Bicornuate Research Articles

Impact of uterine malformations on pregnancy and neonatal outcomes of IVF/ICSI-frozen embryo transfer.

What is the impact of uterine malformations on reproductive and neonatal outcomes of IVF/ICSI-frozen embryo transfer? Unification defective uteri are associated with poorer neonatal outcomes including higher preterm delivery rate and lower birthweight, and septate uteri are associated with worse fertility outcomes including higher miscarriage and lower live birth rates (LBRs). Several studies have investigated the negative effects of uterine malformations on pregnancy outcomes. However, an all-round and definitive conclusion has not been reached yet owing to the relatively low incidence of the disease and the heterogeneity of study populations, especially among women undergoing ART. This was a retrospective cohort study including 411 women with congenital uterine anomalies and 14 936 women with a normal uterus who underwent first frozen-thawed embryo transfer cycles of IVF/ICSI from July 2008 to August 2019. We compared reproductive outcomes. Reproductive outcomes of women with uterine malformations were studied through three propensity score-matched comparisons (patients with bicorporeal uterus, septate uterus and hemi-uterus [bicorporeal, septate and hemi-uterus groups, respectively] along with corresponding control groups without uterine malformations). We also compared pregnancy and neonatal outcomes, and performed subgroup analysis addressing didelphus, bicornuate uteri and septate uteri before and after surgery independently. Compared to the matched control group, women with a bicorporeal uterus had a significantly lower LBR (24.4% versus 34.8%, odds ratio (OR) 0.61 [95% CI: 0.37, 1.00], P = 0.048). The incidence of miscarriage and preterm delivery was higher but not statistically significant (29.0% versus 18.1%, OR 1.85 [95% CI: 0.82, 4.19], P = 0.135; 22.6% versus 9.9%, OR 2.64 [95% CI: 1.07, 6.52], P = 0.063, respectively). In addition, the bicorporeal group had a significantly lower gestational age, higher caesarean rate and lower birthweight than bicorporeal control. Women with a septate uterus had comparable clinical pregnancy rates to controls (43.3% versus 49.9%, OR 0.77 [95% CI: 0.57, 1.04], P = 0.091), increased miscarriage rates (23.5% versus 13.0%, OR 2.05 [95% CI: 1.18, 3.58], P = 0.010) and lower LBRs (29.4% versus 42.2%, OR 0.57 [95% CI: 0.41, 0.79], P = 0.001). In both singleton and twins pregnancies, pregnancy and neonatal outcomes were comparable between women with a septate uterus and control. Women with a hemi-uterus had a tendency for lower clinical pregnancy rate (36.8% versus 42.3%, OR 0.80 [95% CI: 0.52, 1.21], P = 0.287) and LBR (29.8% versus 33.1%, OR 0.86 [95% CI: 0.55, 1.34], P = 0.502), compared to women without malformations. The incidences of miscarriage and preterm delivery, respectively, were 16.7% versus 16.6% (OR 1.01 [95% CI: 0.41, 2.47], P = 0.989), and 9.5% versus 11.4% (OR 0.82 [95% CI: 0.27, 2.51], P = 1) in women with a hemi-uterus as compared to control. This was a single-centre, retrospective study in which neonatal data were extracted from parental questionnaires. The information on uteri septum type and surgery methods was poorly presented, with limited detail. In patients with uterine malformations, the number of babies with birth defects and twin pregnancies was relatively small, limiting the power of the study. Compared to patients with a normal uterus, women with uterine malformation have poorer reproductive outcomes. Pregnant women with a uterine anomaly need to be managed as high-risk pregnancies and followed with appropriate obstetric review. This work was supported by the National Ministry of Technology (2018YFC1003000), the Elite Team Project of Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JY201801), Shanghai Sailing Program (21YF1423200) and the Fundamental Research Program Funding of Ninth People's Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JYZZ117). B.W.M. is supported by an NHMRC Investigatorgrant (GNT1176437). B.W.M. reports consultancy (with stock options) for ObsEva. B.W.M. has received research funding from Ferring and Merck. The authors declare no other competing interests. N/A.

