Peripartal management of dichorial twin pregnancy in a bicornuate bicollis uterus: a case report and review of the literature.

INTRODUCTION: The management of a pregnancy in a bicornuate uterus is particularly challenging. A bicornuate uterus is a rare occurrence and a twin pregnancy in a bicornuate uterus even more rare. These pregnancies call for intensive diagnostic investigation and interdisciplinary care. CASE PRESENTATION: We report on a 27-year-old European woman patient (gravida I, para 0) with a simultaneous pregnancy in each cavity of a bicornuate bicollis uterus after embryo transfer. The condition was confirmed by hysteroscopy and laparoscopy. Several unsuccessful in vitro fertilization (IVF) attempts had been performed earlier before embryo transfer in each cornus. After a physiological course of pregnancy with differential screening at 12 + 6 weeks and 22 + 0 weeks of gestation, the patient presented with therapy-resistant contractions at 27 + 2 weeks. This culminated in the uncomplicated spontaneous delivery of the leading fetus and delayed spontaneous delivery of the second fetus. DISCUSSION: Only 16 cases of twin pregnancy in a bicornuate unicollis uterus have been reported worldwide and only 6 in a bicornuate bicollis uterus. The principal risks in such pregnancies are preterm labor, intrauterine growth restriction, malpresentation and preeclampsia. These typical risk factors of a twin pregnancy are greatly potentiated in the above mentioned setting. CONCLUSION: A twin pregnancy in the presence of a uterine malformation is rare and difficult to manage. These rare cases must be collected and reported in order to work out algorithms of monitoring and therapy as well as issue appropriate recommendations for their management.

Accessory and cavitated uterine masses: a case series and review of the literature.

Objectives: The purpose of this study is to report nine patients of young women who underwent a surgical treatment of an accessory and cavitated uterine mass (ACUM) in our hospital between 2014 and 2022 and review all cases described in the literature. Material and methods: The principal outcomes measured are the imaging techniques used to determine the diagnosis, the type of surgery used and the post-operative evolution of symptoms. We also report and analyse the 79 patients found in the literature since 1996 in addition to our 9 patients. Results: Surgical excision is the only long-lasting treatment. Small invasive surgery with laparoscopic access is the gold standard and most widely used (83.0%). Some new therapeutic procedures have been recently described of which ethanol sclerotherapy seems very promising. Post-operatively, 54.5% of patients have a complete relief of symptoms. MRI is the best imaging technique to identify ACUM. Finally, we refine the description of this pathology and give a more precise definition of it. Conclusion: Through our literature review and the analysis of our cases, we want to underline an important diagnostic criterion of this pathology: the fallopian tube on the homolateral side of the ACUM never communicates with the latter. It is a capital element for differential diagnosis.

Robotic-assisted laparoscopic cervicouterine anastomosis in a patient with agenesis of the uterine isthmus.

OBJECTIVE: To demonstrate the surgical management of agenesis of the uterine isthmus. DESIGN: Stepwise description of robotic-assisted laparoscopic cervicouterine anastomosis. SETTING: Academic medical center. PATIENT(S): A 27-year-old nulligravida with primary amenorrhea and cyclic pelvic pain. INTERVENTION(S): The patient underwent a robot-assisted cervicouterine anastomosis using the following surgical steps: adhesiolysis of the right ovary from the rudimentary uterine horn; vesicouterine peritoneal fold dissection and mobilization of the cervical canal; the opening of the cervical canal and dilatation with Hegar dilators; longitudinal incision of the lower third of the anterior uterine wall up to the endometrial cavity; insertion of a 14 Ch Foley catheter, not inflated, fixed to the cervix with a suture and removed after 7 days; and closure of the cervicouterine breach with a double-layer Vicryl suture. Informed consent was obtained from the patient for the use of video and images. MAIN OUTCOME MEASURE(S): After 3 months, the patency of the anastomosis site was assessed via hysteroscopy. Subsequent follow-up was performed by referring physicians. RESULT(S): Postoperatively, anatomic continuity was restored and the patient was menstruating with regular monthly cycles; furthermore, cyclic pelvic pain was relieved. Few cases of this condition have been reported in the literature and, currently, surgical treatment of agenesis of the uterine isthmus is controversial, with some treatments including laparoscopic-assisted uterocervical anastomosis using a stent to prevent restenosis, primary cervicouterine anastomosis by laparotomy performed with a Foley catheter in the cervical canal, and anastomosis of the uterine isthmus agenesis. However, to our knowledge, we are the first to use a robotic approach. Preservation of reproductive function and symptom relief represent the goals of the surgery. Therefore, hysterectomy cannot be considered as a treatment option. However, after a cervicouterine anastomosis procedure, the normal uterine morphology cannot be achieved; cyclic abdominal pain may remain after surgical treatment. In this case, an alternative surgical approach, such as hysterectomy, can be considered. CONCLUSION(S): Robotic-assisted treatment of this uncommon müllerian anomaly is feasible and may be an alternative to hysterectomy in individuals who wish to preserve fertility. Follow-up is needed to evaluate fertility and reproductive function.

