UTERINE ABNORMALITIES

INTRODUCTION

 

        The female genital tract is formed in early embryonic life when a pair of  ducts develop.  These paramesonephric or Mullerian ducts come together in the midline and fuse into a Y-shaped canal.  The open upper end of this structure lead into the peritoneal cavity and the infused portions become the uterine tubes.  The fused lower portions become uterovaginal area, which further develops into the uterus and vagina.  Various types of structural abnormality can result from failure of fusion of the nullerian ducts.

UTERINE ABNORMALITIES

 

        The most common types of uterine abnormalities are caused by incomplete fusion of the Mullerian ducts.

 

        Complete failure is less and results in double vagina, double cervix and double uterus.

 

        Variants may occur depending on the degree of malformation of the Mullexian ducts.  More extensive fusion of the mullerian ducts results in a single vagina single cervix and double or single horned uteruses which are partially fused.

 

PREVALENCE

        The prevalence of uterine malformation is estimated to be 6.7 percent in the general population, slightly higher (7.3%) in the infertility population and significantly higher in a population of women with a history of recurrent miscarriages (16%).

Types

        There are six different uterine malformations.

1.  Arcuate Uterus:

·        The arcuate uterus has a depression at the fundus.

·        A woman with an arcuate uterus carries a baby to full – term pregnancy.  However, this condition is associated with a higher risk for miscarriage and premature births.

 

2. Bicornuate uterus: (Uterus with two horns)

        Bicornuate uterus is heart shaped with a marked indentation and is separated into two cavities.  The part of the Mullerian duct that forms the upper part of the uterus fails to fuse.  Thus, the candal part of the uterus is normal, the eranical part is bifurcated.

        The primary risk with having a bicornuate uterus is preterm labour and cervical incompetency during the second trimester of pregnancy.  In some cases, a woman with this type of uterus can carry the baby to full term with no complications.

 

Didelphic uterus (double uterus)

        The double uterus has a duplication of the uterus has and duplication of the cervix.  In this malformation, there are two uterine cavities and two cervixes accompanying each cavity.

        Women with this type of uterus often suffer dysmenorrheal and dyspareunia.  Premature births and malpresentations are common.

        Twin pregnancies are commonly associated with didelphic uterus.  There is a good chance that the births can occur at separate times.

Unicornuate uterus (One sided uterus)

        Only one side of the mullerian duct forms.  There is a single uterine cavity with a cervis and one fallopian tube coming out of the uterus.  Only one side of the uterus forms and the other side may have a rudimentary horn.  The uterus has a typical ‘Penis shape’ on imaging systems.

 

Septate uterus (Uterine Partition)

        A septum separates the uterine cavity into two separate cavities.  The septum will arise at the top of the uterine cavity and then extend down to the cervix and vagina.  This develops when the two mullerian ducts have fused, but the partition between them persisted splitting the system into two parts.

        When the defect is partial, the septum affects only the cranial (top) part of the uterus.  Uterine septum is the most common forms of malformation and a cause for abortion.  These is a chance of preterm labour if pregnancy progress.

 

Absent Uterus (Uterine agenesis)

        This is the most severe form of uterine malformation.  There is failure of uterus cervix and vagina to develop.

·        A girl with this malformation will experience puberty with the absence of menstruation.

·        The woman will have only a small dimple in the place where the vagina should be ok.

·        The external view of the genitals will be normal.

·        With closer examination, a shallow vagina will be noticed.

·        There is, greater chance for abnormalities of kidneys and / or bones to be present with this malformation.

·        The woman with this malformation can have sexual intercourse after having a surgical procedure to extend the length of vagina.

Diagnosis

·        Ultrasound examination

Hysterosalpinogoprahy which allows evaluation of the uterine cavity and tubul patency.

·        MRI Scan is considered the best imaging technique for uterine abnormalities hysteroscopy.

Complications:-

·        Dysmenorrhea.

·        Hematometra

·        Complications during pregnancy and labour.  Late marriage, premature labour uterine rupture, malpresentations, obstructed labour, retained placenta, postpartum hemorrhage.

·        Fertility is unaffected except for uterine agencies.

MANAGEMENT

·        Surgical intervention depending on the type of abnormality on enabling a viable pregnancy.

·        A septate vagina and rudimentary horn of a bicornuate uterus are usually removed.

·        A uterine reconstruction may be done for bicornuate or septate uterus (Metroplasty) which is considered to be the cause of recurrent miscarriages.

·        It is  important to rule out the other causes of abortion prior to embarking on any corrective surgery for mullerian anomalies.

1.        Strassman utriculoplasty operation with a transverse fundal incision for reunification of the uterine cavity certainly improves the obstetric outcome in women with bicornuate uterus, who have suffered earlier pregnancy losses.  Injury to the fallopian tubes during surgery must be guarded against.  The risk of rupture of such a repaired uterus during future labour is very real, hence it is wise to perform an elective caesarean section close to term as a precautionary measure.

2.        Tone’s Operation of wedge resection of a part of the fundus of the uterus along with the septum followed by uniting the two horns vertically, in women with a septate uterus and previous pregnancy loss has resulted in subsequent successful pregnancies.

3.        Tomkin’s operation for a septate uterus consists of incising the fundus in the midline, exposing the septum and excising it, followed by reuniting the two parts in the midline.

 

NURSING MANAGEMENT

·        Preoperative care

·        Detailed history should be taken

·        Physical examination and routine investigation should be done.

·        Pre-operative consent. Take signature of patient on consent form.

·        Preoperative teaching

Teaching the patient about why she needs the        surgery.  Expected discomforts etc.

·        Physical preparation of the patient

·        Advice the patient to eat light diet in the previous evening and nothing in the morning of operation.

·        Nothing by month for at least 8 hours to keep the stomach empty at the time of anesthesis.

·        Enema should be given in the evening before surgery.

·        Skin preparation by shaving of the operative area or clipping of hair is done to reduce the chance of infection.

·        Pre-operative checklist is completed before the patient goes to operating room.

·        Presurgery medications should be given such as transquillizer or sedative medication in night before surgery.

Post Operative care

Initial and ongoing assessment of the postoperative patient includes

·        Level of consciousness

·        Vital signs

·        Oxygen saturation

·        Skin colour and temperature

·        Comfort positioning

·        Fluid balance

·        Dressing and drains

·        Managing Pain

·        Providing wound care

 

Conclusion

 

        When pregnancy occurs in the woman with an abnormal uterus, the outcome depends on the ability of the uterus to accommodate the growing fetus.  A problem exists only if the tissue is insufficient to allow the uterus to enlarge for a full term lying longitudinally.

        If there is insufficient hypertrophy the possible difficulties are abortion premature labour and abnormal of the fetus.  In labour, poor uterine function may be experienced.

BIBLIOGRAPHY

 

1.   A comprehensive Textbook of Midwifery and Gynecological Nursing, Annamma Jacob, Third Edition, Pg.No.702-704.

2.   Text Book of Gynaecology D.C.Dutta Fifth Edition, Pg.No.43-45.

3.   Myles Textbook for midwives Diane M.Fraser, Fourteenth Edition Pg.No.116.