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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 13  |  Page : 40-42

Subseptate uterus causing recurrent miscarriage


1 Department of Radiology, Federal Medical Centre, Owerri, Nigeria
2 Department of Obstetrics and Gynaecology, Imo State University Teaching Hospital, Orlu, Imo, Nigeria

Date of Web Publication19-Feb-2019

Correspondence Address:
Chijioke Okeudo
Department of Obstetrics and Gynaecology, Imo State University Teaching Hospital, Orlu, Imo
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nnjcr.nnjcr_2_18

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  Abstract 


Subseptate uterus is a variety of congenital uterine malformations that can result in recurrent pregnancy wastages. A high index of suspicion with the application of radiological imaging by experienced personnel will go a long way in achieving the early diagnosis of this uncommon condition. This was a case of 29-year-old Para 0+4 who presented with recurrent miscarriages and was diagnosed of having subseptate uterus using histerosalpingogram, but she declined corrective surgery.

Keywords: Incidental finding, recurrent miscarriage, subseptate uterus


How to cite this article:
Moemenam OO, Okeudo C. Subseptate uterus causing recurrent miscarriage. N Niger J Clin Res 2019;8:40-2

How to cite this URL:
Moemenam OO, Okeudo C. Subseptate uterus causing recurrent miscarriage. N Niger J Clin Res [serial online] 2019 [cited 2020 Aug 15];8:40-2. Available from: http://www.mdcan-uath.org/text.asp?2019/8/13/40/252581




  Introduction Top


Abnormal fusion of Mullerian (paramesonephric) duct during embryonic life results in a variety of congenital uterine malformations. The prevalence of these anomalies ranges from 0.001% to 10% in the general population and from 8% to 10% in women with an adverse reproductive history.[1] The most common Mullerian duct anomalies include subseptate uterus, bicornuate uterus, unicornuate uterus, and uterus didelphys.[2]

The anomalies are usually asymptomatic and are often discovered during pregnancy, at the time of miscarriage or during evaluation for infertility. In general, complications such as preterm delivery and first trimester miscarriages have been found to be higher in women with congenital uterine malformations.[3]

We hereby present a case of subseptate uterus a rare cause of recurrent miscarriage that was discovered at hysterosalpingography (HSG).


  Case Report Top


Mrs. CN was a 29-year-old Para 0+4 referred to the Radiology Department of Federal Medical Centre, Owerri, for HSG as a routine investigation for recurrent spontaneous miscarriages. She presented with a history of recurrent pregnancy loses over a 3 years' period. She has been married for 3 years and has had recurrent spontaneous miscarriages at about the 10th–12th week of gestation, for four consecutive times. The last episode was 2 months before presentation. There was no history of ingestion of any medications apart from routine drugs given to her during antenatal visits. There was no history of fever, abnormal vaginal discharge, or trauma during pregnancy. She was rhesus positive, and her hemoglobin genotype was AA. Her age at menarche was 14 years, and she has been having regular 28-day cycle with 4 days of normal menstrual flow.

For this complaint, she had visited various private hospitals where laboratory investigations carried out were all normal. She also had a series of pelvic ultrasound scans (USSs) done at different private diagnostic centers and hospitals that were reported as normal findings. She never had HSG done out of fear for the procedure. Family history was not contributory.

Physical examination findings were normal.

HSG revealed partially divided uterine cavity with intercornual angle of 65°. Bilateral-free peritoneal spillage was noted, although only the right tube was demonstrated [Figure 1]. Abdominopelvic USS showed the uterus with two separate endometrial stripes [Figure 2]. No adnexal masses were noted, and other intra-abdominal organs were normal. The provisional diagnosis of the septate uterus with a differential diagnosis of bicornuate uterus was made for which magnetic resonance imaging (MRI) of the uterus was requested for to confirm the diagnosis. Coronal T2-weighted MRI of the uterus showed the two horns of the uterine cavity, separated by a septum that does not reach the cervical canal. The fundal contour was slightly indented with a cleft depth of 8 mm and intercornual distance of 36 mm [Figure 3]. A diagnosis of subseptate uterus was made. The patient was offered surgery to correct the anomaly, but she declined it for no obvious reasons.
Figure 1: Hysterosalpingogram demonstrating each half of the uterine cavity, which inclines away from each other, making an angle of 65° (long arrows). There is intraperitoneal spillage of contrast (short arrows)

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Figure 2: Transverse sonogram of the uterus demonstrating two separate endometrial stripes (long arrows)

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Figure 3: T2-weighted coronal magnetic resonance imaging of the uterus demonstrating the two horns of the uterine cavity (thin arrows), separated by an incomplete septum (thicker arrow)

