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CONGENITAL UTERINE ANOMALIESCAUSE RECURRENT FOETAL WASTAGE FACT OR FICTION
ABHA BHAT*, VD PATKAR, SG ALLAHBADIA**,RAHUL MAYEKAR***, APARNA NENE****
Dept. of Obst and Gynaecology, LTMG Hospital and LTM Medical College, Sion, Mumbai.
Aim : To determine the pregnancy outcome in mullerian anomalies.
Material and Methods : The study was carried out at LTMGH over a period of 5 years. Patients with diagnosed anomalies and anomalies incidentally detected in labour or surgical procedure were included and their pregnancy outcome evaluated.
Results : Forty seven patients were detected to have uterine anomalies. In 12 patients of bicornuate uterus there was one spontaneous abortion. In 10 patients of unicornuate uterus there were 3 abortions, 1 ruptured rudimentary horn. Only 1 patient of didelphys uterus was found and she had spontaneous abortion.
Conclusion : There is an increased incidence of early pregnancy losses in patients with mullerian anomalies. The abortion rate as well as preterm delivery rate was significantly higher (P < 0.001) than the general population.
INTRODUCTION
Congenital uterine anomalies have always been a topic of considerable interest amongst obstetricians and gynaecologists.
Besides being mere anatomic curiosities, pregnancy in these patients may present with unusual and difficult obstetrical problems of which the most significant is recurrent pregnancy wastage. Though infrequent these uterine anomalies have now become sufficiently important to demand the attention of every practising obstetrician.
AIMS AND OBJECTIVES
1.To compare the pregnancy outcome of patients with congenital uterine anomalies.
2.To prove / disprove that mullerian anomalies cause recurrent pregnancy loss.
MATERIAL AND METHODS
A five year retrospective study was conducted from 1995-1999. The inclusion criteria were :
(i) Patients diagnosed to have mullerian anomalies by suitable investigations and
(ii). Patients clinically suspected to have uterine anomalies and confirmed either prenatally / antenatally / intrapartum.
Forty seven patients were thus evaluated and their pregnancy outcome studied.
RESULTS
During the study period, a total of 2,32,457, patients presented in the out-patient department. Fifty six patients with mullerian anomalies were detected (Incidence : 0.024%). Institutional deliveries were 34,065 during the period. Forty seven patients had anomalies which were compatible with pregnancy (Incidence : 0.14%). The other anomalies were 7 cases of Meyer-Rokitansky-Kuster-Hauser syndrome, 1 patient each of Fraser syndrome and cervical canal agenesis.
The most common anomaly was vaginal septum followed by bicornuate uterus whereas didelphys uterus was rarest in this study (Table 1).
Type of anomaliesType of anomaly No. of patients Bicornuate uterus 12 Unicornuate uterus 10 Septate uterus 7 Arcuate uterus 4 Didelphys uterus 1 Vaginal septum 13
The worst pregnancy outcome was in unicornuate uterus with a mere 30% live birth rate. Four patients had abortions, 2 patients had to undergo exploration for ruptured ectopic pregnancy and rudimentary horn and 1 patient with placenta praevia with antepartum haemorrhage had to undergo hysterotomy.
Inspite of the high rate of caesarean sections, patients with bicornuate uterus had a good prognosis as far as live birth rate is concerned. However almost all were incidentally diagnosed to have the anomaly at the time of LSCS.
The only patient of didelphys uterus had a spontaneous abortion. However this figure is too low to comment on the pregnancy outcome in didelphys uterus (Table 2).
Reproductive performance and pregnancy outcomeBicornuate
Unicornuate
Septate
Arcuate
Didelphys
No. of patients 12 10 7 4 1 Abortions 1 4 3 2 1 Preterm vaginal deliveries 1 Full term vaginal deliveries 2 1 Preterm LSCS 2 2 2 1 Full term LSCS 6 2 1 Others 1 Ectopic pregnancy
1 Hysterotomy
1 ruptured rudimentary hornLive birth rate 11 (92%) 3 (30%) 4 (57%) 2 (50%) 0 (0%)
Pregnancy loss in uterine anomalies
The total number of abortions in patients with uterine anomalies was 12. Thus incidence of abortions is 25.53%. Preterm delivery rate was 31.9%.
Four patients in our study had undergone a reconstructive surgery. Of these 1 patient had a spontaneous abortion (abortion rate 25%) (Table 3).