Diagnóstico de malformación uterina en una paciente de 10 años con piometra. A propósito de un caso / Diagnosis of uterine malformation in a ten-year-old patient. Case report

Las malformaciones uterinas congénitas son poco frecuentes. El útero bicorporal tiene una prevalencia del 0,4%. Generalmente asintomático, se puede manifestar como dolor pélvico por un hematometra o menstruación retrógrada de un cuerno uterino no comunicante. Se presenta el caso de una niña de 10 años a quien, en el contexto de dolor abdominal y fiebre, se le realizaron pruebas de imagen y en quien se objetivó un útero bicorporal ocupado por lo que parecía un hematometra. Se intervino a la paciente para drenarlo, por vía histeroscópica y laparoscópica, y se comprobó que se trataba de un piometra. Se realizó hemihisterectomía, sin incidencias, con el fin de preservar su fertilidad y resolver el cuadro infeccioso.(AU)

Congenital uterine malformations are rare. The bicorporal uterus has a prevalence of 0.4%. Generally asymptomatic, it can manifest as pelvic pain from a haematometra or retrograde menstruation from a non-communicating uterine horn. The case of a 10-year-old girl is presented who, in the context of abdominal pain and fever, underwent imaging tests revealing a bicornuate uterus occupied by what appeared to be a haematometra. The patient was operated on to drain it, hysteroscopically and laparoscopically, confirming that it was a pyometra. Hemihysterectomy was performed without incident to preserve fertility and resolve the infection.(AU)

The Rule of 10: a simple 3D ultrasonographic method for the diagnosis of T-shaped uterus.

PURPOSE: To investigate and propose a new simple tridimensional (3D) ultrasonographic method to diagnose a T-shaped uterus (Class U1a). METHODS: A multicenter non-experimental case-control diagnostic accuracy study was conducted between January 2018 and December 2019, including 50 women (cases) diagnosed with T-shaped uterus (U1a class) and 50 women with a "normal uterus" (controls). All the enrolled women underwent 3D ultrasound, drawing four lines and recording the length of three of them as follow: draw and measure the interostial line (R0); draw from the midpoint of R0 a perpendicular line length 20 mm; draw and measure in the uterine cavity a line parallel to R0 at 10 mm below R0 (R10) and a second line parallel to R0 at 20 mm below R0 (R20). The diagnostic performance of all sonographic parameters statistically significantly different between T-shaped and normal uteri was estimated using the receiver operator characteristic (ROC) curve analysis. RESULTS: R10 and R20 were statistically significantly shorter in the T-shaped than the normal uterus. R10 reported the highest diagnostic accuracy with an area under the ROC curve of 0.973 (95% CI 0.940-1.000). R10 length maximizing the Youden's J statistic was 10.5 mm. Assuming R10 length equal to or shorter than 10 mm as the cut off value for defining a woman as having a T-shaped uterus, the new ultrasonographic method following the proposed protocol (R0, R10, and R20) reported sensitivity for T-shaped uterus of 91.1% (95% CI 0.78-0.97%) and a specificity of 100% (95% CI 0.89-100%). The positive likelihood ratio was higher than 30, and the negative likelihood ratio was 0.09 (95% CI 0.04-0.26). CONCLUSIONS: Measuring the length of the intracavitary line parallel to the interostial line at 10 mm from it and using a length ≤ of 10 mm as cut off value (the "Rule of 10") appears a simple and accurate 3D ultrasonographic method for the diagnosis of a T-shaped uterus.

