An understanding of congenital anomalies as they are encountered in clinical practice is greatly enhanced by not only a knowledge of normal embryology and the mechanism of formation of normal infants, but also an insight into the processes that result in the development of anomalies. An awareness of malformations and a systematic examination and appraisal of every neonate will greatly increase the number of such anomalies found. In some instances, e.g., congenital adrenal hyperplasia, imperforate anus, diaphragmatic hernia, and esophageal atresia, early detection and prompt intervention may be lifesaving. In adults, amenorrhea is an important clue and may suggest an imperforate hymen, vaginal septum or absence of the uterus.
The finding of one anomaly should stimulate a careful gynecologist to carry out a complete study to detect renal and ureteral anomalies, particularly the solitary pelvic kidney which might be removed as a “pelvic mass”. Many anomalies occur infrequently so that only physicians in large medical centers may see them frequently enough to be aware of the possible anomalies and their causation, prognosis, and, in some cases, correction. The identification and interpretation of such abnormalities constitute a real challenge to the clinician. A knowledge of the problems and pitfalls in the management of these defects will benefit both the obstetrician and the gynecologic surgeon.
Causes of abnormalities
The causes of congenital malformations or abnormalities present at birth may be either environmental or genetic (chromosomal abnormalities). It is not always easy to separate the two factors; both may be at work in the same embryo or fetus. Rapidly growing embryonic organs are the most sensitive to environmental influences.
Millen has classified the mechanisms of anomaly production as follows:
1. Developmental arrest—cessation of development before completion
2. Agenesis or aplasia—failure of normal development
3. Hyperplasia or local overgrowth
4. Aberrant development
5. Failure of normal resorption (either too much or too little) or resorption in the wrong locations
6. Secondary degeneration of normally developed structures
Millen also emphasizes “that the period when environmental agents may affect the development of an embryo is very short, being nearly over by the end of the eighth week of pregnancy”. Organogenesis occurs from day 13 to day 60; teratogenic (G. teras, monster) agents are most dangerous during this period. There is a time relationship between specific organ systems and sensitivity to environmental factors as well as a relationship between specific teratogens and specific organ systems. Examples are rubella infections occurring in the first trimester, with a high incidence of cataracts, deafness, and cardiac malformations, and use of thalidomide, with varied malformations of arms and legs.
Nutgen has evaluated in detail the mechanisms of action of various environmental teratogenic factors. These include the following:
1. Ionizing radiation
2. Vital disease and related infections
3. Chemical factors
4. Immunologic disturbances
6. Nutritional factors
Ionizing radiation is probably one of the best known damaging factors. Infections such as rubella virus, cytomegalovirus, and Toxoplasma gondii can cause severe damage to the eyes and central nervous system. Chemicals include aminopterin (causing skeletal defects and nervous system damage), methotrexate, and thalidomide. Immunologic disturbances include Rhesus incompatibilities. Hormone damage is particularly interesting: the administration of exogenous testosterone, synthetic progestogens, and similar preparations can cause iatrogenic deformities of the female genitalia.
Pathologic hyperandrogenemia, as seen in luteomas of pregnancy, can result in virilization in the female newborn. Environmental factors, such as exposure to diesel fumes, have also been associated with virilization due to inhibition of aromatase and accumulation of excess testosterone. Nutritional factors apparently have little direct teratogenic effect on the fetus.
The most frequent uterine anomalies (Fig. 3) are those resulting from varying degrees of failure of fusion of the müllerian ducts. This variability makes classification difficult and determination of the true incidence uncertain. Many of these malformations are detected by radiologic or sonographic studies. Estimates of incidence vary from 0.13% to 4.0%. The incidence of müllerian anomalies in patients with infertility has been reported to be as high as 6.3%.Pregnancy occurs in many women despite these anomalies. The complication rates with pregnancy are considerably increased; complications include abortion, prematurity, postpartum hemorrhage, retained placenta, and breech presentation. Not surprisingly, the rate of cesarean delivery is markedly higher.
Uterus duplex, or the bicornuate uterus, is the most frequent uterine anomaly. The unicollis type in which there is a single cervix with a septum that does not reach the cervix is the most frequent type, occurring in over one third of all patients with uterine anomalies.