Pattern of Morphological Anomalies of Uterus as Observed by Modern Investigation Techniques

Abstract Background: Due to the high prevalence and possible impact on the reproductive health of the of woman, congenital uterine malformation of female genital tract is a challenge for the therapeutic decision-making process. The current study aimed to evaluate the morphological anomalies of the uterus as observed by modern investigation techniques. Methods: This cross-sectional observational study was done in Prathima Institute of Medical Sciences, Nagnoor, Karimnagar, Telangana state. Women who were infertile and anxious to conceive and women were subjected to 2D ultrasound Screening followed by Hysterosalpingography. Those women who were fertile and found to have uterine anomalies and needed reconfirmation of the provisional diagnosis were subjected to Hysterosalpingography. Results: Out of n=300 cases studied n=288 (96%) were with normal uterine anatomy and n=12 (4%) cases were detected with uterine malformations as seen by USG. N=5 (40.5%) had a Bicornuate Uterus. While uterus didelphys and unicornuate uterus were seen in n=2 (16.67%) each. Arcuate uterus, uterine septum, uterine Aplasia/Hypoplasia were seen in n=1(8.33%) women each respectively. Conclusion: Due to the psychological consequences associated with infertility, the effects of uterine anomalies on the life of women are very important. It is critical to know the exact nature of the anomaly, to plan for the most appropriate treatment modality. As most of these anomalies cannot be rectified by medical management, they need surgical correction. For optimal results, it is important to know the exact type of anomaly for surgical correction. The 2D USG can be recommended as the basic modality to evaluate uterine anomalies. HSG/MRI may be used to delineate detail of anomalies if initially detected by the 2D scan.

Short Bones, Renal Stones, and Diagnostic Moans: Hypercalcemia in a Girl Found to Have Coffin-Lowry Syndrome

Pathogenic variants in RPS6KA3 are associated with Coffin-Lowry syndrome (CLS), an X-linked semidominant disorder characterized by intellectual disability, stimulus-induced drop attacks, distinctive facial features, progressive kyphoscoliosis, and digit anomalies in hemizygous males. Heterozygous females may also have features of CLS; however, there can be considerable phenotypic variation, often attributed to ratios of X-inactivation in various tissue types. Although skeletal anomalies and short stature are hallmarks of CLS, hypercalcemia has not been reported. Here we describe a 30-month-old girl with gross motor delays, short stature, dysmorphic features, bilateral duplicated renal collecting systems, and no family history of hypercalcemia who required multiple admissions for idiopathic hypercalcemia necessitating bisphosphonate infusions at 12.5 and 15 months of age. A maternally inherited likely-pathogenic variant in RPS6KA3 was identified by trio exome sequencing, consistent with the diagnosis of CLS in the proband and her mother. Maternal history was notable only for decreased height compared to first-degree relatives, bilateral genu valgum, and a bicornuate uterus; she was later found to also have a partially duplicated left renal collecting system. Subsequent X-inactivation studies in blood aligned with the phenotypic variation between mother and daughter. Although hypercalcemia is not a reported feature in CLS, there is evidence of interrupted osteoblast differentiation, providing a potential mechanism for hypercalcemia in this genetic condition. The hypercalcemia in this case may represent a severe presentation of an unrecognized clinical feature in CLS that resolves with age. This case further highlights the intrafamilial phenotypic variation of CLS among females, suggesting X-inactivation as the underlying mechanism, and demonstrates the value of exome sequencing in patients for whom a genetic disorder is highly suspected but not identified despite thorough evaluation.

Early Abortion of a Spontaneous Twin Pregnancy in a Unicervical Bicornuate Uterus: Accidental Discovery at the Principal Hospital in Dakar, Senegal

Early Abortion of a Spontaneous Twin Pregnancy in a Unicervical Bicornuate Uterus: Accidental Discovery at the Principal Hospital in Dakar, Senegal

Case of total laparoscopic hysterectomy in a patient with a uterus bicornis bicollis with vaginal septum

Case of total laparoscopic hysterectomy in a patient with a uterus bicornis bicollis with vaginal septum