Comparison of Virtual Ultrasonographic Hysteroscopy with Conventional Hysteroscopy in the Workup of Patients Who Are Infertile.

STUDY OBJECTIVE: To compare the tolerability and diagnostic accuracy of virtual ultrasonographic hysteroscopy (VUH) with that of conventional diagnostic outpatient hysteroscopy in the workup of patients who are infertile. DESIGN: A single-center, retrospective cohort study. SETTING: Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery Unit of Sacred Heart Hospital Don Calabria in Negrar, Italy. PATIENTS: A total of 120 consecutive women who underwent hysterosalpingosonography and subsequent VUH and conventional hysteroscopy for infertility evaluation were included. The inclusion criterion was infertility for at least 1 year, with evaluation in the early or intermediate follicular phase of the menstrual cycle. INTERVENTIONS: After the placement of an intracervical catheter, a Ringer Lactate solution was injected into the uterine cavity and fallopian tubes, and a 3D volume was obtained. The ultrasound volume acquired was successively elaborated offline, and a VUH was performed. Subsequently, a variable amount of air was introduced into the uterine cavity, and the patency of the salpinges was evaluated. MEASUREMENTS AND MAIN RESULTS: The VUH findings were compared with those of conventional hysteroscopy performed in the subsequent month. For the detection of endometrial pathology in the overall pool, the sensitivity and specificity of VUH in comparison with conventional hysteroscopy were 100% (95% confidence interval [CI], 84.6%-100%) and 100% (95% CI, 96.3%-100%), respectively. For the detection of uterine cavity pathology and uterine malformations in the overall pool, the sensitivities of VUH were 80% (95% CI, 28.4%-99.5%) and 100% (95% CI, 75.3%-100%), respectively, with specificities of 100% (95% CI, 96.8%-100%) and 100% (95% CI, 96.6%-100%), respectively, when compared with conventional hysteroscopy. The positive predictive values for endometrial pathology, uterine cavity alterations, and uterine malformations were 100% (95% CI, 84.6%-100%), 100% (95% CI, 39.8%-100%), and 100% (95% CI, 75.3%-100%), respectively, with a receiver operating characteristic area of 100%, 90% (95% CI, 70%-100%), and 100%, respectively. There were no cases of severe vasovagal reactions or other complications. Most patients (67%, 81 of 120 women) described the examination as "less painful than expected," 25% (30 of 120 women) "just as expected," and only 7% (9 of 120 women) as "more painful than expected." CONCLUSION: VUH was well tolerated and showed a high accuracy (100%) in the study of the uterine cavity when compared with conventional hysteroscopy.

Uterine factor in recurrent pregnancy loss.

OBJECTIVE: To review the current understanding of the role the uterus plays in recurrent pregnancy loss. FINDINGS: Congenital and acquired uterine abnormalities are associated with recurrent pregnancy loss in the first and second trimester. Relevant congenital Mullerian tract anomalies include unicornuate, didelphys, bicornuate and septate uteri. Pregnancy loss has also been associated with acquired uterine abnormalities that distort the uterine cavity such as intrauterine adhesions and submucosal myomas. Initial evaluation of women with recurrent pregnancy loss should include a uterine assessment such as a pelvic ultrasound or sonohysterography. Uterine abnormalities such as uterine septum, intrauterine adhesions and submucosal myomas may be managed surgically with operative hysteroscopy. CONCLUSION: Uterine abnormalities, both congenital and acquired, can be responsible for recurrent pregnancy loss.

Undescended ovary and fallopian tube presenting as appendiceal mucocele.

Undescended ovary is a rare congenital gynecologic condition, frequently associated with urogenital malformations including unicornuate uterus and ectopic kidneys or renal agenesis. Although ectopic ovaries are mostly found during an infertility work up, its role in infertility is still unknown. We report a 38-year-old patient presenting with pain in the right lower quadrant. Explorative laparoscopy reveals a unicornuate uterus and a malpositioning of the right ovary and distal ending of the right fallopian tube. Through this report, we try to provide hints for guiding the diagnostic management of similar patients in terms of fertility, renal function and tumour formation.