Uterus duplex bicollis, in which two cervices are present, is less frequent. Obstetric complications are frequent, but live births do occur.
Uterus didelphys, with completely separate uterine cavities, is also frequent. The cervices are externally united and the uterine fundi are externally separate. In most patients the vagina is septate, causing a double vagina. The halves of such a uterus are often of different sizes. If there is an asymmetric vaginal septum which occludes one vagina, mucocolpos or hematocolpos may result. Communicating uteri, involving an incomplete uterine septum with part of the fetus in each uterine cavity, occasionally occur.
Uterus septus is an essentially normal uterus with a septum reaching to the cervix.
Uterus subseptus involves a partial septum that does not reach the cervix. Twins apparently occur approximately three times more often in women with this condition than in women with normal uteri; the cause is not clear.
Uterus arcuatus is a normal uterus without a septum. The fundus, however, is notched or flattened. There is usually no interference with normal pregnancy.
Uterus unicornis is a uterus with a single horn. A normal vagina and a single normal tube are usually present. The other half of the uterus is usually absent or rudimentary. In most patients the kidney is missing on the side of the missing uterus. Successful pregnancy can occur.
Separate hemiuteri with separate vaginas is a rare condition that is usually associated with duplications of urethra and bladder or of the colon and anus. Pregnancy in each of the two hemiuteri in the same woman at different times has been reported.
These anomalies result from failure of fusion of the paired müllerian ducts, but in some instances there is a true duplication of the ducts on one or both sides. Such duplications result from splitting of the müllerian duct during the seventh week of development. Accessory tubes or ovaries may be present.
Semmens extensively reviewed the literature on genital tract anomalies and evaluated 56 personal patients as well as 500 cases from the literature. He employed a simplified classification, based entirely on the functional capacity of the uterine cavity, which divided genital tract anomalies into two groups: group I—hemiuterus of single müllerian origin, paired or otherwise, and group II—uterus of dual müllerian origin, associated with varying degrees of absorption. He concluded that if the entire functional component has been derived from a single müllerian duct and its vaginal outlet is a cervical canal of similar origin its capacity is smaller than that of the uterus resulting from fusion of bilateral ducts.
By contrast, if the uterus is derived from two müllerian ducts, its capacity is larger. Semmens concluded that the space available for the developing fetus as well as the variations in uterine circulation had a direct effect on the length of gestation, onset and behavior of labor, and overall fetal salvage. The diagnosis of uterine anomalies during pregnancy is always difficult. The most important factor is awareness of their existence and frequency and of the problems that frequently develop. Findings such as a floating head at term without apparent cause, notching and broadening of the uterine fundus, abnormal lie, recurrent breech presentations, prolonged third stage of labor, and trapped or retained placenta indicate the possibility of an anomaly. In abnormal uteri, triangular spasm and cornual pocketing of the placenta may occur and necessitate manual removal of the placenta.
The administration of oxytocin under these circumstances usually increases the degree of pocketing in an abnormal uterus. Among antepartum patients, pyelitis (often associated with a urologic anomaly), passage of a decidual cast, hemorrhage, and premature rupture of the membranes are the most common complications. Intrapartum complications include septal dystocia, incarcerated nongravid horn, uterine inertia, and retained placenta. Fetal dystocia is considerably increased. Postpartum complications are few and include hemorrhage, retained placenta, and failure of uterine involution. Most complications of uterine anomalies in the pregnant woman can be anticipated and managed successfully if the clinician is alert to the possibility of anomalies and if the nature of the anomaly is known.
The finding of an asymmetrically located cervix in the vaginal fornix, an excessively large cervix whether or not a septum is present, or a duplicated cervix suggests uterine abnormality. Abnormal configurations of the fundus of the uterus in the third trimester should suggest abnormalities to the clinician, as should abnormal presentations and failure of the presenting part to engage without apparent reason. An obstetric history of successive abortions, recurrent breech presentations, or recurrent pyelitis should alert the obstetrician to the possibility of anomalies and, in nonpregnant women, to the need for hysterosalpingogram, saline sonography, magnetic resonance imaging, and renal imaging.
Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals with over 14 years of experience in handling all kinds of Gynecological conditions including uterine abnormalities.