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A study of genital tract anomalies and reproductive outcome.

INTRODUCTION: The Mullerian ducts differentiate to form the fallopian tubes, uterus, cervix and superior aspect of vagina. Malformations of the mullerian duct range from uterine and vaginal agenesis to duplication of uterus and vagina to minor uterine cavity abnormalities. These anomalies are related to poor reproductive outcomes and hence their diagnosis is important.

The prevalence of major uterine anomalies is estimated to be 5% in general population, 3% in infertile and 5-10% in case of recurrent miscarriages, some of the congenital uterine anomalies is asymptomatic and hence are unrecognised. Such anomalies are diagnosed either during antenatal checkup or during caesarean delivery. (1)

Diagnoses of Genital tract anomalies are important as treatment is aimed at improvement of symptoms. These range from simple resection of uterine septum to vaginoplasty. The study aims to know the clinical characteristics of different anomalies of the reproductive tract and their reproductive outcome.

MATERIALS AND METHODS: A total of 45 patients with genital tract anomalies were studied in Obstetrics and Gynaecology department of Belagavi Institute of Medical Sciences from a period of August 2010 to July 2012. Number of uterine anomalies was 35 and vaginal anomalies were 10. Uterine anomalies were detected during labour and emergency LSCS. Vaginal anomalies were detected in OPD patients. Uterine anomalies presented with various reproductive outcomes ranging from infertility to labour complications and term deliveries. These women underwent detailed history regarding menstrual pattern, duration of infertility and previous obstetric outcomes. These women were either diagnosed earlier or were asymptomatic being diagnosed at surgery.

Vaginal anomalies presented with primary amenorrhoea and dyspareunia. Vaginal anomalies were diagnosed and managed.

Design: Prospective observational study.

Main outcome Measures:--Infertility, Miscarriages, Preterm delivery, Term delivery, Labour complications, Menstrual disturbances and Coital difficulties. In vaginal anomalies reproductive outcome not studied as compliance of patient was poor.

RESULTS: In our study (Among uterine anomalies).

Out of 35 cases 32 cases were diagnosed during emergency LSCS and 3 cases were delivered vaginally and had retained placenta. Bicornuate uterus was the commonest uterine anomaly with an incidence of 52.94%. We report a live birth rate of 88.88%, term deliveries rate of 66.66%, Pre term rate of 22.22%, Malpresentation rate of 55.55% & Retained placenta rate of 5.55% and an infertility rate of 11.11%.

Unicornuate uterus with non-communicating rudimentary horn was next common with an incidence of 29.41%. We report a 100% live birth with term delivery 85.71% and preterm delivery 14.28%. 85.71% presented with malpresentation. Unicornuate uterus with rupture of non-communicating horn had an incidence of 8.81% with live birth rate of 3.3% and miscarriage rate of 66.66%.

The incidence of unicornuate uterus with communicating horn was 5.88% with a live birth rate of 100% and 100% rate of non-progress of labour. The incidence of uterine didelphys was 11.76% with infertility rate of 50% and a miscarriage rate of 25% and 25% menstrual abnormality rate. Uterine anomalies presented with various reproductive outcomes ranging from infertility to term delivery and labour complications.

The results are tabulated in Table No. 1

Of the vaginal anomalies imperforate hymen was highest with an incidence of 36.36% and longitudinal vaginal septum was next common with an incidence of 18.18%. Of the reported vaginal anomaly some patients presented with menstrual abnormalities and others with dyspareunia. There were both menstrual and coital abnormalities in some patients.

The results are tabulated in Table No. 2.

DISCUSSION: Congenital uterine anomalies are always interesting as they are associated with different obstetrical and gynaecological problems. The prevalence of uterine anomaly varies widely between 0.1-3.5 percent. [1] The prevalence is higher among women with fertility problems as compared to general population. Rega (1995) et al reported that the overall frequency of uterine malformation was 4.0 percent. [2]

The Bicornuate uterus results when two normally differentiated ducts partially fuse in the region of the fundus. It was found to be associated with better live birth rate of 88.88% with a term delivery rate of 66.66% and preterm delivery rate of 22.22% these two results are comparable with studies of Rega etal [2] and Fauzia butt [3] 55.55% were associated with Malpresentations.

