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Case Presentation
B.S
42 years old
Filipino, Married, Roman Catholic,
Elementary school teacher
2034 Leveriza St., Pasay City
G2P0 (0010)
Admission date: January 25, 2017
M: 14 y/o
I: Regular
D: 3-4 days
A: 3-4 pads/ day
S: (+) dysmenorrhea, no meds
Gynecologic History
TVS Impression:
Nov 3, 2014 Bicornuate uterus vs septate (complete)
AMCM R subserous myoma
R anterior intramural myoma with subserous component
Abdominal Smaller posterior intramural myoma close to the serosa
enlargement Intact endometrial cavities
Normal looking R ovary
L ovary not seen
Findings:
There are 2 endometrial cavities joining at the region of internal os.
There is a big ovoid hypoechoic mass 88x63mm bulging out on R
anterolateral aspect of R fundal region. Its base 40mm.
There is a rounded hypoechoic mass 52.35mm on lower to midlevel
L of hemiuterus bulging into urinary bladder
A smaller mass 16x13.5mm is seen in the outer posterior wall,
upper level
Gynecologic History
TVS Impression:
April 11, 2015 Bicornuate uterus, single cervix
SJDDH Adenomyoma – anterofundal
Secretory endometrium
Normal ovaries with corpus luteum, R
Findings:
There is an irregularly bordered hypoechoic area anterofundally
(3.35x4.05.2.57cm)
There is fluid – culdesac
Obstetric History
G2P0 (0010)
Year
1 March Complete abortion – 6 wks AOG
2016 No D&C
2 Present pregnancy
• TVS:
• (+) whitish vaginal discharge, non-
Findings:
foul smelling; (+)2pruritus
Pregnancy endometrial cavities noted.
6 wks AOG •uterine
Isoxsuprine HCl 10mg
6 1/7wks, tab TID,
Live embryo Neo-
is in R endometrial cavity
Penotran vaginal
live, singleton supp. X
3 myomas:7 days
Multiple myoma, 1. Fundus: 1.9 x 1.5 mm
intramural 2. Ant. uterine wall: 2.3 x 1.9 mm
Bicornuate 3. Post uterine wall: 1.8 x 1.3 mm
uterus
TVS Imp:
Single, live, intrauterine pregnancy, 12 4/7 wks by CRL and
Oct 1, 2016 mean sac diameter with good cardiac activity
SJDDH
Normal both ovaries
Myoma nodule was described
>No subjective
No adnexal masses seen
complaints
>Normal results:
Findings:
CBC, UA, HbsAg,
Presence of bicornuate uterus is difficult to determine at present
VDRL
scan however well circumscribed hypoechoic structure on
anterior wall 3.89 x 3.31 cm
TAS Imp:
Dec 6, 2016 Pregnancy uterine 21 6/7 wks AOG by fetal biometry
AMCM Live singleton in variable presentation
Adequate amniotic fluid volume
Myoma nodules as described.
>No subjective
complaints Findings:
Myoma 1 – 16.4 x 28.4 x 25.9 mm – anterior wall, intramural
Myoma 2 – 32.1 x 26.4 x 32.8 mm – R lateral anterior
History of Present Pregnancy
TAS Imp:
Pregnancy uterine 25 6/7 wks AOG by biometry, complete
Jan 4, 2017 breech, live, singleton, normal amniotic fluid, male fetus,
multiple uterine myomas
Findings:
Uterine myoma 1 – 23 x 2o mm intramural, L upper anterior
2 – 21 x 18 mm intramural, R anterior
3 – 32 x 35 mm intramural vs subserous
component, R lower lateral
History of Present Pregnancy
General (-) body weakness , (-) loss of appetite, (-) weight loss, (-) fever, (-)
easy fatigability
Integument (-) rashes, (-) jaundice, (-) wound, (-) pruritus, (-) pallor
HEENT (-)headache, (-)dizziness, (-)neck pain, (-) blurring/dimming of
vision, (-)epistaxis, (-)throat pain
Respiratory (-) cough and colds, (-) hemoptysis (-) pleuritic chest pain
Cardiovascular (-) cold perspirations (-) angina, (-) orthopnea, (+) palpitations
GIT (-) abdominal pain (-) abdominal distention, (-) constipation, (-)
hematochezia, (-) diarrhea, (-) melena
GUT (-) polyuria, (-) dysuria, (-) flank pain, (-) dysuria, (-) anuria, (-)
gross hematuria, (-) oliguria
Musculoskeletal/ (-) fracture, (-) weakness, (-) myalgia, (-) joint swelling, (-) joint
Extremities pain, (-) edema
GENERAL SURVEY:
conscious, coherent
Ambulatory
Not in cardiorespiratory distress
VITAL SIGNS:
PR: 82 bpm
RR: 21 cpm
T: 36.6 0C (axillary)
BP: 110/80 mmHg
Ht: 147 cm
Prepregnant wt: 50kg
Current wt: 70.45 kg
BMI: 23.15 (normal)
Skin:
Brown complexion
HEENT:
Anicteric sclerae, pink palpebal conjunctivae,
no tonsillophrayngeal congestion, no neck vein
engorgement, no cervical lymphadenopathy
No neck mass/enlargement
Chest/ Lung:
(-) gross abnormalities such as lesions, masses,
deformities,
Symmetrical chest expansion
No retractions;
No crackles and no wheezes
Heart:
Adynamic precordium.