A discussion of diagnostic value and diagnostic indicator in distinguishing arcuate uterus from septate uterus by three dimensional sonography / 中华医学超声杂志（电子版）

Objective To discuss the accuracy of three-dimensional (3D) sonography in diagnosing arcuate uterus and septate uterus and propose a quantitative indicator in distinguishing arcuate uterus and septate uterus.Methods Ninety-six patients with suspected congenital uterine malformation underwent 3D sonography to assess uterine anomalies at Obstetrics and Gynecology Hospital of Fudan University from August 2011 to March 2013.Uterine coronal section was reconstructed and measured in onmi view imaging mode of 3D sonography.Then qualitative diagnosis and categorization was done.The results were compared with diagnosis of hysteroscopy,hysteroscopy combined with laparoscope to determine the sensitivity,specificity,positive predictive values,negative predictive values and total accuracy of 3D sonography in diagnosing arcuate uterus,partial and complete septate uterus respectively.The variable was created in coronal section of uterus constructed through 3D imaging mode to differentiate arcuate uterus from septate uterus.Results There were 33 cases (34.4％,33/96) of arcuate uterus,54 cases (56.2％,54/96) of partial septate uterus and 9 cases (9.4％,9/96) of complete uterus in 96 cases diagnosed by 3D sonography.The accuracy of 3D sonography in diagnosing arcuate uterus and septate uterus was 86.5％.We concluded that 3D sonography had 100％ sensitivity,82.9％ specificity,60.6％ positive predictive value and 100％negative predictive value in the diagnosis of arcuate uterus.The sensitivity of 3D sonography for diagnosis of partial septate uterus was 80.6％,the specificity was 100％,the positive predictive value was 100％,and the negative predictive value was 69.1％.The sensitivity,specificity,positive and negative predictive values of 3D sonography for detecting complete septate uterus were all 100％.The ratio of depth of uterine internal indentation and depth from uterine fundus to the top of intemal indentation was more than 50％ for septate uterus,while less than 50％ for most of the arcuate uterus.Conclusions The diagnostic efficiency of 3D sonography in specific uterine malformation is different.The new quantitative indicator maybe helpful in improving the accuracy of 3D sonography in diagnosing arcuate uterus and septate uterus.

Congenital renal anomalies in cloacal exstrophy: Is there a difference?

INTRODUCTION: Cloacal exstrophy (CE) is the most severe manifestation of the epispadias-exstrophy spectrum. Previous studies have indicated an increased rate of renal anomalies in children with classic bladder exstrophy (CBE). Given the increased severity of the CE defect, it was hypothesized that there would be an even greater incidence among these children. OBJECTIVE: The primary objective was to characterize renal anatomy in CE patients. Two secondary objectives were to compare these renal anatomic findings in male and female patients, and female patients with and without Müllerian anomalies. STUDY DESIGN: An Institutional Review Board-approved retrospective review of 75 patients from an institutional exstrophy database. Data points included: age at analysis, sex, and renal and Müllerian anatomy. Abnormal renal anatomy was defined as a solitary kidney, malrotation, renal ectopia, congenital cysts, duplication, and/or proven obstruction. Abnormal Müllerian anatomy was defined as uterine or vaginal duplication, obstruction, and/or absence. RESULTS: The Summary Table presents demographic data and renal anomalies. Males were more likely to have renal anomalies. Müllerian anomalies were present in 65.7% of female patients. Girls with abnormal Müllerian anatomy were 10 times more likely to have renal anomalies than those with normal Müllerian anatomy (95% CI 1.1-91.4, P = 0.027). DISCUSSION: Patients with CE had a much higher rate of renal anomalies than that reported for CBE. Males and females with Müllerian anomalies were at greater risk than females with normal uterine structures. Mesonephric and Müllerian duct interaction is required for uterine structures to develop normally. It has been proposed that women with both Müllerian and renal anomalies be classified separately from other uterine malformations on an embryonic basis. In these patients, an absent or dysfunctional mesonephric duct has been implicated as potentially causal. This provided an embryonic explanation for uterine anomalies in female CE patients. There were also clinical implications. Women with renal agenesis and uterine anomalies were more likely to have endometriosis than those with isolated uterine anomalies, but were also more likely to have successful pregnancies. Males may have had an analogous condition with renal agenesis and seminal vesicle cysts. Future research into long-term kidney function in this population, uterine function, and possible male sexual duct malformation is warranted. CONCLUSION: Congenital renal anomalies occurred frequently in children with CE. They were more common in boys than in girls. Girls with abnormal Müllerian anatomy were more likely to have anomalous renal development. Mesonephric duct dysfunction may be embyologically responsible for both renal and Müllerian maldevelopment.

