Pregnancy outcome in uterus didelphys: case report

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Abstract

Most malformations of the female reproductive organs, depending on their features, have a serious impact on reproductive function and the condition of pregnant women. Therefore, all women with uterine and vaginal malformations require counseling in preparation for pregnancy, follow-up during the pregnancy from the early stages, taking into account possible complications, adequate pregnancy management and prevention of complications, as well as fetal monitoring according to gestational age and planning the term and method of delivery.

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Congenital anomalies of the development of female genital organs (Muller malformations) are a heterogeneous group of malformations of the body and cervix, vagina and fallopian tubes, resulting from improper formation, incomplete fusion or stopping the development of mesonephral (Muller) ducts. The probable cause of the development of uterine abnormality is the impact of adverse factors during various periods of pregnancy [4, 5, 6]. The type and severity of the birth defect depends on the time of exposure. The number of unfavorable factors provoking abnormalities of the uterus in a female fetus includes: infectious diseases suffered during pregnancy in the mother, especially in the first trimester (measles, rubella, influenza, STIs); metabolic disorders and endocrine pathology (thyroid disorders, vitamin and trace element deficiencies); intoxication (a woman's use of alcohol, narcotic substances, taking medications before pregnancy and during pregnancy, having embryotoxic and teratogenic effects on the fetus); hereditary factor (chromosomal and gene mutations); negative environmental impact; severe psychological stress.

The reproductive function and condition of pregnant women are seriously affected by most malformations of the female genital organs, depending on their characteristics and the presence of concomitant gynecological pathology [7, 8, 9]. The presence of uterine malformation may be asymptomatic, but at the same time, the reproductive potential of patients is reduced and unfavorable reproductive outcomes are possible. Thus, in women with abnormalities of uterine development, there is a high incidence of spontaneous abortions, premature birth, premature detachment of the normally located placenta, fetal death [10, 11].

The mechanism of termination of pregnancy in uterine malformations is associated with violations of the process of implantation of the fetal egg, insufficient development of the endometrium, due to insufficient vascularization of the organ, functional features of the myometrium. Termination of pregnancy with uterine malformations can be at any time: before the implantation period, after implantation, and only 2-3% of pregnancy losses occur after 8-10 weeks of pregnancy [12, 13, 14]. In this regard, the study of the peculiarities of the course of pregnancy, taking into account the form of congenital anomalies of the development of the genitals, the method of correction is important in determining the tactics of management from an early stage [15].

It is possible to diagnose the pathological development of the uterus during ultrasound (examination of the pelvic organs), magnetic resonance imaging (obtaining tomographic images to study the degree of doubling of the uterus and tissue deformation) and sonohysterosalpingography. The combination of hysteroscopy and laparoscopy is considered the "gold standard" in determining the type of uterine malformation due to the safety of the technique, high accuracy and the possibility, if necessary, of simultaneous surgical correction [16,17,18,19.20,21].

In order to optimize the diagnosis and approaches to the choice of tactics for the management and treatment of patients with uterine malformations, many classifications are presented. The classification of the American Society for Reproduction (American Fertility Society, 1988) is generally recognized [22] and the improved classification of ESHE and ESGE, in 2015 in Thessaloniki, based on the description of anomalies in the development of the female reproductive tract, depending on the degree of deviations from the norm, characteristic clinical manifestations, necessary treatment and prognoses for reproductive outcomes [23, 24].

In our country, the classification of L.V. Adamyan, proposed in 1998 and improved in 2014, is widely used, developed taking into account the anatomical features and embryonic origin of malformations of female genital organs [25], characterized by a clinical and anatomical approach that facilitates the diagnosis and choice of management tactics for patients.

The following variants of uterine abnormalities are distinguished: I - Vaginal aplasia; II - One-horned uterus; III - Doubling of the uterus and vagina; IV - Two-horned uterus; V - Intrauterine septum; VI - Malformations of the fallopian tubes and ovaries; VII - Rare forms of genital defects.