Point of maximal impulse is at 4th intercostal
space left anterior axillary line, no thrills, no
heaves
Normal regular rate and rhythm, (-) murmur
Abdomen:
Globular
(+) infraumbilical midline scar
(+) linea nigra, (-) striae gravidarum, (-)dilated
veins, (-) discolorations
FHT: 140s (RLQ)
Fundic height: 29 cm
EFW: 1355g
Soft and nontender
Genitourinary:
Normal external genitalia
IE: not done
Extremities:
No gross deformity
42 year old
G2P0 (0010) PU 28 6/7wks AOG
Hypogastric pain with uterine
contractions
No watery vaginal discharge, no vaginal
bleeding, good fetal movement
Bicornuate uterus on Ultrasound
Multiple myoma on Ultrasound
Differential diagnosis
Bicornuate uterus
Rule IN Rule OUT
Bicornuate uterus
Septate uterus
Didelphys uterus
Arcuate uterus
Admitting diagnosis
Findings:
There is 22 x 16 mm subserous myoma in midanterior region.
Other previously seen myomas are not visible at present
Course in the WARD
Hospital Day 1
BP 110/60 Continue management
HR 100
RR 22
Temp 36
FHT: 140s
Contractions- 1/15min
No vaginal bleeding
Good fetal movement
Hospital Day 2
BP 110/70 May go home.
HR 81 Take home meds:
RR 22 1. Coamoxiclav 625mg tab, 1 tab BID to complete 7 days
Temp 36.1 2. Iberet FA tab, 1 tab BI x 2 weeks then OD for next 2 weeks
FHT: 140s 3. Isoxilan 10mg tab, 1 tab TID x 3 days, then PRN
Contractions- 1/15min Follow up after 1 week
No vaginal bleeding
Good fetal movement
Final diagnosis
Arcuate – 7 %
Hypo- or aplastic – 4%
Embryology
Week 6
Week 10
v
Agenesis of both
ducts
Unilateral
maturation of on
mullerian duct
Absent or faulty
midline fusion of
ducts
Defective
canalization
Diagnosis
Hysterosalpingography
Sonography
MRI
Laparoscopy
Hysteroscopy
Diagnosis
Hysterosalpingography MRI
Fertility evaluation Best imaging modality
For uterine cavity and patency Provides clear delineation of
assessment both internal and external
Poorly defines external uterine uterine anatomy
contour Renal and skeletal anomalies
Contraindicated during may be evaluated
pregnancy Precaution with pregnancy
Sonography
SIS – saline infusion Laparoscopy and
sonography hysteroscopy
Improves delineation of Infertility evaluation
endometrium and internal Assess for mullerian
uterine morphology anomalies, screen for
Only in a patent endometrial endometriosis, tubal and
cavity uterine pathologies
Contraindicated in pregnancy
Poor obstetric outcomes
Increased rates:
↓ cavity size recurrent pregnancy
insufficient musculature loss (RPL; 21–33%)
preterm delivery
impaired ability to
Malpresentation
distend IUGR
abnormal myometrial Cesarean section
and cervical function delivery
Other: cervical
inadequate vascularity incompetence,
abnormal endometrial pregnancy-induced
hypertension and
development. antepartum and
postpartum bleeding
Unicornuate (Class II)
Risk of ectopic
pregnancy
Even in noncommunicating
horn, thru transperitoneal
sperm migration
40% will have renal
anomalies
Mngt:
If pregnant: treated
medically or surgically
If nonpregnant:
prophylactic excision of
horn that has cavity
Didelphys (Class III)
Resorption defect
MRI and 3D to differentiate
from bicornuate
Mngt: Hysteroscopic septal
resection
Arcuate (Class VI)
References:
Matthew Kaufman, Latha Stead, Jeane Holmes, Priti Schachel First
Aid for the Obstetrics and Gynecology Clerkship, Third Edition First
Aid Series 2010-16
William’s obstetrics, 24th edition
Beth W. Rackow and Aydin Arici , Reproductive performance of
women with mu ¨ llerian anomalies
Propst AM, Hill JA 3rd. Anatomic factors associated with
recurrent pregnancy loss. Semin Reprod Med. 2000;18(4):341-
50.
Golan A, Langer R, Bukovsky I, Caspi E. Congenital anomalies
of the müllerian system. Fertil Steril. 1989:51(5):747-55.