UTERINE MALFORMATION

1. UTERINE MALFORMATIONS
MERLIN MARY JAMES

2. INTRODUCTION
 It is of vital importance that the organs within the female reproductive system
are of normal anatomy and physiology in order to attain normal pregnancy
and childbirth.
 However, this is not the case for certain women, who are born with anomalies
which may lead to difficulty in conception and childbirth, adding burden on
mother and fetus
 Nonetheless, due to advancement in medicine, there are corrective surgeries
for the same which may enable these women to conceive normally.

3. DEFINITION
 A uterine malformation is the result of an abnormal
development of the Mullerian ducts during
embryogenesis.
 Symptoms range from amenorrhoea, infertility, recurrent
pregnancy loss, and pain, to normal functioning
depending on the nature of the defect.

4. EMBRYOLOGICAL DEVELOPMENT OF UTERUS
 The female genital tract is formed in early embryonic life when a pair of ducts
develops.
 These paramesonephric or mullerian ducts come together in the midline
and fuse into a Y- shaped canal.
 The open upper ends of this structure lead into the peritoneal cavity and the
unfused portions become the uterine tubes.
 The fused lower portion forms the uterovaginal area, which further develops
into the uterus and vagina.

5. INCIDENCE
 The prevalence of uterine malformation is estimated to be 6.7% in the general
population, slightly higher (7.3%) in the infertility population, and
Significantly higher in a population of women with a history of recurrent
miscarriages (16%).

6. AMERICAN FERTILITY SOCIETY CLASSIFICATION
 Class I : Agenesis or hypoplasia: segmental or complete (absent uterus).
 Class II : Unicornuate uterus with or without rudimentary horn (a one-sided
uterus).
 Class III : Didelphys uterus also uterus didelphis (double uterus)
 Class IV : Bicornuate uterus: complete or partial (uterus with two horns)
 Class V : Septate Uterus: complete or partial (uterine septum or partition).
 Class VI : Arcuate uterus: There is a concave dimple in the uterine fundus
within the cavity.
 Class VII : DES-related abnormalities: The uterine cavity has a "T-shape" as
a result of fetal exposure to diethylstilbesterol

8. CLASS I : AGENESIS OR HYPOPLASIA: SEGMENTAL OR COMPLETE (ABSENT
UTERUS).
 Diagnosed at the age of 15 -18
 Assessment and physical examination
 Treatment: Surgical correction-Plastic surgery
 Sexuality and motherhood • Counselling

9. CLASS II : UNICORNUATE UTERUS WITH OR WITHOUT RUDIMENTARY HORN
(A ONE-SIDED UTERUS).
 Types • Communicating contralateral rudimentary horn contains
endometrium (10%) • Non-communicating contralateral rudimentary horn
contains endometrium (22%) • Contralateral horn has no endometrial cavity
(33%) • No horn (35%)
 Treatment • No surgical intervention is required unless endometrial tissue in a
rudimentary horn results in pain or a pelvic mass or unless an incompetent
cervix is suspected during pregnancy. • A rudimentary horn may be excised to
treat endometriosis and prevent an ectopic pregnancy. • Cervical encerclage
may be recommended during pregnancy in women with a history of
miscarriage and/or premature birth or if an incompetent cervix is observed.

10. CLASS III : DIDELPHYS UTERUS ALSO UTERUS DIDELPHIS (DOUBLE
UTERUS)
 Uterus Didelphys, more commonly knows as a double uterus, is a condition where a woman’s
uterus forms differently, creating a double uterus, two separate cervices and sometimes two
vaginas (though not always).
 It’s exact cause is unknown, but it is generally present from birth, though often only becomes
noticeable after puberty.
 Diagnosis is carried out using a physical examination alongside ultrasound scans and 3-D
ultrasounds more recently.
 There is no treatment as such for the condition, but it must be managed, especially during
pregnancy. • Women with this condition will frequently have a slightly higher risk of late
miscarriage, premature delivery and bleeding during pregnancy. • Often birth by Caesarean
section is considered in these circumstances, to lessen the risk of complications.

11. CLASS IV : BICORNUATE UTERUS: COMPLETE OR PARTIAL (UTERUS WITH
TWO HORNS)
 Pregnancies in a bicornuate uterus are usually considered high risk and require extra
monitoring because of association with poor reproduction potential.
 A bicornuate uterus is associated with increased adverse reproductive outcomes, such as:
1. Recurrent pregnancy loss
2. Preterm birth: The rate of preterm delivery is 15 to 25%. • A pregnancy may not reach full
term in a bicornuate uterus when the baby begins to grow in either of the uterine horns. • A
short cervical length seems to be a good predictor of preterm delivery in women with a
bicornuate uterus
3. Malpresentation (breech birth or transverse presentation): a breech presentation occurs in
40-50% of pregnancies with a partial bicornuate uterus and not at all in a complete
bicornuate uterus. • Deformity: Offspring of mothers with a bicornuate uterus are at high risk
for "deformities and disruptions" and "malformations." • Previously, a bicornuate uterus was
thought to be associated with infertility, but recent studies have not confirmed such an
association

12. CLASS V : SEPTATE UTERUS: COMPLETE OR PARTIAL (UTERINE SEPTUM OR
PARTITION).
 A septum can be resected with surgery.
 Hysteroscopic removal of a uterine septum is generally the preferred method, as the
intervention is relatively minor and safe in experienced hands.
 A follow-up imaging study should demonstrate the removal of the septum.
 It is not considered necessary to remove a septum that has not caused problems, especially in
women who are not considering pregnancy.
 There is controversy over whether a septum should be removed prophylactically to reduce
the risk of pregnancy loss prior to a pregnancy or infertility treatment.

13. CLASS VI : ARCUATE UTERUS
 An arcuate uterus is characterized by a mild indentation of the endometrium
at the uterine fundus. It occurs as the result of near complete resorption of
the uterovaginal septum
 Many patients with an arcuate uterus will not experience any reproductive
problems and do not require any surgery. In patients with recurrent pregnancy
loss thought to be caused by an arcuate uterus hysteroscopic resection can be
performed.

14. CLASS VII : DES-RELATED ABNORMALITIES
 The uterine cavity has a "T-shape" as a result of fetal exposure to
diethylstilbesterol
 Reproductive performance : • - Lower conception rates • - Increased incidence
of abortion : due to structural anomalies and cervical incompetence • -
Increased incidence of ectopic pregnancy : due to tubal and uterine anomalies
• - Infertility : due to cervical hypoplasia and atresia

15. COMPLICATIONS OF UTERINE MALFORMATIONS
 Abortion
 Weak uterine action
 Post partum haemorrhage
 Adhesion of the placenta
 Malpresentations
 Prolonged or obstructed labour
 Uterine rupture due to its poor development.
 The placenta, if it is formed on the septum, may be adherent and may cause post
partum haemorrhage.