septum, however, may interfere with descent.

A transverse septum causes an obstruction of variable

thickness, and it may develop at any depth within the vagina.
Occasionally, the upper vagina is separated from the rest of
the canal by a septum with a small opening. Gibson (2003)
reported this in association with miscarriage and described
dilatation of the septal opening to permit evacuation of products.
In labor, such strictures may be mistaken for the upper
limit of the vaginal vault, and the septal opening is misidentified
as an undilated cervical os. If encountered during labor,
and after the external os has dilated completely, the head
impinges on the septum and causes it to bulge downward.
If the septum does not yield, slight pressure on its opening
usually leads to further dilatation, but occasionally cruciate
incisions are required to permit delivery (Blanton, 2003). If
there is a thick transverse septum, however, cesarean delivery
may be necessary.
■ Cervical Abnormalities
Developmental abnormalities of the cervix include partial
or complete agenesis, duplication, and longitudinal septa.
Uncorrected complete agenesis is incompatible with pregnancy,
and IVF with gestational surrogacy is an option. Surgical correction
by uterovaginal anastomosis has resulted in successful
pregnancy (Deffarges, 2001; Fedele, 2008). There are significant
complications with this corrective surgery, and the need
for clear preoperative anatomy delineation has been emphasized
by Rock (2010) and Roberts (2011) and their colleagues.
For this reason, they recommend hysterectomy for complete
cervical agenesis and reserve reconstruction attempts for carefully
selected patients with cervical dysgenesis.
■ Uterine Abnormalities
From a large variety, a few of the more common congenital
uterine malformations are shown in Table 3-1. Accurate population
prevalences of these are difficult to assess because the
best diagnostic techniques are invasive. The reported population
prevalence ranges from 0.4 to 5 percent, and rates in
women with recurrent miscarriage are significantly higher
(Acién, 1997; Byrne, 2000; Chan, 2011b). In a review of 22
studies with more than 573,000 women who were screened for
these malformations, Nahum (1998) reported the distribution
of uterine anomalies as follows: bicornuate, 39 percent; septate,
34 percent; didelphic, 11 percent; arcuate, 7 percent; unicornuate,
5 percent; and hypo- or aplastic, 4 percent.
Müllerian anomalies may be discovered at routine pelvic
examinations, cesarean delivery, during laparoscopy for tubal
sterilization, or during infertility evaluation. Depending on
clinical presentation, diagnostic tools may include hysterosalpingography,
sonography, MR imaging, laparoscopy, and
hysteroscopy. Each has limitations, and these may be used in
combination to completely define anatomy. In women undergoing
fertility evaluation, hysterosalpingography (HSG) is
commonly selected for uterine cavity and tubal patency assessment.
That said, HSG poorly defines the external uterine contour
and can delineate only patent cavities. It is contraindicated
during pregnancy.
In most clinical settings, sonography is initially performed.
Transabdominal views may help to maximize the viewing
field, but transvaginal sonography (TVS) provides better
image resolution. For this indication, the pooled accuracy for
TVS is 90 to 92 percent (Pellerito, 1992). Saline infusion
sonography (SIS) improves delineation of the endometrium
and internal uterine morphology, but only with a patent
endometrial cavity. Also, SIS is contraindicated in pregnancy.
Three-dimensional (3-D) sonography is more accurate than
2-D sonography because it provides uterine images from virtually
any angle. Thus, coronal images can be constructed,
and these are essential in evaluating both internal and external
uterine contours (Olpin, 2009). Both 2-D and 3-D sonography
are suitable for pregnancy. In gynecological patients,
these are ideally completed during the luteal phase when
the secretory endometrium provides contrast from increased
thickness and echogenicity (Caliskan, 2010).
Several investigators have reported very good concordance
between 3-D TVS and MR imaging of müllerian anomalies,
although MR imaging is currently preferred for imaging such
defects (Bermejo, 2010; Ghi, 2009). MR imaging provides
clear delineation of both the internal and external uterine
anatomy and has a reported accuracy of up to 100 percent in
the evaluation of müllerian anomalies (Fedele, 1989; Pellerito,
1992). Moreover, complex anomalies and commonly associated
secondary diagnoses such as renal or skeletal anomalies
can be concurrently evaluated. Precautions with MR imaging
in pregnancy are discussed in Chapter 46 (p. 934).
In some women undergoing an infertility evaluation, hysteroscopy
and laparoscopy may be selected to assess for müllerian
anomalies;