Surgical Management of Uterine Abnormality

Ulun ULUĞ, M.D.Bahceci Women Health Group, Istanbul, Turkey

Congenital genital abnormalities encompass embrionic maldevelopment of paramesonephric ducts and and urogenital sinüs

Therefore congenital genital abnormalities carry out disorders of internal and external genitalia and sometimes both

Underlying etiologies are genetic, hormonal and usually multifactorial

Mullerian anomalies are usually associated with malformations of kidney and skeleton. They are often diagnosed as late as puberty when menarche does not occur or sexual activity is not possible or even later if infertility is the only symptom.

Uterine anomalies are more common than generally recognized by many practicing clinicians.Prevalence in general population :1 in 201 (0.5%)According to “Acien,” 2-3% of fertile women and 3% of infertile women and 5-10% of those with repeated miscarriages.

• True incidence and prevalence are difficult to assess. Why?

Selection biasDifferent classification systemsLack of standards in acquired diagnostic data

DysparaneuDysmenorheaPelvic massInfertilityPoor obstetric outcome

There are 2 types of classification, which both needs clarification. A new revised standart system is needed

Oppelt et al• Vulvar cervical uterin

adnexal and associated malformations

(VCUAM)

AFS classification

American Fertility Society Classification Mullerian Anomalies

Uterine shape decision during hysteroscopy by different clinicians (Smit et al, 2013)

Distribution

Bicornuate (%) 39

Septate (%) 34

Didelphys (%) 11

Arcuate (%) 7

Unicornuate (%) 4

The presence of a malformed uterus increases obstetric complications:

Spontaneous abortion

First trimester bleeding

Preterm labor

Premature rupture of membrane

Abnormal fetal positioning

Plasental abruption

Fetal growth restriction

Fetal death

(Grimbizis et al.,2001)

Uterine anomalies and pregnancy outcome

• 105 women with uterine anomaly vs 182 women with normal shaped uterus:

• Highest incidence of early spontaneous abortion in septate uterus

• Highest incidence of preterm labor in arcuate and bicornuate uterus

(Zlopasa G. 2007)

tr= trimester, pr= pregnancy(Zlopasa G, 2007)

Pregnancy outcome before and after hysteroscopic treatment of anomaly in 25 women

Outcome Before Treatment

After treatment

1st tr loss 34 (77.3) 18 (34.6) <0.001

2nd tr loss 7 (15.9) 3 (5.8)

Total pr loss 41 (93.2) 21 (40.4) <0.001

Term Deliveries

0 23 (44.2)

Class II Abnormality (Unicornuate Uterus)

Usually on the right sideRudimentary horn are detected in 70% About 50% of rudimentary horns have

endometrial tissuePrimary symptom may be dysmenorrheaAssociated with spontaneous abortion and

preterm delivery

20 studies consisting of 290 women with unicornuate uterus are examinedOccurs in 1:4020 women in general populationMore common in infertile women and in women with repeated poor outcomes

(Reichman et al., 2009)

Main etiologies explaining poor obstetrical outcomes:

Small cavityDiminished myometrium massAbnormal uterine blood flowCervical incompetence

Unicornuate Uterus

(Reichman et al., 2009)

Expectant management

Cervical length measurement

Cervical suturing in selected cases

Remove rudimentary horn if present

Unicornuate UterusManagement

Uterus Didelphys

Non-obstructed failure of lateral fusion involving both uterus and vaginaReproductive outcomes are slightly better than unicornuate uterus

(DeviWold et al., 2006)

Spontaneous abortion rate: 43%Premature birth rate: 38%Fetal survival rate: 54%

Uterus Didelphys

(Propst AM., 2000)

Surgical intervention: Unclear.Surgical metroplasty should be

reserved for selected patients suffering from recurrent pregnancy loss or preterm births.

Uterus Didelphys

(Reichman et al., 2010)

Class IV (Bicornuate Uterus)

Is a result of incomplete fusion of the uterine horns at the level of fundus

Obstetrical outcomes are reported to be better than unicornuate uterus.

(Sinha et al., 2006; Lolis et al., 2005)

Spontaneous abortion 36%

Premature birth 21%

Fetal survival 60%

Bicornuate Uterus

Expectant managementCervical suturing in selected casesMetroplasty ?

Class V (Septate Uterus)

• The most common uterine anomaly is septate uterus with a mean incidence of 35%

(Tulandi et al., 1980; Acien, 1993; Raga et al., 1997; Woelfer et al., 2001, Zlopasa, 2009)

Uterine Septum

Reproductive outcome is poorSpontaneous abortion 26%-94% Premature labor 9%-33%Fetal survival 10%-70%

(Toriano et al., 2004)

Diminished connective and muscular tissues has

been found in septum and it was proposed that uncoordinated contractions and relaxations lead to abortions (Dabirashafi et al).

MRI studies have shown the presence of myometrium in the septum (Arıcı et al).

Septum resection with transervical scissors by Hirsh (1919) Currently this technique employs endoscopic scissors and is performed under

USG. Abdominal metroplasty The first application of hysteroscopic septum resection was by Edstrom in

1974. Currently it is performed with resectoscope,laser, and scissors. Hysteroscopic technique presents all benefits of endoscopy to the patient. The duration of postoperative conception time has decreased to 1 month The necessity of a cesarean section has disappeared with this technique. The cost is very low.

Management:

Obstetric outcome after hysteroscopic metroplasty

(Homer et al., 2000)

Reproductive outcome H/S metroplasty

(Homer et al., 2000)

Grup AN=44

Septa + Unexplained infertility

Group BN=132

Unexplained infertility

Hysteroscopic metroplasty

Ekspectantmanagement

All women were followed-up for 1 year without any intervention

(Mollo et al., 2009)

Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained

infertility: a prospective controlled trial

Pregnancy and live birth rate are significantly higher in patients who had undergone

hysteroscopic metroplasty

(Mollo et al., 2009)

Recurrent abortionsPreterm deliveryInfertility

Those who will have ARTDysmenorrea and dysparunia

When should we operate uterine septum?

Preoperative Danazol,GnRh analogues or progestins decrease operative bleeding and shorten procedure.

However, hormonal therapy thins myometrium and increases the risk of perforation. Operation is suggested immediately after the days of mensturation.

To avoid postop adhesions IUD ,baloon, estrogen administration for 3 months

Postoperative control by office hysteroscopy or HSG Uterus can appear arcuate. Resection of fundus should not be

complete

Pre- and postoperative managements

Wide septum can cause more intraoperative bleeding Peroperative perforation Liquid loading (hyponatremia) Infection Rupture during pregnancy and complications associated with

placenta Intrauterine syneshia (regardless of techniques)

Complications

Class VI (Arcuate Uterus)

The near complete resorption of the uterovaginal septum may lead to a mild concave indentation of the cavity, giving the uterus an arcuate configuration.

Arcuate Uterus

In a retrospective case series of 176 patients 45% early abortion rate was reported (Acien et al).In contrast, another study reported only 13% early miscarriage rate (Raga et al). Pregnancy losses during second trimester have been reported (Zlopasa et al)

The treatment is usually expectant.Reconstructive procedures do not improve pregnancy outcomes.

Arcuate UterusManagement

Conclusion

Uterine anomalies consist of a wide range of defects that may vary from patient to patient. Therefore, their management must also be individual, taking anatomical and clinical points into consideration, as well as the patient's wishes.