Re: Uterus Didelphus (pg & loss ment--graphic description of c-section)

[Guest guest]

> Do any of you know the difference in UD Bicollis and UD Unicollis.

> From my Lap It looks like I am Bicollis but I am not sure. I just

> want to find out the difference!

I found the article below. It's long, it's graphic, and it suggests

that if the uterus is divided (i.e. not fused) clear down to the top

of the vagina, but still has only one cervix, it is UD unicollis.

But what is the difference between UD unicollis and a complete BU???

Please keep in mind that this article is from the 1940s (!) and may

be far from the final word.

As for the BU woman in tyhe case study who delivered *ten *(10) term

babies, I would like to know which medal she gets. What a production

run!

Warning: the second case study is very sad . . . an account of a

maternal and fetal demise from pregnancy within the rudimentary horn

of an assymetrical BU. Sensitive readers may want to avoid it.

I also found these laparoscopic pix:

UD bicollis

http://www.wegrokit.com/uterineanomalies/gallery/udbicollap.jpg

UD unicollis

http://www.wegrokit.com/uterineanomalies/gallery/udunicollap.jpg

BU (Complete)

http://www.wegrokit.com/uterineanomalies/gallery/bulap.jpg

:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

http://165.220.12.163/pjss/v01/v01n1/article04.html

DYSTOCIA FROM DEVELOPMENTAL ANOMALIES OF THE UTERUS: OBSTRUCTED

DELIVERY IN A UTERUS DIDELPHYS UNICOLLIS, AND PREGNANCY IN THE

RUDIMENTARY HORN - CASE REPORTS

Three cases of uterus duplex have been already reported by Acosta-

Sison and Katigbak,1 and with the exception of one case of pregnancy

occurring in the rudimentary horn, no mishap had occurred. In the

case of uterus bicornis unicollis accidentally discovered by

laparotomy, the patient was a multipara who had delivered

spontaneously ten full term babies without difficulty. From the easy

deliveries of this patient the authors concluded that in cases of

double uterus, as long as the uterine cavities have access to the

cervix and vaginal canal no fear should be entertained as to the

possibility of dystocia caused by the anomaly. This conclusion is

shown to be erroneous by the present case of double uterus here

reported.

Both cases had two uterine bodies and only one cervix. One delivered

successfully ten consecutive full term babies without difficulty,

whereas the other had threatened uterine rupture due to obstruction

of the non-pregnant uterus. Both cases would be classified in

obstetric text books as uterus bicornis unicollis. But we would give

them separate names because one would not give rise to any difficulty

of labor while the other would invariably cause dystocia in full term

deliveries. Why was there no dystocia in the first case? Because the

external separation of the uteri was only as far as the upper segment

though an interior partition existed as low down as the cervix. When

the pregnant uterus enlarges it brings its partner with it above the

pelvic inlet, so that altho it undergoes some hypertrophy it will not

constitute an obstruction at the pelvic inlet or at the pelvic

cavity. This form of uterus Acosta-Sison would designate as uterus

bicornis unicollis.

In the second case of double uterus with one cervix here reported,

the external division of the uteri included the lower segment as far

down as the insertion of the vaginal cuff. To this form of uterus

Acosta-Sison would suggest the term of uterus didelphys unicollis,

meaning two independent uteri but with one common cervix.

Textbooks2 apply the term uterus didelphys only when there are two

separate uteri with their corresponding independent cervices. To this

we would suggest the term uterus didelphys bicollis to distinguish it

from our case of uterus didelphys unicollis. It is in the uterus

didelphys unicollis, and I would venture to include also the uterus

didelphys bicollis, where obstructive dystocia is to be feared.

When the pregnant portion enlarges, because of the softening of the

independent lower segments, the non-pregnant uterus which also

undergoes hypertrophy is not lifted up by the partner above the

pelvic inlet but remains in the pelvic cavity throughout pregnancy

and at the time of delivery it constitutes a serious obstruction to

the successful delivery of a full term child.

