The uterus is the heart of our reproductive system. Let’s imagine that a beautiful but complex symphony sounds through the entire history of mankind, repeating in each of us. An orchestra under the direction of a conductor performs it and passes it on to the next generations – but sometimes something goes wrong: either the musicians do not come, or the instrument is out of tune. Then the melody does not sound, and the conductor can stop playing.
The body is also an orchestra with its own complex symphony, and you cannot remove an element without disturbing the harmony of the whole. If there is a violation in the development of the fetus, the mother may not tolerate it: her body – the “conductor” – subtly feels the vices incompatible with life. It also happens that during the performance, someone manages to slip through unnoticed; then the child is born with some malformation. What anomalies of uterine development can lead to this – in today’s article.
What are the anomalies of the uterus?
Humans are symmetrical creatures: one half of the body mirrors the other, and even such an odd organ as the uterus develops from the fusion of two similar parts – the Müllerian ducts. If this fusion does not proceed correctly, it is considered an anomaly of the uterus. The specific anomaly is determined by the stage at which the fusion has stopped.
For example, it can be only muscle rolls – then it turns out aplasia of the uterus; an unicornuate uterus, if only one of the rolls is stretched in length; a bicornuate uterus – a partial fusion of the stretched rolls. With incomplete resorption of the duct wall in the uterine cavity, a uterus with a septum is formed, and with incomplete formation of the uterine cavity – a morphologically altered uterus.
Classification
In 2013, the European Ecological Society of Human Reproduction and Embryology created a modern classification of anomalies, which also took into account possible concomitant anomalies of the cervix and vagina:
U0 – normal uterus
U1 – Morphologically altered uterus
a. T-shaped uterus
b. Infantile
c. Other
U2 – Uterus with septum
a. Partial
b. Complete
U3 – Bicornuate uterus
a. Partial
b. Complete
c. Bicornuate with septum
U4 – Unicornuate uterus
a. With rudimentary cavity
b. Without rudimentary cavity
U5 – Uterine aplasia
a. With rudimentary cavity
b. Without rudimentary cavity
U6 – Not classified cases
C0 – Normal cervix
C1 – Cervix with a septum
C2 – Double normal cervix
C3 – Unilateral cervical aplasia
C4 – Aplasia of the vagina
V0 – Normal vagina
V1 – Longitudinal non-obstructive vaginal septum
V2 – Longitudinal obstructive vaginal septum
V3 – Transverse vaginal septum and/or non-perforated hymen
V4 – Vaginal aplasia
We can say that anomalies in the development of the uterus are a musician who made a mistake at the beginning of his part, and now his neighbors – other organs – can also easily go astray. This applies to the cervix, vagina, the entire genitourinary system and even the axial skeleton, which can also be affected.
Why do uterine anomalies appear?
65% – unknown factors;
25% – genetic factors;
10% – environmental factors: the influence of medications, environment, bad habits, infectious diseases of the mother.
How do uterine anomalies affect a woman’s life?
Aplasia
In aplasia without a residual (rudimentary) cavity, there is no menstruation; if there is a rudimentary cavity, then there is no expected menstruation, but every 2-3 weeks blood accumulates in the uterus, which causes cramping pain in the lower abdomen. The uterus becomes round and tense due to the contents, urination becomes painful and rapid, and the abdomen increases. In such cases, immediate surgical treatment is necessary.
Unicornuate uterus
If the rudimentary cavity does not connect to the unicornuate uterus, it can manifest itself in the same way as aplasia. If it does connect, the blood outflow may be impaired. That is, blood is retained in the uterine cavity and fallopian tube, can reach the pelvic cavity and give complications in the form of adhesions or foci of endometriosis. Because of this, on the 3-4th day of menstruation, the abdomen begins to hurt, and the discharge (heavy or, conversely, insignificant) can last up to 10 days.
The unicornuate uterus without a rudimentary horn or with a rudimentary horn without a cavity, the bicornuate uterus and the uterus with a septum may not be clinically manifested: the symptoms depend on the accompanying anomalies of the vagina or cervix.
Infantilis uterus
The infantile uterus has a reduced size; menstruation begins at the age of 16; it is irregular, scanty and accompanied by painful sensations. An infantile uterus may not manifest itself in everyday life, but still affect fertility.
How do anomalies affect pregnancy and childbirth?
All congenital anomalies are associated with primary or secondary infertility, spontaneous abortion and premature birth.
In case of uterine aplasia or Mayer-Rokitansky-Kuester syndrome (combining uterine and vaginal aplasia), independent conception and development of pregnancy is impossible. But the ovaries are preserved, so surrogacy is possible. Also in 2010, a donor uterus was successfully transplanted for the first time.
With an unicornuate uterus, there is always a possibility of ectopic pregnancy in the rudimentary horn – both if it is connected to the cavity of the main horn and if it is closed. This leads to its rupture with massive intra-abdominal bleeding and death if not treated in time.