Bicornuate Uterus with Previous C-Section: A Case Report

Abstract: Bicornuate uterus is a type of Mullerian duct malformation caused by incomplete fusion of fundal uterine cornu that leads to two connected uterine cavities and one cervix. The incidence of bicornuate uterus is estimated to be 0.1-0.6% and it is believed to account for 10% of all uterine anomalies. We reported a case of bicornuate uterus with previous cesarean sections in an expecting mother presented in labor during her 38-39 weeks of pregnancy. She had a history of two previous cesarean sections. Based on physical examination and transabdominal USG, the fetus was found in breech presentation. She was managed with another cesarean section. During the operation it was found that she had a bicornuate uterus. The main problems for this case were pregnancy with bad obstetric history, previous cesarean sections, breech presentation, and complications that could occur in future pregnancy. The patient was presented already in labor, so she was managed with emergency cesarean section to reduce the risk of uterine rupture. During the operation, she was found to have a bicornuate uterus. This proved that the cause of repeated breech presentation was one of the complications that could occur in pregnancy with bicornuate uterus. The most ideal management for this patient was elective cesarean section. In conclusion, uterine abnormalities are accompanied with uneventful outcomes such as preterm labour, fetal malpresentations, and even perinatal mortality. However, these anomalies may not be suspected before the occurrence of abortion or its complications. A high index of suspicion is needed to diagnose uterine abnormalities before the occurence of its complicationsKeywords: bicornuate uterus; breech presentation; pregnancy; Mullerian duct anomalies

Embarazo a término en útero bicorne con cuerno rudimentario no comunicante. Reporte de un caso

The bicorne uterus with a rudimentary non-communicating horn may be associated with gynecological and obstetric complications such as infertility, endometriosis, hematometra, urinary tract abnormalities, abortions, and preterm deliveries. Excision of the rudimentary horn should be done outside of pregnancy, with followup during pregnancy, looking for complications. We present the case of a 40-year-old patient, who presented abdominal pain and vaginal bleeding, with a full-term pregnancy in a rudimentary non-communicating horn of a bicorne uterus. Physical examination showed abdominal distention and loss of uterine contour and no fetal parts were palpated. The provisional diagnosis of rupture of the uterus was made. Emergency laparotomy revealed a dead and deformed fetus, 37 weeks old, in a bicorne uterus with a broken rudimentary non-communicating horn, along with an acretic placenta. Extraction of the gestational sac, fetus and placenta and subtotal hysterectomy with conservation of the left annex were performed. Keywords: Rudimentary horn not communicating, Bicornuate uterus, Term pregnancy

Expression of the anti-Müllerian hormone receptor (AMHR2) in the endometrium of patients with uterine anomalies

BACKGROUND: Uterine anomalies are a cause of female reproductive failure. Originally, malformations of the Mllerian ducts are believed to be the main reason for uterus abnormalities. There is an assumption that anti-Mllerian hormone (AMH) or AMH receptor (AMHR2) gene mutation may lead to alterations in the formation of the Mllerian ducts in female fetuses resulting in uterine anomalies.
 AIM: The aim of this study was to assess the AMHR2 expression in the endometrium of patients with uterine anomalies and a history of reproductive failure.
 MATERIALS AND METHODS: The present study included 112 women, of whom 92 patients were diagnosed with uterine anomalies (main groups): arcuate uterus (n = 30), septated uterus (n = 30), bicornuate uterus (n = 12), unicornuate uterus (n = 10), didelphys uterus (n = 10); and 20 patients had normal uterine anatomy (control group), with the secretory phase (n = 10) and the proliferative phase (n = 10) of menstrual cycle evaluated. Histological and immunohistochemical studies of the endometrium were carried out according to the standard technique with an assessment of AMHR2 marker expression in the biopsy samples.
 RESULTS: The AMHR2 area expression in the endometrial stroma was significantly lower in patients with septated uterus compared to those with arcuate uterus (р 0.001). The same tendency was noted when compared to other uterine anomalies and healthy controls. AMHR2 expression in the endometrial stroma of patients with arcuate uterus was significantly higher compared to unicornuate uterus (p 0.05).
 CONCLUSIONS: The data obtained suggest that morphofunctional characteristics of the endometrium in patients with uterine anomalies have no specific pathognomonic features. The decline in AMHR2 expression in the endometrial stroma seems to be related to chronic endometritis, as an inverse correlation exists between the AMHR2 area expression and chronic endometritis, compromising pregnancy occurrence.

