Uterine Anomalies And Its Treatment Options.
Uterine malformation or anomalies is a type of female genital malformation resulting from abnormal development of the Müllerian duct (s) during embryogenesis.
MULLERIAN DUCT ANOMALIES
Three main principles govern the practical approach to Mullerian anomalies.
1. Mullerian and Wolffian ducts are so closely related embryologically that Mullerian anomalies are commonly associated with anomalies of kidney and ureter.
2. The development of gonads is separate from ducts so normal ovaries are present in Mullerian anomalies.
3. Mullerian anomalies may be associated with anomalies in the sex chromosome makeup of the individual.
Complete formation & differentiation of Mullerian duct into female the reproductive system depends on completion of 3 phases of development as follows- ♦ Organogenesis ♦ Fusion ♦ Septal resorption
ORGANOGENESIS: One or both Mullerian duct may not develop fully-Uterine agenesis or hypoplasia Unicornuate uterus.
FUSION: Lateral fusion- a process during which lower segment of paired Mullerian duct fuse – Uterine didelphys or Bicornuate uterus, Arcuate uterus. Vertical Fusion- Fusion of ascending sinovaginal bulb with descending Mullerian duct – Transverse vaginal septum, Imperforate hymen.
SEPTAL RESORPTION – after fusion central septum persist later resorts to form single uterocervical cavity – Septate uterus.
INCIDENCE There are irregularities in incidence & prevalence rate because of Nonstandardization of the classification system. – Non-uniform diagnostic modalities.– Different study population.
Normal / Fertile women-1.5-4.5% Infertile patients – 3-6% Women with recurrent miscarriage – 5-10% DISTRIBUTION Septate uterus- 35% Bicornuate-26% Arcuate uterus-18% Unicornuate uterus-10% Didelphys uterus-8%
Uterine anomalies are often an incidental diagnosis while seeing the patient for
a different complaint. The Patient can present with:
♦ Pelvic pain (cyclic or non-cyclic)
♦ Abnormal vaginal bleeding
♦ Vaginal pain
♦ Uterine rupture during pregnancy
♦ Recurrent pregnancy loss
♦ The patient may have a concurrent renal abnormalities
CLASSIFICATION AMERICAN FERTILITY SOCIETY CLASSIFICATION (1988)
I. Segmental or complete agenesis or hypoplasia Agenesis and hypoplasia may involve the vagina, cervix, fundus, tubes, or any combination of these structures. Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is the most common example in this category.
II. Unicornuate uterus With rudimentary horn –With endometrial cavity-Communicating -Non communicating □ Without endometrial cavity Without rudimentary horn
III. Didelphys uterus • Complete or partial duplication of the vagina, cervix, and uterus characterizes this anomaly.
IV. Bicornuate uterus • Complete bicornuate uterus -uterine septum that extends from the fundus to the cervical os. • Partial bicornuate uterus – the septum, which is located at the fundus. • In both variants, the vagina and cervix each have a single cavity.
V. Septate uterus • A complete or partial midline septum is present within a single uterus.
VI. Arcuate uterus • A small septate indentation is present at the fundus.
VII. DES-related abnormalities • T-shaped uterine cavity with or without
dilated horns is evident. Not associated with renal anomalies.
Treatment of uterine anomalies
Uterine anomalies can be diagnosed with a physical exam, imaging test, or laparoscopy procedure (which allows the physician to use a laparoscope to view the inside of a woman’s uterus). Many women with uterine anomalies do not require treatment. If pain, miscarriage, or infertility is an issue, a physician may recommend correcting the anomaly
surgically. Most cases of uterine anomalies can be corrected through minimally invasive techniques, such as laparoscopy or hysteroscopy. In the instance of a unicornuate uterus, and obstructed Hemi-uterus can be removed
if the other side of the uterus is intact and functional. A dividing uterine septum can usually be removed as well to open up the uterus. Women who are at risk for preterm delivery or late pregnancy loss due to a uterine the anomaly may need a stitch to be placed in the cervix (called a cervical cerclage) to prevent premature dilation.
MANAGEMENT •Depend on 1. The presence and severity of menstrual pain, fertility, and sexual function problems. 2. The type of anomaly. The mere presence of an abnormality does not necessitate treatment unless the patient is
symptomatic as a result of it. Sexual function can be affected in a couple of ways.
1.a complete absence of the vagina. In this circumstance, normal intercourse would be impossible and the creation
of a neovagina may be appropriate.
2. In the case of both a transverse and longitudinal septum, a physical barrier may make intercourse difficult, painful, or even impossible Vaginal septum, if the patient is symptomatic, can usually be treated with a simple resection if small. In cases of absence of the vagina: I. If the uterus is present: the creation of the neovagina, with a communication to the cervix II. If these do not exist, or if there is no uterus:
1. Nonsurgical methods should be employed initially (the use of subsequently larger vaginal dilators to stretch the area where the vagina is to be created). Surgical procedures. a. McIndoe: space is dissected between the rectum and the
bladder a split-thickness skin graft from the buttocks is used to form the vagina; dilator at the time of the procedure creates continuous dilation of the vagina while the graft heals. Other procedures: Williams vulva vaginoplasty, It uses full-thickness skin flaps from the labia majora to create a vaginal pouch which axis is directly posterior and horizontal to the perineum; however, the vagina is functional and well received by patients Musculocutaneous flaps and free intestinal grafts. The decision of which approach to take is dictated by the patient’s characteristics and needs.