The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies.

STUDY QUESTION: What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system? SUMMARY ANSWER: The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented. WHAT IS KNOWN ALREADY: Accurate diagnosis of congenital anomalies still remains a clinical challenge because of the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes. STUDY DESIGN, SIZE, DURATION: The ESHRE/ESGE CONgenital UTerine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital anomalies. The CONUTA working group and imaging experts in the field have been appointed to run the project. PARTICIPANTS/MATERIALS, SETTING, METHODS: The consensus is developed based on: (i) evaluation of the currently available diagnostic methods and, more specifically, of their characteristics with the use of the experts panel consensus method and of their diagnostic accuracy by performing a systematic review of evidence and (ii) consensus for the definition of where and how to measure uterine wall thickness and the recommendations for the diagnostic work-up of female genital anomalies, based on the results of the previous evaluation procedure, with the use of the experts panel consensus method. MAIN RESULTS AND THE ROLE OF CHANCE: Uterine wall thickness is defined as the distance between the interostial line and external uterine profile at the midcoronal plane of the uterus; alternatively, if a coronal plane is not available, the mean anterior and posterior uterine wall thickness at the longitudinal plane could be used. Gynecological examination and two-dimensional ultrasound (2D US) are recommended for the evaluation of asymptomatic women. Three-dimensional (3D) US is recommended for the diagnosis of female genital anomalies in 'symptomatic' patients belonging to high risk groups for the presence of a female genital anomaly and in any asymptomatic woman suspected to have an anomaly from routine evaluation. Magnetic resonance imaging (MRI) and endoscopic evaluation are recommended for the subgroup of patients with suspected complex anomalies or in diagnostic dilemmas. Adolescents with symptoms suggestive for the presence of a female genital anomaly should be thoroughly evaluated with 2D US, 3D US, MRI and endoscopically. LIMITATIONS, REASONS FOR CAUTION: The various diagnostic methods should always be used in the proper way and evaluated by experts to avoid mis-, over- and underdiagnosis. WIDER IMPLICATIONS OF THE FINDINGS: The role of a combined US examination and outpatient hysteroscopy should be prospectively evaluated. It is a challenge for further research, based on diagnosis, to objectively evaluate the clinical consequences related to various degrees of uterine deformity. STUDY FUNDING/COMPETING INTERESTS: None.

Relevant factors analysis of hysterosalpingography countercurrent / 实用放射学杂志

Objective To study on the factors of countercurrent occured in hysterosalpingography to improve the understanding of countercurrent.Methods 180 patients who underwent hysterosalpingography due to infertility were recruited,and 63 of them who were involved in countercurrent in the process of hysterosalpingography were analyzed statistically.Results The single factor analy-sis demonstrated that such four factors of primary/secondary infertility,menstrual clean days,tubal obstruction or not,and depth of cannula were associated with countercurrent,while Logistic regression analysis indicated that the factors of menstrual clean days, tubal obstruction or not,and depth of cannula during the hysterosalpingography operation were closely related.Conclusion Counter-current are caused by the comprehensive impact of several comprehensive factors like menstrual clean day,tubal obstruction or not, and cannula operation.Therefore adequate preparation should be made before and during the operation,to reduce the occurrences of countercurrent.

[Uterine anomalies in women with recurrent pregnancy loss]. / A méhüreg anatómiai rendellenességei habituális vetélokben.

