Uterine septum
| Uterine septum | |
|---|---|
| Classification and external resources | |
| ICD-10 | Q51 |
| ICD-9 | 752.2 |
A uterine septum is a form of a congenital malformation where the uterine cavity is partitioned by a longitudinal septum; the outside of the uterus has a normal typical shape. The wedge-like partition may involve only the superior part of the cavity resulting in an incomplete septum or a subseptate uterus, or less frequently the total length of the cavity (complete septum) and the cervix resulting in a double cervix. The septation may also continue caudally into the vagina resulting in a "double vagina".[1]
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[edit] Etiology
The uterus is formed during embryogenesis by the fusion of the two mullerian ducts. During this fusion a resorption process eliminates the partition between the two ducts to create a single cavity. This process begins caudally and advances cranially, thus a complete septum formation represents an earlier disturbance of this absorption than the incomplete form. Causes for incomplete absorption are not known.
[edit] Prevalence
Most studies are based on populations of women who have experienced a pregnancy loss and thus do not address the issue of the prevalence in the general population. A screening study by Woelfer et al. of women without a history of reproductive problems found that about 3% of women had a uterine septation; the most common anomaly in their study was an arcuate uterus (5%), while 0.5% were found to have a bicornuate uterus.[2] In contrast, in about 15% of patients with recurrent pregnancy loss anatomical problems are thought to be causative with the septate uterus as the most common finding.[3]
[edit] Clinical presentation
The condition may not be known to the affected individual and not result in any reproductive problems; thus normal pregnancies may occur.[4] However, it is associated with a higher risk for miscarriage, premature birth, and malpresentation. According to the classical study by Buttram there is a 60% risk of a spontaneous abortion, this being more common in the second than in the first trimester.[5] However, there is no agreement on this number and other studies show a lower risk. Woelfer found that the miscarriage risk is more pronounced in the first trimester.[2]
The condition is also associated with abnormalities of the renal system. Further, skeletal abnormalities have been linked to the condition.[6]
[edit] Diagnosis
A pelvic examination may reveal a double vagina or double cervix that should be further investigated and may lead to the discovery of a uterine septum. In most patients, however, the pelvic examination is normal. Investigations are usually prompted on the basis of reproductive problems.
Helpful techniques to investigate a septum are transvaginal ultrasonography and sonohysterography, MRI, and hysteroscopy. More recently 3-D ultrasonography has been advocated as an excellent non-invasive method to delineate the condition.[2] Prior to modern imaging hysterosalpingography was used to help diagnose the uterine septum, however, a bicornuate uterus may deliver a similar image.
[edit] Management
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 lesion.
A septum that has not caused problems may not be removed. There is controversy whether a septum should be removed prophylactically prior to a pregnancy or infertility treatment.[7]
[edit] Differential diagnosis
Other forms of uterine malformation need to be considered in the work-up for uterine septum. An arcuate uterus contains a residual cranial septum that is smaller than an incomplete septum but definitions between the two conditions are not standardized, - a cause for discrepancies in the literature.
A bicornuate uterus is sometimes confused with a septate uterus as in each situation the cavity is partitioned, however, in the former case the uterine body is cranially doubled (two uterine horns) while in the latter a single uterine body is present. The former represents a malformation of incomplete fusion of the mullerian systems, and the latter of incomplete absorption. A hysterosalpingogram may not be able to distinguish between the two conditions. The differentiation, however, is important as a septum can be corrected by hysteroscopy, while a bicornuate uterus would be corrected by a metroplasty via laparotomy if necessary.
[edit] References
- ^ Heinonen PK (March 2006). "Complete septate uterus with longitudinal vaginal septum". Fertil. Steril. 85 (3): 700–5. doi:10.1016/j.fertnstert.2005.08.039. PMID 16500341.
- ^ a b c Woelfer B, Salim R, Banerjee S, Elson J, Regan L, Jurkovic D (December 2001). "Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening". Obstet Gynecol 98 (6): 1099–103. doi:10.1016/S0029-7844(01)01599-X. PMID 11755560.
- ^ Propst AM, Hill JA (2000). "Anatomic factors associated with recurrent pregnancy loss". Semin. Reprod. Med. 18 (4): 341–50. doi:10.1055/s-2000-13723. PMID 11355792.
- ^ Creasy RK, Resnik R (1994). Maternal-Fetal Medicine. Principles and Practice.. Philadelphia: W.B.Saunders. p. 447. ISBN 0-7216-6590-0.
- ^ Buttram VC, Gibbons WE (July 1979). "Müllerian anomalies: a proposed classification. (An analysis of 144 cases)". Fertil. Steril. 32 (1): 40–6. PMID 456629.
- ^ Li S, Qayyum A, Coakley FV, Hricak H (2000). "Association of renal agenesis and mullerian duct anomalies". J Comput Assist Tomogr 24 (6): 829–34. doi:10.1097/00004728-200011000-00001. PMID 11105695. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0363-8715&volume=24&issue=6&spage=829.
- ^ Ozgur K, Isikoglu M, Donmez L, Oehninger S (March 2007). "Is hysteroscopic correction of an incomplete uterine septum justified prior to IVF?". Reprod Biomed Online 14 (3): 335–40. doi:10.1016/S1472-6483(10)60876-0. PMID 17359587. http://openurl.ingenta.com/content/nlm?genre=article&issn=1472-6483&volume=14&issue=3&spage=335&aulast=Ozgur.
[edit] External links
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