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Europ. J. Ohstet. Gwec. reprod. Biol.

, 17 (1984) 345-350 345


Elsevier

EJO 00081

Uterus didelphys: a report of 26 cases

P.K. Heinonen

HEINONEN, P.K. (1984): Uterus didelphys: a report of 26 cases. Europ. J. Ohstet. Gyttec. reprod. Biol.,
17/5, 345-350.
Twenty-six female patients with uterus didelphys were observed over a period of 21 yr. All the patients
also had a longitudinal vaginal septum. Dysmenorrhea, dyspareunia and leukorrhea were the most
common symptoms among the symptomatic cases. Eighteen women had a total of 40 pregnancies with a
fetal survival rate of 67.5%. and perinatal mortality rate of 3.6%. Premature delivery occurred in 21% of
the pregnancies. Breech presentation occurred in 43% and cesarean section was performed in 82% of the
cases. Of the 17 intravenous pyelograms performed six (35%) showed abnormalities and four had the
absence of a kidney. Women with uterus didelphys belong to a high-risk group, although pregnancy
outcome is comparatively good.

kidney anomaly; uterine anomaly: vaginal septum

introduction

Uterus didelphys is the result when two mullerian ducts do not reach each other
and develop side by side. This genital anomaly has been the subject of many case
reports of simultaneous pregnancies in each uterus, pregnancy wastage and obstetric
complications, but the interpretation of such reports is difficult, since no uniform
criteria for case definition have been used. For example, the didelphic and un-
icornuate uteri are often grouped together with a hemiuterus. Didelphic uterus is
often associated with a longitudinal vaginal septum which may cause dyspareunia,
dystocia, leukorrhea and hemivagina if it is completely obstructed.
The aim of this study was to analyse in more detail the gynecologic and obstetric
implications in 26 females with uterus didelphys.

Materiaf and methods

A total of 26 females with uterus didelphys were observed at the Department of


Obstetrics and Gynecology, at the University Central Hospital of Tampere, Finland,
from March 1962 to June 1983. The reproductive and operative history of each
patient was retrospectively studied. Legal abortions were excluded. Table I shows
the primary clinical complaint the patients had at the admittance to hospital.

0028-2243/84/$03.00 0 1984 Elsevier Science Publishers B.V.


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Hysterosalpingogram (HSG) and laparotomy or laparoscopy was performed in 8


cases, cesarean section in 8 cases, HSG, laparotomy and laparoscopy each in 1 case,
curettage in 4 cases, ultrasound in 2 cases, and only pelvic examination in 1 case.
Intravenous pyelogram was obtained in 17 patients for the evaluation of renal status.

Results

The mean age of the patients was 24.8 yr (range, 17 to 45 yr). Menarche ranged
from 11 to 18 yr (mean, 12.9 yr). All except 5 women had a history of normal regular
menses. Sixteen (62%) of the 26 patients had dysmenorrhea.
Twenty-four women had a complete longitudinal vaginal septum and 2 women
had a partial vaginal septum. Hemivagina caused by an obstructed vaginal septum
was not found in any of the cases, although a partially obstructed septum was found
in 4 cases. Six patients suffered from dyspareunia, which indicated excision of the
vaginal septum. In addition the septum was excised in 1 case because it caused
dystocia, and in 1 case leukorrhea indicated removal of the vaginal septum. A
rectovesical ligament was found during the operation in 10 cases (Fig. 1.).
Two women had primary infertility. The reason for infertility was hormonal in
both cases. Both of them conceived after diagnostic curettage without any treatment.
An intrauterine device in both uterine cavities was used in 2 cases without complica-
tions. Metroplasty was not performed in any case.
Eighteen of the women had been pregnant and 8 women had not been pregnant.
One woman had 4 pregnancies, 6 women had 3 pregnancies, 7 women had 2
pregnancies and 4 women had 1 pregnancy. Table II summarizes the outcome of the
pregnancies. The fetal survival rate was 67.5% and the perinatal mortality rate 3.6%
Threatened abortion occurred in 9 (32%) cases, and hemorrhage was mostly from the
nonpregnant uterus caused by decidual reaction in the same uterus. Pregnancy was
in the right uterus in 12 women, in the left uterus in 5 women, and in both uteri in
turns in 2 cases.
Cervical cerclage was applied in 2 patients, both of whom had a history of
second-trimester miscarriage. In the first case, the cerclage was applied around both
cervices, and in the second case only around the cervix of the pregnant uterus. The

TABLE I

Primary clinical complaints in 26 patients with uterus didelphys

Complaint No. of
patients

Pregnancy
Routine examination
Abdominal pain
Dyspareunia
Bleeding
Leukorrhea
Pelvic tumor
Primary infertility
Fig. 1. Uterus didelphys photographed at cesarean section. Rectovesical ligament folds between the uteri
attach to the sigmoid which is partially adhered to the right uterus where the pregnancy was.

frequency of breech presentation was 4356, which is high when compared with the
overall annual incidence of breech deliveries in our hospital (3.0-4.1s). The rate of
cesarean section was very high (82%). Besides the genital anomaly, indications for

TABLE II
Obstetric complications and pregnancy outcome in 18 patients with uterus didelphys

Observation No. (S)