INTRODUCTION: One percent of couples trying to have children are affected by recurrent miscarriage. These pregnancy losses have different pathogenetic (genetic, endocrine, anatomic, immunologic, microbiologic, haematologic and andrologic) backgrounds, but recurrent miscarriage remains unexplained in more than half of the affected couples. AIM: To explore risk factors for recurrent pregnancy loss the authors studied the incidence of anatomic disorders of the uterine cavity occur in Hungarian women with recurrent miscarriage. METHOD: Medical records of 152 patients with recurrent miscarriage were analyzed retrospectively. In order to explore disorders of the uterine cavity hysteroscopy or 3-dimensional sonography in 132 women, hysterosalpingography in 16 and hysterosalpingo-sonography in 4 patients were used. RESULTS: Incidence of anomalies in the uterine cavity was found in women with recurrent miscarriage to be 15.8%. A variety of the uterine anomalies was found including uterine septum in 6.5%, endometrial polyp in 2.6%, arcuate and bicornuate uteri both in 2% and 2%, submucosal myoma in 1.3 %, and intrauterine synechiae in 1.3%. CONCLUSIONS: These findings suggest that morphologic disorder of the uterine cavity is frequent in Hungarian women with recurrent miscarriage. Therefore, assessment of the uterine anatomy is recommended in such patients.

Diagnóstico ecográfico de embarazo en útero doble / Ultrasound Diagnosis of Pregnancy in Double Uterus

El útero doble es una malformación congénita, resultado de un desarrollo anormal de los conductos müllerianos durante la embriogénesis, presentándose de manera asintomática en la mayoría de las pacientes, aunque se puede asociar a trastornos de fertilidad y complicaciones obstétricas en la etapa reproductiva, tales como amenaza de aborto y abortos, parto pretérmino, anomalías de posición fetal y otras. Se presenta el caso de una paciente que acude al cuerpo de guardia de ginecología refiriendo dolor en hipogastrio de 6 h de evolución acompañado de sangramiento genital con falta de menstruación de 9 a 10 semanas, en la que el examen clínico hace sospechar una amenaza de aborto con mioma uterino; pero, al realizar ecografía ginecológica abdominal, se constata la presencia de dos úteros, uno de estos con embarazo normal de 11 semanas(AU)

Double uterus is a congenital malformation resulting from abnormal development of Mullerian ducts during embryogenesis. It is asymptomatic in most patients, although it may be associated with fertility disorders and reproductive obstetric complications such as abortion and abortion threat, preterm delivery, fetal stage position anomalies, and others. It is presented here the case of a patient who comes to gynecological emergency referring pain in lower abdomen for 6 hours and genital bleeding with lack of menstruation for 9-10 weeks. Clinical examination raises suspicion of abortion threatening with uterine fibroids; but, when performing gynecological abdominal ultrasound, the presence of two uteri is observed, one of these with normal pregnancy of 11 weeks(AU)

Diagnóstico ecográfico de embarazo en útero doble / Ultrasound Diagnosis of Pregnancy in Double Uterus

El útero doble es una malformación congénita, resultado de un desarrollo anormal de los conductos müllerianos durante la embriogénesis, presentándose de manera asintomática en la mayoría de las pacientes, aunque se puede asociar a trastornos de fertilidad y complicaciones obstétricas en la etapa reproductiva, tales como amenaza de aborto y abortos, parto pretérmino, anomalías de posición fetal y otras. Se presenta el caso de una paciente que acude al cuerpo de guardia de ginecología refiriendo dolor en hipogastrio de 6 h de evolución acompañado de sangramiento genital con falta de menstruación de 9 a 10 semanas, en la que el examen clínico hace sospechar una amenaza de aborto con mioma uterino; pero, al realizar ecografía ginecológica abdominal, se constata la presencia de dos úteros, uno de estos con embarazo normal de 11 semanas.

Double uterus is a congenital malformation resulting from abnormal development of Mullerian ducts during embryogenesis. It is asymptomatic in most patients, although it may be associated with fertility disorders and reproductive obstetric complications such as abortion and abortion threat, preterm delivery, fetal stage position anomalies, and others. It is presented here the case of a patient who comes to gynecological emergency referring pain in lower abdomen for 6 hours and genital bleeding with lack of menstruation for 9-10 weeks. Clinical examination raises suspicion of abortion threatening with uterine fibroids; but, when performing gynecological abdominal ultrasound, the presence of two uteri is observed, one of these with normal pregnancy of 11 weeks.