Undiagnosed advanced abdominal pregnancy: a case report

<p class="abstract">Abdominal pregnancy is a rare form of extra-uterine gestation in which implantation occurs in the peritoneal cavity, unlike this case it rarely reaches advanced gestation and viability of fetal outcome are not commonly documented. Abdominal pregnancy accounts for about 1-2% of ectopic gestation. It is associated with poor fetal outcome and great morbidity and mortality due to heamorrhage especially in a low resource setting. We present an undiagnosed advanced case of abdominal pregnancy of a 30 yr old unbooked G2P1+0 (1A) with early ultrasound estimation of 37 weeks and 6 days. She presented with (abdominal) labour pains and ultrasound diagnosis of breech presentation, suspicion of a bicornuate uterus and intrauterine growth restriction. She was planned for emergency cesarean delivery on this basis but found advanced abdominal pregnancy, and subsequently on delivery had good maternal and fetal outcome. Abdominal pregnancy with live fetus is extremely rare, and requires a high index of suspicion, to avoid high risk of maternal morbidity and mortality and it is also imperative for all healthcare givers to localized pregnancy whenever they get in contact with a woman who has recently missed her period.</p>

Correlation of laparoscopic finding with ultrasonography and hysterosalpingography findings in females with infertility

Infertility is best defined as the inability to conceive after one year of unprotected regular intercourse or many couples, infertility and its treatment cause a serious strain on their interpersonal relationship, and cause disturbed relationships with other people.Diagnostic laparoscopy is generally not a part of initialinfertility evaluation, however, number of reports haveshown that it is effective procedure for evaluation of long- term infertility. A total of 207 patients were studied from at GMCH, Gondia, Maharashtra. Total 207 patients had primary/secondary infertility and 5 patients had primary amenorrhea were selected for study. Uterus, ovaries, tubes and cul de sac were inspected and findings noted. Next chromopertubation test was done with 10-15 ml of 1% aqueous methylene blue via the leech-Wilkinson cannula was inserted and findings noted and statistical Analysis was done.India showed the mean age of infertility was 28.4years. 81.16% subjects had primary whereas 16.43% had secondary infertility.In the present study maximum 165 (79.7%) had normal size uterus. Out of which 8 (3.86%) had bicornuate uterus.6.28% subjects had large size uterus. Out of which 5.80% had fibroid and 0.48% had adenomyosis.Diagnostic Laparoscopy and hysteroscopy is a better modality for diagnosing uterine, tubal and ovarian causes of infertility compared to hysterosalpingography and ultrasonography. Most of the patients had normal ultrasonographic, hysterosalpingographic and laparoscopic findings. Out of the rest, Structural adhesions were the most common cause of infertility among women in reproductive group.

Childbirth of twins in a woman with a bicornuate uterus

In the literature available to us, we have never met a single case of childbirth with viable fetuses with a two-horned uterus, pregnant with twins, and therefore we consider it interesting to cite our observation.