Doubling of the uterus refers to very rare congenital disorders. We are talking about a malformation of the reproductive organ, which in the course of its development becomes paired, as a result of embryogenetic non-fusion of the Muller ducts. The frequency of propagation ranges from 1:1000 to 1:30,000. A double uterus has two separate necks and sometimes even a double vagina. Each of the formed queens is connected to one fallopian tube and the corresponding ovary [26]. The organs are usually more or less closely in contact with each other or partially fused. The degree of maturity of organs with this abnormality of uterine development can vary significantly – from two equally mature uterus and vaginas on both sides to extremely uneven development (a full pair of organs on the one hand and rudimentary on the other). With sufficient development of both pairs of organs, menstruation and pregnancy can occur in both one and the other uterus [27].

More often, the patient does not even suspect that she has such a feature – a double uterus. A woman lives an ordinary life, gets married, gets pregnant, gives birth to a child. Some patients have copious and painful periods: such a violation can serve as a reason to consult a doctor, where an anomaly of development is detected [28, 29]. Problems in intimate life may appear if we are talking not only about a double uterus, but also about a double vagina.

According to experts, when conducting dynamic monitoring of women with an anomaly during pregnancy, increased blood pressure, swelling of pregnant women are more often noted, and the development of preeclampsia is 2 times more common than in other pregnant women with a normal uterus. An unfavorable outcome of pregnancy - miscarriage and premature birth, incorrect fetal position, development of placental insufficiency and delay in fetal development or the birth of a child with a low body weight leads to an expansion of the indications of operative delivery [30, 31].

A clinical case. Patient A., 21 years old, was admitted to the maternity ward in the direction of a women's consultation with the diagnosis: Pregnancy III 35 weeks. Burdened obstetric and gynecological history (2 miscarriages at 5-6 weeks). Arterial hypertension. Edema of pregnant women. The threat of premature birth. From anamnesis: Was born from the second pregnancy, at the age of 32. The mother's first pregnancy ended in childbirth on time. I grew up in a single-parent family. In physical development, she did not lag behind her peers. In childhood, he notes frequent exacerbations of acute respiratory viral infections, chronic tonsillitis. Menarche from the age of 15, established after 1 year, not regular, with delays of up to 2 weeks and a duration of 7-10 days, noted constant pain in the lower abdomen, did not seek medical help. Sexual life since the age of 17, pain syndrome has always been noted. In 2019, the first pregnancy occurred and was interrupted at 5-6 weeks. In the hospital, an ultrasound OMT was performed and a doubling of the uterus, cervix and vaginal septum was revealed. In 2020, the second pregnancy that occurred was also interrupted at the gestation period of 6-7 weeks. The previous 2 pregnancies were diagnosed in the right uterus. Taking into account the burdened obstetric and gynecological anamnesis, a clinical and laboratory examination was conducted. Pregravidar preparation was carried out and the third pregnancy in the left uterus occurred in 2021. In the first and second trimesters, she was hospitalized for the threat of termination of pregnancy. From 34 weeks, edema on the lower extremities and arterial hypertension appeared, for which she was hospitalized in the maternity hospital. At 37-38 weeks, due to the progression of symptoms of moderate preeclampsia (increase in proteinuria), fetoplacental complex with pathological uteroplacental blood flow, it was decided to terminate the pregnancy by cesarean section as planned. A fetus weighing 2380 grams was born, according to Apgar 7-8 points.

During the operation, during the revision of the abdominal cavity and pelvic organs, two uterus are visualized, with a weight of up to 2 cm between them. Each uterus has a sacro-uterine ligament. The fallopian tubes on both sides and the ovaries are not visually altered. The postoperative period proceeded without peculiarities, according to ultrasound: the right uterus is 54×45×44, the cavity is not expanded, the left uterus is 104×62×83. The cavity is up to 5 m. She was discharged home with her child for 5 days.

Thus, the relevance of studying the features of reproductive function and its implementation in patients with uterine malformations is of interest in improving the diagnosis of this pathology in order to reduce the frequency of adverse reproductive outcomes by preventing them and carrying out timely correction.

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About the authors

Olga V. Chechulina

Kazan State Medical Academy – Branch Campus of the Russian Medical Academy of Continuous Professional Education

Author for correspondence.
Email: chechulina01@gmail.com
ORCID iD: 0000-0001-9378-9888
SPIN-code: 3958-6825
Scopus Author ID: 36929228300

Dr. Sci. (Med.), Prof.

Russian Federation, Kazan

Liliia R. Davliatshina

City Clinical Hospital №16

Email: chechulina01@gmail.com
ORCID iD: 0000-0001-9006-0362

Deputy Chief doctor

Russian Federation, Kazan

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