The second uterine anomaly here presented is one of missed labor in a

case of pregnancy in the rudimentary horn causing the retention of a

seven-month dead fetus. The condition was not diagnosed during life

and the result was, as in the previously reported case, fatal.

The third uterine anomaly is one accidentally discovered by

laparotomy for pelvic trouble. It is the uterus unicornis or a uterus

that has only one tube and one ovary. As far as procreation is

concerned, it is possible provided that no infection. occludes the

tube, and of course no dystocia is to be expected unless the uterine

musculature be somewhat weaker than in the normal uterus.

CASE REPORTS

Case I. Dystocia due to uterus didelphys unicollis ( Fig. 1-A and 1-

. I. D. Para II, 23 years old, was admitted 5 p. m., Oct. 2, 1944

for ineffective strong labor pains for 1 hour after she was injected

one ampule of pitocin at her home by a physician. First pregnancy was

a placenta previa marginalis ending in the prolonged but spontaneous

delivery of a small, slightly premature child after l ampule of

pitocin injection. The baby is now one year old.

The second pregnancy is full term. Labor pains began 10 hours before

admission. The private physician gave pitocin after 9 hours of weak

labor pains but though the pains became stronger after the injection,

the head would not engage. On admission the patient had 37.2° C;

pulse 103, respiration 20, the abdominal enlargement was in oblique

direction with the fundus in the left subcostal margin. The lower

segment was markedly bulging and tender and was demarcated from the

upper segment by a transverse groove situated a little above midway

between the umbilicus and symphysis pubis. The upper segment was in

tetanic contraction. There was no sign of superficiality of the fetal

parts. Internal examination, showed slight bleeding, a high non-

engaged head, ruptured membranes, non-pulsating coil of cord and a

tumor mass at the posterior and left fornices which prevented the

descent of the head. The head could not be pushed upward because of

the tetanic contraction of the uterus. The diagnosis of impending if

not actual uterine rupture was made and laparotomy under local

anesthesia was immediately performed. On opening the peritoneal

cavity there was free blood but no complete uterine rupture was

found.

The lower uterine segment along with the bladder was markedly

bulging. Since many vaginal examinations outside and inside the

hospital have been performed, a Porro cesarean section was thought to

be the operation indicated. Accordingly, after extracting a large

child together with its detached placenta thru a longitudinal

incision at the upper segment a supravaginal hysterectomy was made.

The uterus was separated from the left broad ligament in the usual

manner. On the right side, however, the uterus was found to have

neither tube nor ovary nor was it connected with the right broad

ligament. After putting a cervical drain and peritonizing the

cervical stump, an examination of the pelvic cavity for the

identification of the obstructing tumor showed another uterus which

was enlarged to the size of a 2 months pregnancy, connected with the

right tube and ovary. It had its lower segment and was connected with

the vagina. It was the mass in the pelvic cavity that blocked the

passage of the fetus. The adbomen was closed putting a cigarete

drain.

Outside of the purulent discharge through the abdominal site of

drainage and a low grade fever for 8 days the postoperative course

was satisfactory, considering the patient's condition before the

operation.

On October 26, 1944, or 24 days after operation, the introduction of

the uterine sound thru the cervical canal showed a uterine cavity of

8 cm. on the right side. This corresponds to the uterus left behind.

Towards the left side the sound could reach only as far as 4 cm.

showing the depth of the cervical stump. This finding showed that the

right uterus left in situ had an outlet into the cervical canal and

was therefore capable of vaginal delivery.

Subsequent history - Menstruation which appeared 5 months after

operation came monthly until November 1945. Patient missed her

menstruation on January 1946.

Pelvic examination on February 17, 1946 showed her to be pregnant for

one and half months.

It was suggested to label this case as pregnancy occurring after a

hysterectomy.

Case 2. Pregnancy in rudimentary horn of a bicornuate uterus. (Fig.

2.) S. U., 24 years, primipara, was admitted on December 12, 1944,

because of labor pains.