Endometrial Micropoliposis, Hysteroscopic Manifestation of Chronic Endometritis

Study Objective Identify the relationship between hysteroscopic findings of micropoliposis and the histopathological result of chronic endometritis in a series of cases. Design Between 02/01/17 and 02/15/21, cases diagnosed with endometrial micropoliposis were analyzed through hysteroscopy and histopathology in the gynecological endoscopic surgery service of the Hospital “Lic. Adolfo López Mateos” ISSSTE. Setting Hysteroscopy in gynecological position, 2.7 mm outer diameter lens, 105 ̊ visual field angle, 4.5 mm outer diameter. Saline solution was used to dilate the uterine cavity. The anterior and posterior uterine walls were examined. Patients or Participants 42 patients undergoing hysteroscopy were included in which micropoliposis was reported. Interventions A biopsy was taken of the compatible lesions with micropoliposis by hysteroscopy, reporting inflammatory infiltration with plasma cells was reported in relation to endometritis. Measurements and Main Results The mean age was 28 years, 39 with abnormal uterine bleeding (92%), 1 with infertility (2%) and 2 with a bicornuate uterus with a non-communicating cavity (4%), no patient presented data of vaginal or pelvic infection, cultures: Mycoplasma hominis in 17 (40%), Ureaplasma urealyticum in 15 (35.7%), Chlamydia in 2 (4%), E. Coli in 4 (8%), Gardnerella vaginalis in 2 (4%) and 2 with Müllerian malformations and negative cultures (4%). All patients were treated according to antibiogram with a new culture after 3 months, the infection persisted in 3 patients (7%), having negative cultures with a second antibiotic scheme. All patients had improvement in bleeding, after the management of the Müllerian malformation, micropoliposis persisted 6 months after surgery. Conclusion Chronic endometritis can be manifested as micropoliposis by hysteroscopy, just with abnormal uterine bleeding without data of an active infectious process. Although chronic endometritis has been mentioned as an infertility factor, none of our patients had a desire for pregnancy. In the presence of endometrial micropoliposis by hysteroscopy, chronic endometritis should be suspected, and special cultures against Mycoplasmas and Chlamydia should be performed. Identify the relationship between hysteroscopic findings of micropoliposis and the histopathological result of chronic endometritis in a series of cases. Between 02/01/17 and 02/15/21, cases diagnosed with endometrial micropoliposis were analyzed through hysteroscopy and histopathology in the gynecological endoscopic surgery service of the Hospital “Lic. Adolfo López Mateos” ISSSTE. Hysteroscopy in gynecological position, 2.7 mm outer diameter lens, 105 ̊ visual field angle, 4.5 mm outer diameter. Saline solution was used to dilate the uterine cavity. The anterior and posterior uterine walls were examined. 42 patients undergoing hysteroscopy were included in which micropoliposis was reported. A biopsy was taken of the compatible lesions with micropoliposis by hysteroscopy, reporting inflammatory infiltration with plasma cells was reported in relation to endometritis. The mean age was 28 years, 39 with abnormal uterine bleeding (92%), 1 with infertility (2%) and 2 with a bicornuate uterus with a non-communicating cavity (4%), no patient presented data of vaginal or pelvic infection, cultures: Mycoplasma hominis in 17 (40%), Ureaplasma urealyticum in 15 (35.7%), Chlamydia in 2 (4%), E. Coli in 4 (8%), Gardnerella vaginalis in 2 (4%) and 2 with Müllerian malformations and negative cultures (4%). All patients were treated according to antibiogram with a new culture after 3 months, the infection persisted in 3 patients (7%), having negative cultures with a second antibiotic scheme. All patients had improvement in bleeding, after the management of the Müllerian malformation, micropoliposis persisted 6 months after surgery. Chronic endometritis can be manifested as micropoliposis by hysteroscopy, just with abnormal uterine bleeding without data of an active infectious process. Although chronic endometritis has been mentioned as an infertility factor, none of our patients had a desire for pregnancy. In the presence of endometrial micropoliposis by hysteroscopy, chronic endometritis should be suspected, and special cultures against Mycoplasmas and Chlamydia should be performed.

A Stepwise Approach to Hysterectomy Complicated By Mullerian Anomaly: A Case of a Bicornuate Uterus

<h3>Study Objective</h3> To demonstrate a stepwise laparoscopic approach to patients with Mullerian anomalies. <h3>Design</h3> N/A. <h3>Setting</h3> Patient with a bicornuate uterus and right ovarian teratoma undergoing total laparoscopic hysterectomy, bilateral salpingectomy, and right oophorectomy. <h3>Patients or Participants</h3> The patient is a 35-year-old G5P0141 female with menorrhagia, pelvic pain, and a right ovarian teratoma undergoing definitive surgical management with a total laparoscopic hysterectomy, bilateral salpingectomy, and right oophorectomy. <h3>Interventions</h3> The hysterectomy started on the side that appeared more anatomically normal. On the contralateral side, the uterine artery was ligated at its origin. A ureterolysis was performed to safely detach the left uterine horn from the side wall. A partial amputation of the accessory horn allowed for completion of the hysterectomy. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Since Mullerian anomalies are uncommon, it is important to have a framework when approaching hysterectomies in patients with Mullerian anomalies.