Accuracy of three-dimensional ultrasound compared with magnetic resonance imaging in diagnosis of Müllerian duct anomalies using ESHRE-ESGE consensus on the classification of congenital anomalies of the female genital tract.

OBJECTIVE: To establish the accuracy of three-dimensional ultrasound (3D-US), compared with magnetic resonance imaging (MRI), for diagnosing uterine anomalies, using the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE-ESGE) consensus on the classification of congenital anomalies of the female genital tract. METHODS: Sixty women with uterine anomalies suspected after examination by conventional two-dimensional ultrasound were evaluated with 3D-US and MRI. These data were analyzed retrospectively to confirm the presence and type of uterine malformation in accordance with the ESHRE-ESGE consensus. Sensitivity, specificity and positive (PPV) and negative (NPV) predictive values were calculated, using MRI as the gold standard, and agreement between the two methods was evaluated by kappa index. RESULTS: Compared with MRI, for the diagnosis of normal uteri, 3D-US had a sensitivity of 83.3%, specificity of 100%, PPV of 100%, NPV of 98.2% and kappa index of 0.900. For dysmorphic uteri and for hemi-uteri, the sensitivity, specificity, PPV and NPV were all 100%, and kappa was 1.00. For septate uteri, the sensitivity was 100%, specificity was 88.9%, PPV was 95.5%, NPV was 100% and kappa was 0.918. For bicorporeal uteri, the sensitivity was 83.3%, specificity was 100%, PPV was 100%, NPV was 98.2% and kappa was 0.900. CONCLUSIONS: 3D-US is highly accurate for diagnosing uterine malformations, having a good level of agreement with MRI in the classification of different anomaly types based on the ESHRE-ESGE consensus.

[Congenital Müllerian anomalies and delivery: analysis of 304 cases between 2000 and 2010 at the University Hospital of Lille]. / Malformations utérines et voie d'accouchement : analyse de 304 cas entre 2000 et 2010 au CHRU de Lille.

OBJECTIVES: This study aimed to determine the conditions and way of delivery in women with congenital uterine malformations. PATIENTS AND METHODS: This retrospective study included a cohort of patients with malformed uterus giving birth in Lille University Hospital between 2000 and 2010, features such as way of delivery, labour, foetal presentation were compared with those patients without uterine malformation. RESULTS: Patients with uterine anomalies had significantly higher rates of breech présentation (36.51% vs 4.52%; P<0.01) and cesarean section (55.26% vs 18.70%; P<0.01) compared to the group of women with a normal uterus. DISCUSSION AND CONCLUSION: Our results suggest that women with uterine malformation should be informed that they have an increased risk of caesarean section due to more frequent malpresentations.

Müllerian duct anomalies diagnosed by saline contrast sonohysterography: prevalence in a general population.

OBJECTIVE: To estimate the prevalence of uterine müllerian duct anomalies in a general population. DESIGN: Cross-sectional study. SETTING: University hospital in collaboration with the Danish Civil Registry. PATIENT(S): A total of 1,654 women randomly recruited from a general population; 686 women were eligible and accepted inclusion (429 pre- and 257 postmenopausal). Saline contrast sonohysterography (SCSH) was finally performed in 622 women (aged 20-74 years) (the procedure was impossible owing to cervical stenosis in 58, contraindicated in 2, other patient-related factors in 4). INTERVENTION(S): The shape of the uterus was dynamically evaluated in the transversal and longitudinal planes during SCSH and classified in accordance with American Fertility Society as normal, arcuate, septate (partial, complete), bicorn (partial, complete), or unicorn. History of previous miscarriage and menstrual cycle was obtained by a questionnaire. MAIN OUTCOME MEASURE(S): Prevalence of müllerian anomalies, miscarriage, and oligomenorrhea. RESULT(S): The overall prevalence of müllerian anomalies was 9.8% (61 of 622) (95% confidence interval [CI] 7.5-12.1). The majority had arcuate uteri (n=42, 6.8%), 17 partial septate (2.7%), 1 complete septate (1.6%), and 1 unicorn uterus (1.6%). Müllerian anomalies were significantly more frequently diagnosed in nulliparous (20% [26 of 128]) compared with parous women (7% [35 of 494]). Müllerian anomalies were more frequent in women with oligomenorrhea compared with women with normal menstrual periods (19% [15 of 79] vs. 10% [34 of 339]). One first-trimester miscarriage or multiple miscarriages (more than one) were not significantly more frequent in premenopausal women with müllerian anomalies compared with women with normal-shaped uteri (24% [6 of 25] vs. 22% [57 of 265]). CONCLUSION(S): In a general population examined by SCSH the prevalence of Müllerian anomalies is estimated at 9.8%. Müllerian anomalies were more frequent in nulliparous women. Both impaired fertility and a pregnancy-associated modulation of the uterine corpus are among explanations. Müllerian anomalies were associated with oligomenorrhea in premenopausal women. In this general population there was no association between miscarriage and müllerian anomalies; however, the number of cases was limited.