Menarche at 14 years. Menses lasted 4 days and reccurred every 28

days.

This was her first pregnancy. Her last menstruation was on November

8, 1943 and patient should have delivered on August, 1944. She had

morning sickness in the first three months and quickening at the 5th

month. Fetal movements ceased in June, 1944, or at the end of 7

months.

On August, 1944, or at the 9th month of amenorrhea, she had moderate

bloody vaginal discharge for two weeks. In November, 1944, or at the

12th month of amenorrhea she had slight labor pains for 4 days.

Condition on admission: Good. The abdominal enlargement was that of a

7 months pregnancy. It was quite firm as if the uterus were in

tetanic contraction and the fetal parts could not be outlined. The

presenting part on external palpation was quite high. Vaginal

examination revealed that the cervix was small but no empty uterus

could be appreciated. On the introduction of the uterine sound, it

seemed as if beyond the cervical canal it encountered a hard stony

material which was thought to be the fetal head. Rectal examination

also failed to reveal a nonpregnant uterus.

Labor induction was attempted on December 17, 1944 by packing the

cervical canal. No labor pain nor dilatation of the cervix was

obtained.

It was then thought that the cervix was too small to allow the

passage of the head, so on December 21, 1944 laparotomy was made. On

incising the parietal peritoneum a sac looking like that of an

ovarian cyst was encountered. It was adherent to all surrounding

structures. It was incised longitudinally and it was noted that it

was very thin, only 2 mm. It was very flabby like an ovarian cyst. An

intact but very solf seven-month fetus with crackling skull was

extracted. There was a very thin little placenta. Apparently most of

it had been absorbed. There was a great amount of vernix caseosa.

Because the sac was thought to be the uterus, the opening into the

cervix was sought for in order to insert a drain into the vagina but

it could not be found. As the sac was very adherent to the abdominal

wall and intestines and its separation entailed much bleeding, it was

sutured after its cavity had been cleaned of what placental vestiges

there were. An abdominal cigarette drain was inserted and the

abdominal wall was closed in the usual manner.

On the afternoon of the operation, the temperature was 40°C but on

the following four days it was not higher than 38°C.

By mistake the intern in charge removed the abdominal drain on the

fourth day. On the fifth day the temperature rose to 41°C and

maintained that height to the 6th day when the patient died. The

abdomen was never tympanitic. It is regretted that sulfa drugs and

especially penicillin were not then available.

Autopsy showed that the condition was pregnancy in the rudimentary

horn of a bicornuate uterus. The rudimentary horn which was on the

right side had become very distended and thinned out. It was

connected blindly with the main uterus, and with the right tube and

ovary. It was adherent to the intestines and abdominal wall.

The main uterus which was very small and compressed was connected

with the left tube and ovary. There was some acute peritonitis which

must have caused the patient's death.

Comment - The true condition of this case, which is pregnancy out

side the main uterine cavity, was not correctly diagnosed because an

empty uterus could not be appreciated by either vaginal or rectal

examination. Usually in extra uterine pregnancy or pregnancy in. the

rudimentary horn the uterus becomes also enlarged and hypertrophied.

But in this case the uterus was small and compressed. The reason for

this is that the patient was not seen. until at least six months had

elapsed after the death of the fetus. During such a time regressive

processes had taken place. The cervix was small and could not admit

even one finger. And when, to exclude an abdominal pregnancy, the

uterine sound was introduced into the cervix, it seemed as if the

sound encountered a hard bony mass which was thought to be the head.

The hard mass was in reality the promontory of the sacrum which was

overhanging the pelvic cavity. The intervening uterine wall was so

thin that it could not be appreciated by the sound.

Even on laparotomy, the true condition of the case was not

appreciated because what appeared to be the sac was firmly adherent

to all the surrounding structures and because of the danger of

hemorrhage and injury to the intestines, further exploration was

given up. The inability to find an opening into the vagina was

attributed to either a very small cervix or an encysted abdominal

pregnancy, tubal or ovarian. Of course it is known that tubal

pregnancy usually ends in rupture before the third month and ovarian

pregnancy is quite a rare phenomenon.

