Unicornuate Uterus: Is There a Place for Hysteroscopic Management?

Abstract

Congenital uterine anomalies afflict 1–10% of the total population, 2–8% of infertile women, and 5–30% of women with a history of miscarriages. Unicornuate uterus, arising due to complete or near-complete arrested development of one of the Müllerian ducts, accounts for 4.4% of all uterine anomalies. It could be associated with renal anomalies, or absence of ipsilateral ovary. Pregnancy occurring in the unicornuate uterus is associated with an increased risk of first-trimester miscarriage, second-trimester loss, cervical incompetence, and a number of obstetric complications such as intrauterine growth restriction (IUGR), preterm delivery, malpresentation, and intrauterine death. The poor obstetric outcomes may be a result of restricted expansion of an abnormal endometrial cavity and abnormal placental implantation. In literature, Xia and colleagues, in two separate case series, have reported improved obstetric outcome in unicornuate uterus after hysteroscopic transcervical uterine incision (TCUI). Considering the obvious fact that the poor obstetric outcome in unicornuate uteri is associated with low uterine volume and a tubular uterine cavity, and the evidence suggesting that women with uncorrected unicornuate uteri have recurrent miscarriages at serially increasing gestational ages, the treatment should be directed towards metroplasty which increases the uterine volume and converts the tubular cavity into a triangular cavity. With this principle in mind, we conducted hysteroscopic fundal and unilateral metroplasty in nine women with unicornuate uterus having mid-trimester abortions, in which we resected both vertically and laterally, keeping in mind the myometrial thickness to avoid perforation and weakening of the cavity. Of the nine cases, six patients conceived. Three of those who conceived continued pregnancy till 32 weeks, two patients till 36 weeks, one patient has an ongoing pregnancy of 23 weeks. Two patients have not conceived yet, and one patient was lost to follow-up. Postoperatively, the women were started on Estradiol valerate for 6 weeks, supplemented with Progesterone in the last 2 weeks. A second look hysteroscopy was performed on day 4–8 of menses after 6 weeks, which revealed an obvious increase in the volume of the cavity. Though this innovative surgery of unicornuate uterus has given promising results in our cases, its universal recommendation , needs larger studies. Hysteroscopy does have a role in the management of unicornuate uteri; however, the best results are only in the hands of the expert.