No. of patients conceiving 18

No. of pregnancies 40

Abortions 12 (30)
I trimester 8
II trimester 3
Ectopic pregnancy 1

Deliveries 28 (70)
Threatened abortion 9
Cerclage applied 2
Toxemia 1
Breech presentation 12 (43)
Cesarean section 23 (82)
Premature 6 (21)
Small for date 3 (II)
Perinatal mortality 1 (3.6)
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cesarean section included breech presentation (9 cases), prematurity (5 cases), and


fetal distress, prolapse of the umbilical cord and repeat cesarean section (1 case).
Of the 17 intravenous pyelograms performed, 6 (35%) showed abnormalities, 4
had the absence of a kidney, and 2 had abnormal shaping of the kidneys. Angiogra-
phy showed abnormal vascularity of both kidneys in 1 of the 2 patients with
abnormal kidney shape. In addition, isotope renogram in 1 case showed normal
functional status of the kidneys. Palpation of the kidneys during cesarean section
was normal in 2 cases.

Discussion

Uterine anomalies are rare, with an incidence of 1 in 200-600 women (Semmens,


1962; Green and Harris, 1976). According to the author’s preliminary results, uterine
anomalies are found in 0.5% of Finnish women. Uterus didelphys occurred in 10%
out of 228 uterine anomalies (Heinonen and Pystynen, 1983). These findings
indicate that uterus didelphys is found in 1 in every 2000 women.
A longitudinal vaginal septum occurred in all women with uterus didelphys. A
vaginal septum is not found solely with uterus didelphys, but it is also common with
other uterine anomalies such as complete bicornuate or septate uterus (Heinonen,
1982). Uterus didelphys without a vaginal septum is rare. A vaginal septum may
cause dyspareunia, leukorrhea and dystocia, which are the most common indications
for its removal. A vaginal septum may cause completely obstructed hemivagina
(Rock and Jones, 1980; Jones, 1981), although it was not found in the present
survey.
The rectovesical ligament is an abnormal structure which occurs only in women
who have either uterus didelphys or a deeply bifurcated bicornuate uterus (Stein-
berg, 1955). This ligament is attached anteriorly to bladder folds between the uteri
and posteriorly to the serosa of the sigmoid (Steinberg, 1955; Mercer et al., 1981).
Both uteri in the uterus didelphys are usually well developed and simultaneous
pregnancy in both is possible (Brody, 1954) though one side is usually dominant. In
the present series pregnancy was in both uteri in 2 cases. Most of the rest of the
pregnancies were in the right uterus. The reason for this is not known.
Dysmenorrhea was a common complaint in women with uterus didelphys, as it is
in women with unicornuate uteri (Heinonen, 1983). Interestingly, infertility was not
common in this group of the uterine anomalies; only 2 patients had primary
infertility. Both of them had a hormonal factor for infertility. It appears that there is
no etiologic relationship between primary infertility and the anomalous uterus
(Heinonen and Pystynen, 1983).
It is possible to apply an intrauterine device to both uterine cavities, and it is even
necessary to give good contraception. It is better to insert devices at different times
to prevent the expulsion of the intrauterine device (Heinonen, 1981).
The fetal survival rate was 68%. Musich and Behrman (1978) reported a 57% fetal
survival rate in 35 pregnancies among 11 patients with uterus didelphys, which was
higher than with other uterine anomalies. Thompson et al. (1966) even found a 93%
success rate of 14 pregnancies in 13 patients. Perinatal mortality (3.6%) was lower
than with other uterine anomalies (Heinonen et al., i982).
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Premature labor is reported to have occurred in lo-90% in uterus didelphys


(Miller, 1922; Green and Harris, 1976). In this study, breech presentation was
common (43%), as reported previously (Green and Harris, 1976). Cervical cerclage
was applied in so few cases that no relevant information is given. The reason for the
high rate of cesarean section is the fact that one uterus may close the pelvic inlet and
cause dystocia similarly to a vaginal septum, which may also lacerate during labor.
It is true that during pregnancy those patients with uterus didelphys belong to a
high-risk group and deserve meticulous prenatal care. We had a follow-up examina-
tion every 4 wk and hospitalization available if there were any complications during
pregnancy. There were 3 small-for-date infants. The measurement of placental
hormones, as well as repeated ultrasonography, is necessary to evaluate fetal
well-being and growth. Cesarean section would now be used as routine at the present
time.
Metroplasty was not performed in any case of the present series. However,
Strassmann-like metroplasty has been reported as being applied to didelphic uteri
(Strassmann, 1966; Capraro et al., 1968; Mercer et al., 1981). The present series
indicates that metroplasty is rarely necessary in these patients. In fact it would be
surprising if the unification of the two uteri gave better results, since both halves of
the uteri are usually well-developed.
Rock and Jones (1980) described a clinical syndrome of the double uterus, a
unilateral partially or completely obstructed vagina and ipsilateral renal aplasia.
Four patients in the present series had renal aplasia and all of them had narrowness
of the vagina caused by septum on the same side, although hemivagina and complete
obstruction were not found in any of the cases. Fistula-like defects at different
points along the septal wall with mucopurulent discharge were found in 4 patients.
Renal anomalies in the uterus didelphys are not so common as in patients with
unicornuate uteri (Woolf and Allen, 1953; Heinonen, 1983). However, the concom-
itant urinary tract anomalies are common (35% in the present series) in women with
didelphic uteri and therefore intravenous pyelography should also be performed in
these patients.

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