But in the light of the actual facts, pregnancy in the rudimentary

horn should always be considered when: 1. The abdominal enlargement

is firmly contracted as it was in this case and there is no bleeding

or anemia to rule out ablatio placenta; 2. no presenting part can be

appreciated with the fingers through the cervical canal; 3. the

feeling of an empty uterus would be diagnostic of pregnancy outside

the uterine cavity. On laparotomy the pregnant rudimentary horn can

readily be appreciated when not adherent. On section, the rudimentary

horn can be differentiated from the main uterus by the thinness of

its walls. It can be differentiated from the sac of an abdominal

pregnancy in that it is made up of muscular tissue and has definite

muscular though blind connection with the main uterus.

Case 3. Uterus unicornis (Fig 3). This condition was accidentally

discovered when a laparotomy was performed because of suspected

ruptured tubal pregnancy. It is here included merely because of the

developmental anomaly. The history is as follows:

M. C., 19 years old, was admitted on December 12, 1945 for severe

hypogastric pain and slight vaginal bleeding. Her last menstruation

was on November 5, 1945 and on December 8, 1945 she had severe

hypogastric pain accompanied by slight vaginal bleeding. Physical

examination showed a marked tenderness over the lower abdomen. On

vaginal examination a sausage like tender mass about 2-1/2 inches

long and 1-1/4 inches wide was felt in the left lateral fornix.

Laparotomy showed no free blood in the peritoneal cavity. The tender

mass that was felt on vaginal examination was the uterus unicornis.

The left tube and ovary were present but the right adnexae were

absent. The posterior wall of the uterus as well as the lower pelvic

cavity were studded with flocculent secretion. This was cleaned off

and sulfanilamide powder was introduced into the affected region. The

abdominal wound was closed after inserting a cigarette drain.

The secretion from the abdominal cavity was negative for gonococcus.

Patient was immediately treated with sulfadiazine and penicillin. The

postoperative course was uneventful.

Comment - In case this patient becomes pregnant, it is not expected

that she will have dystocia on account of her uterine anomally.

SUMMARY

Together with the published first series of three uterine

developmental anomalies encountered in the Philippine General

Hospital this report comprises 6 cases: 2 cases of uterus bicornis

unicollis both of which did not give rise to difficult labor, 2 cases

of pregnancy in the rudimentary horn which ended fatally for mother

and fetus, 1 case of uterus didelphys unicollis ending in dystocia,

supra vaginal hysterectomy and subsequent uterine pregnancy, and 1

case of uterus unicornis.

The term uterus didelphys unicollis is proposed to designate that

anomaly where the external division of the uterus takes place in the

lower segment but has one infra-vaginal cervix. Such a uterus gives

rise to obstructive dystocia in the passage of a full term fetus. The

term uterus bicornis unicollis should be limited to that uterus where

the external division is only at the upper segment so that both uteri

have only one common lower segment and one cervix. Such a uterus will

not give rise to dystocia.

Pregnancy in the rudimentary horn of a bicornuate uterus is always a

menace to the life of the mother and calls for an early extirpation

of the blind horn.

ACKNOWLEDGMENT

Thanks are due to Dr. A. de la Paz for having assisted in the

operation of the patients with didelphys unicollis, and to Mr. Fu,

Sun Yuan for drawing the accompanying illustrations.

Pregnancy in Uterus Duplex. With Report of Three Cases. Acosta-Sison,

H. and Katigbak, J. R. J. Phil. M. Ass. December 1938, XVII, 12,

751:757.

Stander, H. J. Textbook of Obstetrics. 1945. D. Appleton Century So.

----------------------------------------------------------------------

----------

* Read before the Philippine College of Surgeons on April 27, 1946.

----------------------------------------------------------------------

----------

Philippine Journal of Surgery

Official Organ Of The Philippine College Of Surgeons

Volume 1 Number 1 July-August 1946

Page 18-25