Isolated pyosalpinx in a pre-teen with bicornuate uterus

Pyosalpinx is a condition usually seen in a sexually active female. In literature, only a few cases have been reported in a virginal girl presenting with pyosalpinx. Herein we report a case of an 11-year-old virginal girl with pyosalpinx treated by laparoscopic drainage and antibiotics.

A successful pregnancy outcome after surgical treatment for a bicornuate uterus. Case report

This article presents a clinical case in a woman with a full two-legged uterus. This pathology in the patient was revealed by ultrasound examination in 2013. There is one spontaneous miscarriage in the anamnesis; later, the patient did not become pregnant with regular sexual activity without contraception. A comprehensive examination of the patient was carried out. It was decided to conduct a hysteroscopy, during which one cervical canal was identified, in the area of the internal pharynx, a division into two hemipolostas was visualized. In the future, the patient underwent Strassmanns reconstructive plastic surgery, which is the gold standard for this pathology. Laparatomic metroplasty is a safe and effective procedure for women with a bicornuate uterine malformation. The postoperative period was uneventful. A year later, the patient became pregnant in the natural cycle. Pregnancy proceeded without complications, culminating in the birth of a healthy child.

O-005 Mullerian anomalies overview

Abstract text Mullerian Duct Anomalies- An Overview Prof. Sudha Prasad President Indian Fertility Society, Director, Matritava Advanced IVF &amp; Training Centre, New Delhi, India Congenital anomalies of the mullerian duct system is one of the complex disorder encountered in gynecological practice. Mullerian ducts are paired embryological structures which undergo fusion and resorption in utero to form the uterus, fallopian tubes, cervix and upper two-thirds of the vagina. Disruption in the mullerian duct development throughout embryogenesis could result a large spectrum of inherent abnormalities identified as mullerian duct anomalies (MDAs). There is a wide variation in the prevalence of MDAs across various studies, ranging from 1–10% in the general population to 2–8% among infertile women and 5–30% among women with a history of miscarriage. These discrepancies in the reported prevalence are mainly attributed to lack of a universal classification system. Different varieties of malformations can occur when this system is not well developed. It ranges from absence of uterus, cervix or vagina, septum/duplication of vagina to of the uterus and vagina to minor uterine cavity abnormalities. Mullerian malformations are frequently associated with abnormalities of the renal and axial skeletal systems. Therefore, on initial examination of MDAs patients, these points should be kept in mind. Most mullerian duct anomalies (MDAs) are associated with functioning ovaries and age-appropriate external genitalia. These abnormalities are often recognized after the onset of puberty. After the onset of puberty, young women often present to the gynecologist with menstrual disorders. Late presentations include infertility and obstetric complications. A meta-analysis of nine studies comprising 3805 women with congenital uterine anomalies reviewed the obstetric outcome. The study reported that canalization defects such as septate and partial septate uteri had reduce fertility and increase rates of miscarriage and preterm delivery. None of the unification defects (bicornuate, unicornuate and didelphic uteri) reduce fertility but some are related to miscarriage and prematurity. Arcuate uteri are specifically associated with second-trimester miscarriage. All uterine abnormalities increase the risk of fetal malformation during delivery1. A retrospective longitudinal study concluded that reproductive performance of the unicornuate and didelphys uteri was poor (20–30% chance of carrying a pregnancy to term), while that of the septate and bicornuate uteri (live birth rate of 62%) was better than expected. The arcuate uterus had no impact on reproductive performance of women2. Agenesis of uterus and vagina requires surgical techniques, such as the Vecchietti and McIndoe procedures, have enabled many women to have normal sexual relations. Uterine transplant has changed the perspective of all other surgical advances and assisted reproductive technologies to improve fertility and obstetric outcomes3, 4,5.

