Doç. Dr. Ulun Uluğ

1. Surgical Management of Uterine
Abnormality

2.  Congenital genital abnormalities encompass embrionic
maldevelopment of paramesonephric ducts and and urogenital sinüs
 Therefore congenital genital abnormalities carry out disorders of
internal and external genitalia and sometimes both
 Underlying etiologies are genetic, hormonal and usually multifactorial

3. Mullerian anomalies are usually associated
with malformations of kidney and skeleton.
They are often diagnosed as late as puberty
when menarche does not occur or sexual
activity is not possible or even later if
infertility is the only symptom.

4. Uterine anomalies are more common than
generally recognized by many practicing
clinicians.
Prevalence in general population :1 in 201
(0.5%)
According to “Acien,” 2-3% of fertile women and
3% of infertile women and 5-10% of those with
repeated miscarriages.

5. • True incidence and prevalence are difficult to
assess. Why?
Selection bias
Different classification systems
Lack of standards in acquired diagnostic data

6. Dysparaneu
Dysmenorhea
Pelvic mass
Infertility
Poor obstetric outcome

7. There are 2 types of classification, which both needs
clarification. A new revised standart system is needed
Oppelt et al
• Vulvar cervical uterin
adnexal and associated
malformations
(VCUAM)
AFS classification

8. American Fertility Society Classification
Mullerian Anomalies

9. Uterine shape decision during hysteroscopy by different
clinicians (Smit et al, 2013)

10. Distribution
Bicornuate (%) 39
Septate (%) 34
Didelphys (%) 11
Arcuate (%) 7
Unicornuate (%) 4

11. The presence of a malformed uterus
increases obstetric complications:
Spontaneous abortion
First trimester bleeding
Preterm labor
Premature rupture of membrane
Abnormal fetal positioning
Plasental abruption
Fetal growth restriction
Fetal death
(Grimbizis et al.,2001)

12. Uterine anomalies and pregnancy outcome
• 105 women with uterine anomaly vs 182
women with normal shaped uterus:
• Highest incidence of early spontaneous
abortion in septate uterus
• Highest incidence of preterm labor in
arcuate and bicornuate uterus
(Zlopasa G. 2007)

13. tr= trimester, pr= pregnancy(Zlopasa G, 2007)
Pregnancy outcome before and after hysteroscopic
treatment of anomaly in 25 women
Outcome Before
Treatment
After
treatment
1st tr loss 34 (77.3) 18 (34.6) <0.001
2nd tr loss 7 (15.9) 3 (5.8)
Total pr loss 41 (93.2) 21 (40.4) <0.001
Term
Deliveries
0 23 (44.2)

14. Class II Abnormality (Unicornuate Uterus)
Usually on the right side
Rudimentary horn are detected in 70%
About 50% of rudimentary horns have
endometrial tissue
Primary symptom may be dysmenorrhea
Associated with spontaneous abortion and
preterm delivery

15. 20 studies consisting of 290 women with
unicornuate uterus are examined
Occurs in 1:4020 women in general population
More common in infertile women and in
women with repeated poor outcomes
(Reichman et al., 2009)

16. Main etiologies explaining poor obstetrical
outcomes:
Small cavity
Diminished myometrium mass
Abnormal uterine blood flow
Cervical incompetence
Unicornuate Uterus
(Reichman et al., 2009)

17. Expectant management
Cervical length measurement
Cervical suturing in selected cases
Remove rudimentary horn if present
Unicornuate Uterus
Management

18. Uterus Didelphys
Non-obstructed failure of lateral fusion involving
both uterus and vagina
Reproductive outcomes are slightly better than
unicornuate uterus

19. (DeviWold et al., 2006)
Spontaneous abortion rate: 43%
Premature birth rate: 38%
Fetal survival rate: 54%
Uterus Didelphys

20. (Propst AM., 2000)
Surgical intervention: Unclear.
Surgical metroplasty should be
reserved for selected patients suffering
from recurrent pregnancy loss or
preterm births.
Uterus Didelphys

21. (Reichman et al., 2010)
Class IV (Bicornuate Uterus)
Is a result of incomplete fusion of the uterine horns at
the level of fundus
Obstetrical outcomes are reported to be better than
unicornuate uterus.

