 in fifth minute was delivered. and Li reported a prevalence of 6.7% in the The placenta was delivered by controlled general population, 7.3 in the infertile cord traction. A close examination after the population and 16.7% among those with delivery of the baby revealed a uterus with an recurrent miscarriages 11. Similarly Chan et al indentation at the fundus into the reported a prevalence of 5.5% among the endometrial cavity measuring 1.5cm. A general population, 8.0% among the infertile diagnosis of severe arcuate uterus was made women, and 13.3% in those with previous and could be the reason for the recurrent miscarriages and 24.5% among those with transverse lie. previous miscarriages in association with infertility15. Żyła et al in their study carried Discussion out on “Pregnancy and Delivery in Women with Congenital uterine anomalies are not Uterine Malformations” concluded that uncommon. Many are asymptomatic and women with uterine defects are subject to an have been associated with normal or adverse increased risk of complications in pregnancy reproductive outcomes. The interference of and delivery. These complications probably Borno Medical Journal January - June 2020 Vol. 17 Issue 1 Page 2 This work is licensed under a Creative Commons Attribution 4.0 International License Recurrent transverse lie in an Arcuate Uterus occurring as premature births, low birth difficult to discern this from the more weight babies and births by cesarean pronounced septate uterus. In Europe, the section16. The index case had cesarean birth in term “arcuate uterus” is no longer in use. All all her pregnancies due to recurrent uteri are either classified as normal or septate transverse. Zyla et al claimed that newborns uterus. However, when arcuate uterus is of women with uterine defects show a worse categorized differently from the septate birth status, based on their Apgar score and uterus, it was found that arcuate uterus low birth body mass14. For this reason, the accounts for 70% of uterine abnormalities, of study recommended that pregnancy in all the uterine anomalies arcuate uterus is the a woman with uterine defects should be least commonly associated with reproductive regarded as a high-risk pregnancy as such failure 17. While, it may not be associated with intensive monitoring of such pregnancy, obstetrics complications such as infertility or labour and delivery with a well-planned miscarriages, some studies have shown some preventive measures is highly indicated 14. correlations with other gynecological diseases, such as endometriosis. For this Arcuate Uterus reason, it can be highly beneficial to separate Arcuate uterus is a Mullerian duct arcuate uterus as a subcategory of a septate abnormality characterized by a mild uterus3. Arcuate uterus can be diagnosed indentation of the endometrium at the uterine with ultrasound or MRI. Arcuate uterus fundus. This occurs as a failure of complete described by Surrey et al as a perpendicular resorption of the utero-vaginal septum that depth from the interstitial line connecting the affects 3.9% of the general population6. The cornua ranging from 4 to 10 mm with a endometrial intention has made it classically myometrial angle >90 degrees18. difficult to define arcuate uterus, as it can be Figure 1: Diagram of Arcuate Uterus Arcuate Uterus is the most common uterine the patients were found to have arcuate anomaly in the general population and in uterus3. La Monica et al in their study women with recurrent miscarriages, while reported a notable similarity. 37% of septate uterus is the commonest anomaly in endometriosis patients were found to arcuate the infertile population15 19 20. Braun et al. in uterus upon laparoscopic and hysteroscopic their study carried out in Spain reported that procedures17. While this in fact, is not a arcuate uterus is the most common uterine majority, it is significant to note asarcuate malformation16. Similarly, Seckin study uterus is reported to be in less than 5% of found a relationship between arcuate Uterus females according to recent studies17. and endometriosis. Of the 260 hysteroscopy Żyła et al in their study on “Pregnancy and conducted at the endometriosis center 38% of Delivery in Women with Uterine Borno Medical Journal January - June 2020 Vol. 17 Issue 1 Page 3 This work is licensed under a Creative
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