O-006 Diagnosis debate – USG vs endoscopy

Abstract text MULLERIAN ANOMAIES – DEBATE USG OR ENDOSCOPY Mullerian duct anomalies are a complex spectrum of congenital anomalies resulting from defective fusion or canalization leading to different uterine anomalies. Early detection and proper diagnosis of uterine anomalies are paramount for proper management. Outflow obstruction defects like transvers septal defects or non canalised functional horn present early with complaint of pain while rest of patients present with amenorrhoea , infertility, repeated first-trimester abortion, fetal intrauterine growth restriction, and obstetric complications.The prevalence of uterine malformations is variable depending on the population studied , 0.4% , 4 % respectively in the general population and in infertile women while a high prevalence between 3 and 38% is reported in patients with repeated spontaneous miscarriages. Imaging plays an important role in diagnosis and treatment planning in mullerian duct anomalies. There are different imaging and endoscopic modalities that can be used for the diagnosis and confirmation of uterine malformations. All modalities are having limitations and one need to select and combine various modalities depending on the clinical presentation of patient and pelvic examination. In younger patients or acute cases, trans abdominal ultrasonography (US) is the preferred method because it is readily available, inexpensive, and rapid and does not use ionizing radiation. However it may not give the complete picture because of poor demarcation especially in fatty patient and owing to complex nature of defects , Field-of-view restrictions with US, patient body habitus, and artefact from bowel gas. Pelvic magnetic resonance imaging (MRI) is an excellent tool in the diagnosis of Mullerian duct anomalies due to high soft tissue resolution. But it is more expensive and less available. 3D ultrasound may be a valid alternative to pelvic MRI as It is less expensive and better tolerated by patients however in doubtful cases of complex nature , hysteroscopy combined with laparoscopy may be considered to confirm the diagnosis. Another advantage of endoscopy is the opportunity to correct the defect in the same sitting in most of the cases. Hysterosalpingography (HSG) and hysteroscopy are considered good modalities to assess the uterine cavity. Hysteroscopy provide the direct visualisation of the defect and considered as gold standard for cavity evaluation in doubtful cases of septate and bicornuate uterus and for simultaneous correction. However outer contour cannot be visualised so one need to use laparoscopy for complete evaluation which is a major drawback. Three-dimensional transvaginal sonography provides image quality like those provided by MRI and is being extensively used for diagnosis of all sorts of mullerian defects. it has got the advantage of realtime imaging which is helpful in distorted pelvic anatomy , visualisation of outer contour is possible ,which is considered very important to differentiate between bicornuate and septate uterus and unicornuate uterus with rudimentary horn. however it may not be possible in all cases to get a definitive diagnosis inspite of using a high end 3D machine specially in presence of artefacts , distorted contour and retroverted uterus. In such cases both modalities including MRI and endoscopy may be required to reach to a definitive diagnosis. It can be concluded that primary imaging tool is still 2d ultrasound but 3D TVS should be included in all suspected anomalies along with complete careful pelvic examination to corroborate the findings of USG. In doubt ful or complex cases, MRI should be performed particularly for cervical and vaginal atresia and septum. endoscopy should be reserved for all doubtful cases for confirmation and for acute cases where a corrective surgery can also be planned to relieve the distress.

P–334 CT virtual Histerotomography: a new method for the evaluation of fallopian tube patency and pelvic organs in patients seeking pregnancy