22. (Sinha et al., 2006; Lolis et al., 2005)
Spontaneous abortion 36%
Premature birth 21%
Fetal survival 60%
Bicornuate Uterus

23. Expectant management
Cervical suturing in selected cases
Metroplasty ?

24. Class V (Septate Uterus)
• The most common
uterine anomaly is
septate uterus with
a mean incidence
of 35%
(Tulandi et al., 1980; Acien, 1993; Raga et al., 1997; Woelfer et al., 2001, Zlopasa, 2009)

25. Uterine Septum
Reproductive outcome is poor
Spontaneous abortion 26%-94%
Premature labor 9%-33%
Fetal survival 10%-70%
(Toriano et al., 2004)

26. Diminished connective and muscular tissues has
been found in septum and it was proposed that
uncoordinated contractions and relaxations lead
to abortions (Dabirashafi et al).
MRI studies have shown the presence of
myometrium in the septum (Arıcı et al).

27.  Septum resection with transervical scissors by Hirsh (1919)
 Currently this technique employs endoscopic scissors and is performed under
USG.
 Abdominal metroplasty
 The first application of hysteroscopic septum resection was by Edstrom in 1974.
 Currently it is performed with resectoscope,laser, and scissors.
 Hysteroscopic technique presents all benefits of endoscopy to the patient.
 The duration of postoperative conception time has decreased to 1 month
 The necessity of a cesarean section has disappeared with this technique.
 The cost is very low.
Management:

28. Obstetric outcome after hysteroscopic
metroplasty
(Homer et al., 2000)

29. Reproductive outcome H/S
metroplasty
(Homer et al., 2000)

30. Grup A
N=44
Septa + Unexplained infertility
Group B
N=132
Unexplained infertility
Hysteroscopic
metroplasty
Ekspectant
management
All women were followed-up for 1 year
without any intervention
(Mollo et al., 2009)
Hysteroscopic resection of the septum improves
the pregnancy rate of women with unexplained
infertility: a prospective controlled trial

31. Pregnancy and live birth rate are significantly
higher in patients who had undergone
hysteroscopic metroplasty
(Mollo et al., 2009)

32. Recurrent abortions
Preterm delivery
Infertility
Those who will have ART
Dysmenorrea and dysparunia
When should we operate uterine septum?

33.  Preoperative Danazol,GnRh analogues or progestins decrease
operative bleeding and shorten procedure.
 However, hormonal therapy thins myometrium and increases the risk
of perforation. Operation is suggested immediately after the days of
mensturation.
 To avoid postop adhesions IUD ,baloon, estrogen administration for 3
months
 Postoperative control by office hysteroscopy or HSG
 Uterus can appear arcuate. Resection of fundus should not be
complete
Pre- and postoperative managements

34.  Wide septum can cause more intraoperative bleeding
 Peroperative perforation
 Liquid loading (hyponatremia)
 Infection
 Rupture during pregnancy and complications associated with
placenta
 Intrauterine syneshia (regardless of techniques)
Complications

35. Class VI (Arcuate Uterus)
The near complete resorption
of the uterovaginal septum may
lead to a mild concave
indentation of the cavity, giving
the uterus an arcuate
configuration.

36. Arcuate Uterus
In a retrospective case series of 176 patients
45% early abortion rate was reported (Acien
et al).
In contrast, another study reported only 13%
early miscarriage rate (Raga et al).
Pregnancy losses during second trimester have
been reported (Zlopasa et al)

37. The treatment is usually expectant.
Reconstructive procedures do not improve
pregnancy outcomes.
Arcuate Uterus
Management

38. Conclusion
 Uterine anomalies consist of a wide range of
defects that may vary from patient to patient.
Therefore, their management must also be
individual, taking anatomical and clinical points
into consideration, as well as the patient's
wishes.