The unicornuate uterus results from normal differentiation of only one mullerian duct. Our study group of unicornuate uterus with non-communicating rudimentary horn had 100% live birth rate with a term delivery rate of 85.71% and preterm rate of 14.28% but it reported the highest rate of malpresentation (85.71%). But, the reproductive outcome worsened when it was associated with rupture of rudimentary horn of uterus. It was associated with an ectopic pregnancy rate of 66.66% and live birth rate of 33%. The ectopic was in rudimentary horn of the uterus. This agrees with the result of Munire. E. Akar et al [4] and Fauzia butt [3]. The live birth rate in Munire. E. Akaretal was 29.2% and ectopic pregnancy rate with Fauzia butt was 50%. We had a 5.88% incidence of unicornuate uterus with communicating horn and it was associated with 100% live term birth rate. But, all the cases presented as failure to progress and hence were taken up for caesarean section. It is to be noted that the obstetric outcome changes drastically with the character of the rudimentary horn i.e., rupture, communicating / non communicating. Uterine didelphys results from complete failure of the mullerian ducts to fuse in the midline. We report an incidence of 11.76% of this anomaly. We had a 50% infertility rate and 25% miscarriage rate which is comparable with the results of Fauzia butt [3]. Also 25% rate of menstrual abnormalities was noted in this group of anomaly.

Imperforate hymen had the highest incidence of 36.36% in our study group of vaginal anomalies. Imperforate hymen is likely the most frequent obstructive anomaly of the female genital tract but estimates of its frequency rate from 1case per 1000 population to 1 in 10,000 population. [5] They presented as primary amenorrhoea with or without haematometra and haematocolpos. Excision of the hymen followed by drainage of blood was done for such cases. Longitudinal Vaginal septum was next common (18.18%) and presented as dyspareunia. They were treated with incision of the septum. 9.09% presented with transverse vaginal septum with dyspareunia. They were treated with incision of septum. An incidence of 1 in 70,000 patients is reported in literature. [6] 9.09% in the study group presented with primary amenorrhoea and total vaginal agenesis. Vaginal agenesis occurs in 1 of every 4000 to 10000 patients. [7] Patient was treated by creation of neovagina along with serial vaginal dilatation. The patient did not develop vaginal stricture after surgery. There was atresia of the lower 1/3rd of vagina in 9.09% of the cases. They were treated with vaginoplasty.

In the study group of vaginal anomalies, 18.18% presented with menstrual abnormalities and 36.36% with dyspareunia. Although some presented with both the symptoms.

Limitations of the Study:

1) The results of the study are limited to a small group and hence it cannot be applied to a wide population group.

2) We had not used imaging modality to confirm the genital tract anomalies in all subjects. They were detected accidentally during labour or during surgery.

3) Outcome of pregnancy was not studied in vaginal anomalies as compliance of the patient was poor.

CONCLUSION: Congenital uterine anomalies are relatively frequent in infertile population. They are associated with higher incidence of miscarriages, preterm deliveries, malpresentations, non-progress of labour, 3rd stage complications of labour. But may be compatible with normal reproductive outcomes. The reproductive outcome with Bicornuate uterus is better compared with other anomalies. Presence of communicating rudimentary horn with or without rupture significantly affects the reproductive outcome. Malpresentation, failure to progress, 3rd stage complications of labour may point out to an underlying undetected uterine anomaly. Vaginal anomalies present with menstrual and sexual disturbances which can be corrected to permit a near normal reproductive outcome and sexual function.

DOI: 10.14260/jemds/2015/282

REFERENCES:

[1.] Acien .P. Incidence of Mullerian defects in fertile and infertile women, Human Reprod 1997; 12:1372-1376.

[2.] RegaF, Bausel C, Remohi J. Reproductive impact of congenital mullerian anomalies. Human Reproduction 1997;12(10):2277-81.

[3.] Fauzia butt. Reproductive outcome in women with congenital uterine anomalies. Ann als Vol 17. No. 2 APR-JUN 2011.

[4.] Munire E. Akar, Didem Bayar, Sema Yildiz et al. Reproductive outcome of women with unicornuate uterus. The Australia and New Zealand Journal of Obst and Gynaecol 2005; 45: 148-150.

[5.] emedicine.medscape.com/article/269050-overview.

[6.] Suidan F Azoury RS; The transverse vaginal septum: A clinic pathological evaluation. Obstet Gynecol 34: 278-283, 1979.