Threat of pregnancy loss
Reproductive disorders can be observed even if the unicornuate uterus is asymptomatic. The high frequency of reproductive losses can be explained by the insufficient development of the main horn and the lack of conditions for the full development of the fetus. The same can be said about double and bicornuate uteri. Often the bicornuate uterus is the cause of isthmic-cervical insufficiency, which can provoke the birth of a child in the 2nd trimester.
If the uterus has a septum, it can lead to spontaneous abortion at an early stage. This is due to the fact that the embryo develops on the septum, where the endometrium is inferior and poorly supplied with blood.
A morphologically altered uterus often leads to ectopic pregnancy, spontaneous abortion and complicated childbirth: with bleeding, weak labor activity, insufficient opening of the uterine pharynx during childbirth.
In women with congenital anomalies of the uterus during pregnancy, there is a threat of abortion, placental insufficiency, isthmic-cervical insufficiency, placental abnormalities, premature discharge of amniotic fluid, premature birth. Preeclampsia may start early and be severe, which may require preterm delivery.
Early treatment
Complications are associated not only with the peculiarities of anatomy, but also with the lack of timely correction. If, in addition to an abnormality of the womb, a woman has concomitant gynecological pathology, a history of spontaneous miscarriages, fractional diagnostic curettage, inflammatory diseases of the genitals, the threat of abortion in the first trimester, premature birth – all this is an unfavorable background for the development of a normal pregnancy.
Abnormalities can also affect the child. Intrauterine fetal growth retardation and hypoxia are possible. Such children are often born in moderate or severe asphyxia, with impaired adaptive capacity.
What to do?
The crucial thing is early diagnosis, which makes it possible to surgically correct the pathology. Developmental anomalies can be diagnosed using ultrasound, hysterosalpingography, MRI, laparoscopy. Recent scientific works have proven the high sensitivity of 3D ultrasound.
Surgical treatment is performed in the absence of menstrual, sexual and reproductive functions or their disorders. In the absence of a burdened anamnesis, surgical intervention is not used.
Uterus with a septum
Surgical tactics – hysteroscopic metroplasty with simultaneous laparoscopy. That is, the vaginal access is used to dissect the septum inside the uterus and simultaneously visualize the abdominal cavity. Laparoscopy (access through the abdominal wall) is necessary to avoid perforation of the uterus, as well as to make sure that there is no other pathology of the pelvic organs. After a month, a control examination is carried out using hysteroscopy, hysterosalpingography or ultrasound.
After recovery, the risk of miscarriage decreases from 88% to 12%, another study shows 80% of births on time compared to 3% before surgery.
Bicornuate uterus
The operation of choice is Strassmann metroplasty. The essence of this operation is to create a single uterine cavity from two uterine horns by removing the wedge-shaped flap between them and then combining the two cavities.
A variant of this operation has also been developed using laparoscopic access (through the abdominal cavity).
As a result of the operation, a scar is formed between the combined cavities, which requires careful monitoring during pregnancy.
According to Strassmann, out of 263 women after metroplasty, 86% of pregnancies ended with delivery on time, with a live fetus.
Doubling of the uterus
There are data on metroplasty in patients with a long history of habitual miscarriage. In this case, Strassmann metroplasty is performed, combining the uterine cavities in the area of the bodies without affecting their cervixes, but there is no scientific data on further reproductive function.
Unicornuate uterus
Indication for the operation is a violation or delay in the outflow of menstrual blood from the rudimentary horn. After the operation, the pain syndrome disappears and the risk of endometriosis and ectopic pregnancy decreases.
Surgical tactics – laparoscopic hemihysterectomy – removal of the rudimentary horn through the abdominal cavity. There is evidence of successful pregnancy outcomes in the main horn after a previous hemihysterectomy.
If no endometrium is detected in the rudimentary horn by ultrasound, the operation is not indicated.
Uterine aplasia
Only removal of the rudimentary uterus is possible in case of impossibility of blood outflow.
After surgical correction of congenital anomalies of the uterus and vagina, half of the patients become pregnant within 3 years.
Early treatment of the anomaly improves the quality of life of women and prevents gynecological complications. At the same time, it provides a stable psycho-emotional condition and normalize the reproductive function.
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Sources:
- Grigoris F. Grimbizis, Stephan Gordts. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Human Reproduction, February 2013
- Elizabeth Taylor, M.D. , Victor Gomel, M.D. The uterus and fertility. Fertility and Steriliti, December, 2007
- Akhtar MA, Saravelos SH. Reproductive Implications and Managementof Congenital Uterine Anomalies. BJOG, November 2019
- Nathan S Fox, Ashley S Roman. Type of congenital uterine anomaly and adverse pregnancy outcomes.Matern Fetal Neonatal Med. 2014
- Homer H.A., Li T.C. The septate uterus: a review of management and reproductive outcome. Fertil Steril. 2000
- Grimbizis G.F.,Camus M.Clinical implications of uterine malformations and hysteroscopic treatment results.Hum Reprod Update, 2001