Patients with reconstructive surgeryNo. of patients 4 Abortions 1 Abortion rate 25%
Eleven patients in our study had a history of recurrent pregnancy losses. Of these 5 had a pregnancy wastage in the present pregnancy (foetal wastage : 45.45%) (Table 4).
Patients with recurrent pregnancy lossesNo. of patients 11 Pregnancy losses 5 Foetal wastage 45.45%
DISCUSSION
The true incidence of mullerian anomalies is difficult to determine because most data is derived from retrospective studies of patients presenting with reproductive problems and accurate diagnosis and complete assessment of uterine morphology has not always been performed. Secondly, an analysis of the reproductive performance of the malformed uteri needs to take into account not only those presenting with reproductive failure but also those with normal reproductive outcome. To add to this are the socioeconomic constraints of the class of patients which prevent thorough workup.
Thus the incidence of all mullerian anomalies in our study 0.024% is considerably lower than other studies :
Raga et al [7], .4%
Zanetti et al [8], .6%
Semmons et al [8], .06%
The frequency of different anomalies has been differently quoted in various studies. Most studies have reported bicornuate uterus as the most common. [2 , 4 , 6 , 9 ]However other studies have found arcuate uterus (Zanetti et al, 1978), didelphys uterus [1] and septate uterus [7] as the most common.
Overall spontaneous abortion rate in our institution was 10.53%. In the study group the abortion rate was significantly higher (P < 0.001) at 25.53%. The preterm delivery rate in the study group was 31.9% which was also significantly higher (P < 0.001) than the general population - 8% as calculated from our institutional data.
According to literature, the pregnancy loss has been higher than general population though the rates vary from study to study (Table 5).
Rate of pregnancy lossStudy Spontaneous abortion Preterm delivery Raga et al,7 28% 30% Michalas, et al,4 36% 22% Stein et al,9 14% 25% Heinonen et al,3 29% 23% Our study 25.53% 31.9%
Our spontaneous abortion rate is low as the preclinical abortions remain undetected and since a lot of patients with spontaneous abortions may not present at all or may go to private practitioners or institutions.
Patients with reconstructive surgery have been reported to have a dramatically better pregnancy outcome (Table 6).
Pregnancy loss before and after metroplastyStudy Before metroplasty After metroplasty Kessler et al, 1985 65.4% 14.2% Musich et al,5 53% 4%
A large proportion of the patients (23.4%) in our study group were already known cases of bad obstetric history. This agrees with the study of Stein et al, [9] who found the incidence of BOH in patients with uterine anomaly was 23% which is very high as compared to the general population which is 0.005-0.01%. The pregnancy loss in such patients has been reported to be significantly higher at 62% by Ben Rafael et al. [6]
CONCLUSIONREFERENCES
- The incidence of uterine anomalies is underreported since mullerian defects can permit an absolutely normal obstetric outcome and so many remain undiagnosed.
- There is an increased incidence of early pregnancy losses in patients with mullerian anomalies.
- Bicornuate uterus has the best pregnancy outcome along with a high caesarean rate and almost 50% continue the pregnancy till term.
1.Fenton AN, Singh BP. Pregnancy associated with congenital abnormalities of female reproductive tract. Am J Obstet and Gynecology April, 1952; 63 (4) : 744-8.
2.Green MK, Harris RE. Uterine anomalies - Frequency of diagnosis and associated obstetrical complications. Obstet and Gynecol April, 1976; 47 (4) : 427-9.
3.Heinonen PK. Clinical implications of unicornuate uterus with rudimentary horn. Int J Gynecol Obstet 1983; 21 : 145-50.
4.Michalas SP. Outcome of pregnancy in females with uterine malformations. Int J Gynecol Obstet 1991; 35 : 215-9.
5.Musich JR, Behrman SJ. Obstetric outcome before and after metroplasty in females with uterine anomalies. Obstet and Gynecol July, 1978; 52 (1) : 63-5.
6.Rafael ZB, Seidman DS, Recabi K, Bider D. Journal of Reproductive Medicine October, 1991; 36 (10) : 723-6.
7.Raga F, Bausel C, Remohi J. Reproductive impact of congenital mullerian anomalies. Human Reproduction 1997; 12 (10) : 2277-81.
8.Semmens et al. Genital tract anomalies : Obstet and Gynecol March, 1962; 19 (3) : 330-44.
9.Stein AL, March CM. Pregnancy outcome in females with mullerian duct anomalies. Journal of Reproductive Medicine April, 1999; 35 (4) : 411-4.
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