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  Discussion Top


A septate uterus is a form of a congenital malformation where the uterine cavity is partitioned by a longitudinal septum.[4] The wedge-like partition may involve only the superior part of the cavity resulting in an incomplete septum or subseptate uterus, or less frequently the total length of the cavity (complete septum) and the cervix resulting in a double cervix. A subseptate variety was found in the index patient. The septation may also continue caudally into the vagina resulting in the double vagina.[4] Septate uterus is the most common Mullerian duct anomaly constituting about 55% of cases.[5]

The majority of the Mullerian duct anomalies occur sporadically or occurrence may be multifactorial in nature.[6] Extrauterine and intrauterine environmental factors such as hypoxia that occur during pregnancy, the use of medications such as methotrexate, thalidomide or diethylstilbestrol, ionizing radiation, and intrauterine viral infections may also contribute towards the occurrence of Mullerian duct anomalies.[6] The index patient had no history of association with these factors.

While the majority of women with Mullerian duct anomalies have little difficulty conceiving, they have higher rates of spontaneous abortion,[7] as was noted in this patient. They are also associated with premature delivery, abnormal fetal lie, and dystocia at delivery.[7] This patient had not experienced the above other complications as she had never had her pregnancy beyond 12 weeks.

Most studies have reported an approximate frequency of 25% for associated reproductive problems in women with Mullerian duct anomalies compared with 10% in the general population.[7]

This condition was discovered in the index patient while being investigated for recurrent miscarriages. Hence, though septate uterus may be a rare condition, there should be a high index of suspicion in a patient presenting with recurrent miscarriage and investigations geared toward that to arrive at the diagnosis as soon as possible.

Imaging modalities that are useful in the diagnosis of Mullerian duct anomalies (septate uterus) are US, HSG, and MRI. The accuracy of HSG alone is 75% for differentiation of septate uterus from bicornuate uterus.[8] On HSG, an angle of <75° between the horns of the endometrial cavity is suggestive of the septate uterus.[9] The intercornual angle of the index patient was 65°. An angle of more than 105° is more consistent with bicornuate uterus.

On ultrasound, depressed uterine fundal contour, divergence of the uterine horns and associated echogenic endometrial stripes may be seen when viewed by transvaginal US.[10] A uterine septum which appears as a convex, hypoechoic fibrous tissue may be seen dividing the uterine cavity distally. Transabdominal US image was not clear enough to demonstrate these findings in this patient and only showed the uterus with two separate endometrial stripes. If the patient had not rejected the transvaginal USS perhaps, the diagnosis may have been made by ultrasound. The pelvic US scans done by the patient at different private diagnostic centers and hospitals were reported as normal, probably due to lack of experience of the operators.

MRI is still the gold standard for imaging uterine anomalies. Most types of uterine anomalies can be diagnosed confidently using pelvic MRI. The distinction between septate uterus and bicornuate uterus has important management implications.

The present patient was offered surgery, but she declined it for no obvious reasons.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pui MH. Imaging diagnosis of congenital uterine malformation. Comput Med Imaging Graph 2004;28:425-33.  Back to cited text no. 1
    
2.
Abdullahi M, Aliyu L. Bicornuate uterus mimicking ectopic pregnancy – A case report. J West Afr Coll Surg 2012;2:84-90.  Back to cited text no. 2
    
3.
Lin PC. Reproductive outcomes in women with uterine anomalies. J Womens Health (Larchmt) 2004;13:33-9.  Back to cited text no. 3
    
4.
Adesiyun AG, Avidime S, Umar H, Akafa R, Aliyu R. Term pregnancy in a patient with septate uterus: Incidental finding at caesarean section. Case Rep Clin Med 2014;3:114-7.  Back to cited text no. 4
    
5.
Moghadam AH, Jozi Z, Dahaz S, Nejad DB. Septate uterus as congenital uterine anomaly: A case report. Repod Syst Sex Disord 2014;3:141-2.  Back to cited text no. 5
    
6.
Ribeiro SC, Tormena RA, Peterson TV, Gonzáles Mde O, Serrano PG, Almeida JA, et al. Müllerian duct anomalies: Review of current management. Sao Paulo Med J 2009;127:92-6.  Back to cited text no. 6
    
7.
Ansbacher R. Uterine anomalies and future pregnancies. Clin Perinatol 1983;10:295-304.  Back to cited text no. 7
    
8.
Dewan K, Hefeda M, ElKholy DG. Septate or bicornuate uterus: Accuracy of three-dimensional trans-vaginal ultrasonography and pelvic magnetic resonance imaging. Egypt J Radiol Nucl Med 2014;45:987-95.  Back to cited text no. 8
    
9.
Atobatele MO, Oyinloye OI, Akande HJ. Poor obstetric outcome in an undiagnosed sub-septate uterus. Sub Saharan Afr J Med 2015;2:184-6.  Back to cited text no. 9
    
10.
Saleem SN. MR imaging diagnosis of uterovaginal anomalies: Current state of the art. Radiographics 2003;23:e13.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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