Case Report

SUCCESSFUL PREGNANCY OUTCOME IN A CASE OF BI-CORNUATE

UTERUS WITH BOH WITH SECONDARY INFERTILITY AND GDM – A VERY
RARE CASE REPORT.

Dr. Pratima Rani Biswas 1, Dr. Gautom Kumar Paul 2, Dr. Mina Chowdhury 3, DR. Shamim Ahmed 4, Dr. Selim 5Dr. Raihan 6

Abstract
Uterine malformations very often result in poor pregnancy outcome. The incidence of uterine
malformations in general population is estimated to be about 3-5% and 5-10% in women with
poor reproductive outcome2. Fertility and evolution of pregnancy depends on the type of uterine
anomaly. Many of them are asymptomatic but it is important to consider this diagnosis in
recurrent miscarriages - early and late, preterm labors, malpresentations, intrauterine growth
restrictions and menstrual disturbances like menorrhagia, dysmenorrhoea. Septate and arcuate
uterus represent approximately 75% of malformations while bicornuate, didelphys and
unicornuate comprise the remaining 25%. Cases of pregnancy in a bicornuate uterus are still of
sufficient interest and rarity to justify being reported. Airoldi et al . reported that high-risk
obstetric intervention did not significantly increase the fetal survival rate for uncorrected uterine
anomalies5. We are reporting a case of bicornuate uterus with a successful pregnancy outcome
diagnosed at 05 weeks gestation in 5th gravida by ultrasound examination.
Key Words: Bicornuate uterus, mullerian anomaly.

Introduction
Uterine anomalies are not uncommon, it occurs due to abnormal fusion of the para-mesonephric duct
(mullerian duct) during embryonic life result in a variety of congenital uterine malformations, such as
uterus didelphys, uterus bicornis bicollis, uterus bicornis unicollis, uterus subseptae, uterus arcuatus,
uterus unicornis. The bicornuate uterus accounts for approximately 10% of the mullerian anomalies.
Women with bicornuate uterus have no extra uterine infertility issues1.The uterine malformations are
known to be associated with spontaneous miscarriages, intrauterine growth restriction, preterm
deliveries, preterm prelabour rupture of membranes, breech presentation and increased rate of caesarean
delivery. The rates of spontaneous abortion and premature delivery have been reported to reflect the
degree of non fusion of the horns. The common complications and adverse reproductive outcomes
associated with bicornuate uterus are recurrent pregnancy loss (25%)1, preterm birth (15-25%)3 and
cervical insufficiency (38%)4. The case reported here was a case of bicornis unicollis pregnancy which was
carried till 38 weeks and had a good outcome.

Case report
A 34 yrs lady anxious to conceive, came to the gynae consultant at Medisun Hospital, 31 Nawab Yusuf
Road, Nayabazar, Dhaka. Her marital life was 8 yrs. She had a history of 4 miscarriages. All were in 2nd
1 1
trimester. 1st at 32 month, 2nd at 4 months, 3rd at 42 month and 4th at 5months. This time she became
pregnant after suffering from 2ndary infertility for 02 years. After ovulation induction she conceived. All
blood test showed normal including thyroid profile. Her weight was 62.2kg, BP 130/80 mmHg. She did
not have any history to consanguineous marriage. Her parent and no other family member had a history
of any abnormal pregnancy. Her mother’s antenatal period was uneventful. She was the 3rd girl to her
parents. Her age at menarche was 12 yrs. Menstrual history was uneventful. There was no history of DM,
Hypothyroidism, Rh incompatibility and TORCH infection. All her miscarriage were at 2nd trimester, so
my probable diagnosis was cervical incompetence. USG of W/A including cervical length measurement
was done. Cervical length was found normal but sonographycally it was diagnosed a case of bi-cornuate
uterus, right horn empty, left horn contain 5 weeks pregnancy. Repeat USG done after 02 weeks which
showed 08 weeks pregnancy with normal cardiac pulsation.