[7.] ACOQ Committee Opinion No. 355: Vaginalagenesis: diagnosis, management and routine care. Obstet Gynecol, Dec 2006; 108(6): 1605-9.

Rajeshwari A. Kadkol (1), R. R. Godbole (2), K. S. Lakshmi (3)

AUTHORS:

(1.) Rajeshwari A. Kadkol

(2.) R. R. Godbole

(3.) K. S. Lakshmi.

PARTICULARS OF CONTRIBUTORS:

(1.) Assistant Professor, Department of Obstetrics and Gynaecology, BIMS, Belagavi.

(2.) Associate Professor, Department of Obstetrics and Gynaecology, BIMS, Belagavi.

(3.) Assistant Professor, Department of Obstetrics and Gynaecology, BIMS, Belagavi.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Rajeshwari A. Kadkol, Assistant Professor, Department of Obstetrics and Gynaecology, BIMS (Civil) Hospital, Belagavi.

E-mail: drrajeshwarimotimath@gmail.com drraj eshwari@hotmail.com

Date of Submission: 16/01/2015.

Date of Peer Review: 17/01/2015.

Date of Acceptance: 30/01/2015.

Date of Publishing: 06/02/2015.

Table No. 1: REPRODUCTIVE OUTCOME OF WOMEN WITH UTERINE
ANOMALIES

Anomaly Incidence    (%)    Live     Term    Preterm
                            Birth     (%)      (%)
                             (%)

Bicornuate uterus   52.94   88.8 8   66.66    22.22

Unicornuate         29.41    100     85.71    14.78
uterus with
non-communicating
horn

Unicornuate         8.81     3.3      --        --
uterus with
rupture of
non-communicating
horn

Unicornuate         5.88     100      --        --
uterus with
communicating
horn

Uterine didelphys   11.76     --      --        --
with unicornis

Anomaly Incidence       Mal-       Failure    Retained    Miscarriage
                    presentation     to       Placenta        Rate
                                   progress

Bicornuate uterus      55.55          --        5.55           --

Unicornuate            85.71          --         --            --
uterus with
non-communicating
horn

Unicornuate              --           --         --          66.66
uterus with
rupture of
non-communicating
horn

Unicornuate              --          100         --            --
uterus with
communicating
horn

Uterine didelphys        --           --         --            25
with unicornis

Anomaly Incidence   Infertility    Menstrual      Ectopic
                                  Abnormalities    Rates

Bicornuate uterus      11.11           --

Unicornuate             --             --
uterus with
non-communicating
horn

Unicornuate             --             --          66.66
uterus with
rupture of
non-communicating
horn

Unicornuate             --             --
uterus with
communicating
horn

Uterine didelphys       50             25
with unicornis

TABLE No. 2: VAGINAL ANOMALY DIAGNOSIS AND MANAGEMENT

Anomaly        Incidence     Coital        Menstrual      Treatment
                           Difficulties   Abnormalities

TRANSVERSE       9.09          YES             --         INCISION
VAGINAL                                                    OF THE
SEPTUM                                                     SEPTUM

LONGITUDANAL     18.18         YES             --            --
VAGINAL
SEPTUM

IMPERPORATE      36.36          --             YES        SURGICAL
HYMEN                                                     EXCISION
                                                          OF HYMEN

TOTAL            9.09          YES             YES        CREATION
ABSENCE OF                                                NEOVAGINA
VAGINA WITH                                                  AND
HYPOPLASTIC                                                SERIAL
UTERUS                                                     VAGINAL
                                                           DILATA-
                                                            TION

ATRESIA OF       9.09           --             YES         VAGINO-
LOWER 1/3RD                                                PLASTY
OF VAGINA

VAGINAL          9.09           --             YES         VAGINO-
ATRESIA WITH                                               PLASTY
RUDIMENTORY
UTERUS

IMPERPORATE      9.09           --             YES        INCISION
HYMEN WITH                                                OF SEPTUM
LONGITUDANAL                                              AND HYMEN
SEPTUM                                                     ECTOMY
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Title Annotation:ORIGINAL ARTICLE
Author:Kadkol, Rajeshwari A.; Godbole, R.R.; Lakshmi, K.S.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Feb 9, 2015
Words:1824
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