Abstract Study question Can computerized virtual histerotomography (CT-HSG) be used for the evaluation of fallopian tube patency and pelvic organs in patients seeking pregnancy? Summary answer: CT-HSG seems to be an adequate test for the evaluation of fallopian tube patency, pelvic organs, and the uterine cavity. What is known already CT-HSG is a minimally invasive exam, which diagnoses variations in the female reproductive system, uses low radiation doses and is well tolerated by patients. It simultaneously evaluates the uterine wall, cavity and cervix, tubes, and adjacent pelvic structures. The exam enables virtual navigation, which consists of the endoluminal view of the cervical canal and uterine cavity and allows 3D reconstruction of images. The exam remains underused to assess infertility, but previous studies have shown potential and its use may be widespread. Study design, size, duration Retrospective cohort study, that included data from 317 women seeking pregnancy, between January/2019 and January/2021. The CT-HSG was indicated for infertility (90.3%) and RPL (0.9%) investigation, and for the evaluation of tubal stump in patients who were planning the tubal reversal surgery (8.8%). Patients filled out a questionnaire about their pain symptoms and data were collected from electronic records. Participants/materials, setting, methods The study analyzed patients’ clinical characteristics and image findings regarding tubes, uterine cavity, and ovaries. For the exam, a catheter was positioned in the cervix, where the contrast medium (iopromide) was injected through an infusion pump at 0.30 ml/s, for a total of 20ml. The tomographic slices were obtained at the 50th second. The CT-HSG images were interpreted by the same gynecologist and radiologist. Data were analyzed using SPSS version 20.0. Main results and the role of chance Women and partners’ mean age was 32.7 ± 5.6 and 34.6 ± 7.7 years, respectively, and women’s mean BMI was 28.4 ± 6.4 Kg/m². The pain scale was applied in 103 patients, who reported 5.4±3.2 pain scale scores at the end of the exam. Among the infertile patients 67% were nulliparous. Regarding the exam findings, most of the uterus findings were normal (72.6%). The variations found were uterine malformations (including unicornuate uterus, uterus didelphys, bicornuate uterus, septate uterus, and arcuate uterus), synechia, fibroids, endometrial polyps, adenomyosis and retractions/lateralizations that may suggest endometriosis. The tubal findings on the right/left (%) were: 65/67.5 patent horn; 18.9/17.7 obstructed tubes; 4/41 dilatation/hydrosalpinx and 9.4/9.1 with previous history of tubal ligation or salpingectomy; 1.5% of the tubal evaluation were inconclusive. Eleven from 317 patients had to repeat the exam due to occurrences during the execution (for example, improper catheter positioning, cuff fall, stenosis of the internal cervical ostium, severe pain).The 3D analysis and virtual navigation assist in the findings assessment, in addition to being simpler for the gynecologists evaluation. Limitations, reasons for caution The sample size is small due to the exam being a new technique. Patient follow-up and correlation with laparoscopy and hysteroscopy, when indicated, are under studied. Wider implications of the findings: The exam seems to be promising for assessing infertility, RPL and the tubal stump. Moreover, it may be a good option to hysterosalpingography as it seems to cause less pain and allows to evaluate the ovaries and the uterine contour, added to 3D reconstructions and to virtual uterine navigation. Trial registration number Not applicable

Management of bladder exstrophy in an adolescent girl: a case report

Bladder exstrophy (BE) is a very rare congenital abnormality, especially in girls. We reported a 17-year-old girl with protruded bladder and urinary incontinence. Her vaginal orifice appeared stenotic and shifted anteriorly. She had an incomplete labia minora, short perineum, and anterior displacement of the anus. The pelvic radiography showed a pubic diastasis with a manta ray sign, and the ultrasonography examination showed a bicornuate uterus. She had undergone a functional reconstruction surgery with cystectomy, ileal conduit, appendectomy, and vaginoplasty along with the advancement of abdominal flap reconstruction with multiple Z-plasty. Functionally, she was able to urinate through the ileal conduit comfortably, had a regular menstrual cycle with minimal pain, had a wider vaginal canal, and had a smooth blood flow. Aesthetically, she had a good lower abdomen appearance, remained dry, and had an odorless urine. In clinical practice, this rare case report can provide additional knowledge and management of the same cases with effective results.

Novel non-operative treatment of uterovaginal prolapse in a preterm neonate

Uterovaginal prolapse (UVP) is a rare condition that occurs in neonates. The case report presented here details an extremely rare, and potentially unique, occurrence of UVP in a premature infant whose prolapse was found to be secondary to an anatomical cause. The preterm newborn developed UVP three weeks after birth. Further investigation identified a bicornuate uterus and an ovarian mucus cyst that was likely secondary to the effect of maternal hormones upon the infant. A conservative and novel management method, using a feeding nipple/sterilized gauze soaked with petroleum jelly, and continuous monitoring, helped resolve the UVP. As a result of this case and our experience in diagnosing and treating UVP, we created a flowchart (included herein) for the diagnosis of UVP in newborns, including those who are premature.