Three-dimensional ultrasound and magnetic resonance imaging assessment of cervix and vagina in women with uterine malformations.

OBJECTIVES: To investigate the accuracy of three-dimensional ultrasound (3D-US) with respect to magnetic resonance imaging (MRI), and compared to clinical examination, in the assessment of cervix and vagina in women with uterine malformations. METHODS: In this prospective study, 16 patients diagnosed with uterine malformation with cervical involvement underwent 3D-US examination. The acquisition of cervical volumes was transvaginal, with four cases repeated in the peri-ovulation period, while vaginal volumes were acquired by transperineal imaging following filling of the vagina with gel. MRI was performed in 13 patients using endovaginal gel. All cases underwent clinical examination, comprising bimanual gynecological examination and speculoscopy. Diagnostic concordance of each of the methods with the gold standard was calculated. RESULTS: 3D-US cervical examinations revealed 12 cases of duplicate cervix, two of complete septate cervix and two of incomplete septate cervix. Images of the cervical canal in the peri-ovulation period were judged subjectively to be better in quality, but did not lead us to change any diagnosis. 3D-US vaginal examinations revealed four cases with a vaginal dividing wall and two with a blind hemivagina. None of the 3D-US findings contradicted the clinical findings of the cervix; however, clinically we observed two cases with vaginal dividing wall that had not been diagnosed with 3D-US. MRI diagnosed nine cases of duplicate cervix, three of complete septate cervix, one of incomplete septate cervix, five of vaginal dividing wall and two of blind hemivagina. One case diagnosed as complete septate cervix was in fact a duplicate cervix on 3D-US and on clinical examination. Compared with the gold standard, both 3D-US and MRI were highly efficient in the diagnosis of anomalies of the cervix and vagina. The overall diagnostic concordance of 3D-US with clinical examination (kappa, 0.84; 95% CI, 0.62-1) was slightly inferior to that of MRI with clinical examination (kappa, 0.9; 95% CI, 0.72-1), but this difference was not statistically significant. CONCLUSIONS: The acquisition of isolated cervical volumes, without including the uterus, defines the extent of the ectocervix and the limits of the cervical canal in uterine malformations. The use of endovaginal gel makes possible the diagnosis of associated vaginal anomalies with 3D-US.

Anatomical causes of female infertility and their management.

The main female anatomical causes of infertility include post-infectious tubal damage, endometriosis, and congenital/acquired uterine anomalies. Congenital (septate uterus) and acquired (myomas and synechiae) diseases of the uterus may lead to infertility, pregnancy loss, and other obstetric complications. Pelvic inflammatory disease represents the most common cause of tubal damage. Surgery still remains an important option for tubal factor infertility, with results in terms of reproductive outcome that compare favorably with those of in vitro fertilization. Endometriosis is a common gynecologic condition affecting women of reproductive age, which can cause pain and infertility. The cause of infertility associated with endometriosis remains elusive, suggesting a multifactorial mechanism involving immunologic, genetic, and environmental factors. Despite the high prevalence of endometriosis, the exact mechanisms of its pathogenesis are unknown. Specific combinations of medical, surgical, and psychological treatments can ameliorate the quality of life of women with endometriosis. In the majority of cases, surgical treatment of endometriosis has promoted significant increases in fertilization rates. There are obvious associations between endometriosis and the immune system, and future strategies to treat endometriosis might be based on immunologic concepts.