Figure: 1 Figure: 2

Rx given tab folneed (5mg) tab gestone (5mg), Tab Microgest (100mg), All given 1 tab TDS upto 16
weeks, inj Proluton Depot (250mg) 1amp IM weekly up to 16 weeks. Advice given - complete bed rest,
avoid journey, avoid sexual intercourse, She was advised to have only USG P/P at 15 weeks pregnancy to
exclude any congenital anomaly. At 15 weeks pregnancy – USG reported 16 weeks pregnancy,
simultaneously enlarged Rt horn and no congenital anomaly seen. Again she asked to follow the
previous advice and next USG done at 22 weeks pregnancy, all parameter correspond to 22 week
pregnancy with no congenital anomaly. Other bio-chemical test were repeated, all were found normal
except rising RBS. Then F, ABF were done, diagnosed a case of GDM. Anti diabetic drug tab comet given.
Patient treated in home by medicine, complete rest and diabetic pregnancy diet.
In the mean time patient got admitted in our hospital in 1st trimester due to hyperemesis gravidarum
treated conservatively. Again she got admitted in our hospital 2 times in 3rd trimester, both time patient
complained less foetal movement which treated conservatively. After 37 weeks completed patient advised
for admission for elective LUCS.

Figure: 3 Figure: 4
At 38 weeks LUCS done, patient delivered a healthy male baby by breech extraction. Per operatively
diagnosed two horn, two cavity continuous with a single cervical cavity. Post operative period was
uneventful. Patient left the hospital with a smiling face( Happy mother with her child).

Discussion
Uterine abnormalities occur as a result of Mullerian or paramesonephric duct anomalies or disturbances
at the time of fusion or development6. One of these abnormalities is identified as bicornuate uterus,
caused by abnormal fusion of
ducts 6. This condition might be diagnosed before or during pregnancy. According to previous studies,
many of these abnormalities might be asymptomatic and may remain undiagnosed until abdominal
surgeries, such as hysterectomy7. In this regard, one of the first diagnostic clues is the occurrence of
obstetrical complications.
Nevertheless, it seems that while bicornuate uterus does not lead to reduced fertility, it is particularly
associated with adverse pregnancy outcomes, such as aberrant complications 8 Studies have shown that
uterine rupture might
occur during pregnancy because of a thin wall and inability of malformed uterus to expand as a normal
one9. Other rare complications, such as failure of contraceptive methods, might also be responsible for
this condition. In this regard, Naghibi et al. reported a case of pregnancy in a horn of bicornuate uterus. A
history of both vaginal and caesarean delivery without any positive history of miscarriage was reported
in the mentioned study. In terms of contraceptive methods, the subject was using intrauterine device
(IUD) at the time, which failed since the device and fetus were in different horns of uterus. After the
cesarean section, the device was removed and a female neonate at gestational age of 32 weeks (2200 gr)
was delivered 11.Early ultrasound is a contributing method for evaluation of the effects of abnormal
uterus on pregnancy . Sensitivity of ultrasound in visualizing the rudimentary horn of uterus is 23%,
which allows the diagnosis of only 14% of patients before the manifestation of clinical symptoms 12. In the
current case report our diagnosis confirmed by ultrasonography.
A case of bi-cornuate uterus with 08 weeks pregnancy in the left horn, in a study by Adeyemi et al.
Similar to the present report, the results of ultrasound revealed a bicornuate uterus in the patient. In
addition, a history of intrauterine fetal mortality at term was affirmed, which was followed by a cesarean
section for delivering a stillborn fetus. After 4th miscarriage, the patient of the mentioned study
successfully gave birth to a healthy boy (weight: 3.2 kg, gestational age: 38 weeks) through a caesarean
section13. Another effective procedure for evaluation of fallopian tubes and uterus is the invasive
hysterosalpingography process, in which patients are exposed to radiati
on. Given the inability of this procedure to visualize the external uterine
contour, non-invasive modalities (e.g., ultrasound) are particularly used for evaluation of uterine
anomalies. Some of the more recent imaging methods, such as 3D transvaginal ultrasound, have been
identified as faster and cheaper procedures, compared to magnetic resonance imaging (MRI). In addition,
they have the ability of evaluating the external uterine contour in women 14.
 Instead of MRI or 3D transvaginal ultrasound only general ultrasound by a good sonographar confirmed
a diagnosis of bi-cornuate uterus which again confirmed at the time of LUCS.

CONCLUSION

Congenital uterine malformations are relatively common and often asymptomatic. Clinicians must
suspect uterine malformations in cases with recurrent miscarriages
and adverse obstetric outcomes and should utilize the opportunity to inspect the uterus by imaging
modalities in such cases. Urinary tract imaging should be performed because of frequent associated
anomalies. A bicornuate uterus does not always lead to complications and may carry a pregnancy to term.
It is necessary to establish a prenatal diagnosis to ensure proper care and prevent complications .
The present case was diagnosed in an early first trimester scan. Awareness of this condition is necessary
to make a diagnosis by an expert sonologist and thereby improve pregnancy outcome. Early diagnosis
and good antenatal care can help to improve the outcome in a bicornuate uterus.

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