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A Case Report of Recurrent Miscarriages in Patient with a Bicornuate Uterus with a Septum

Published Date: September 29, 2017

A Case Report of Recurrent Miscarriages in Patient with a Bicornuate Uterus with a Septum

Artur Wdowiak1*, Michal Filip1, Anita Wdowiak1 and Igor Sorochynskyy2

1Diagnostic Techniques Unit, Faculty of Health Sciences, Medical University, Staszica 4-6, 20-081 Lublin, Poland

2Ivano-Frankivsk National Medical University, Ukraine

*Corresponding author: Artur Wdowiak, Diagnostic Techniques Unit, Faculty of Health Sciences, Medical University, Staszica 4-6, 20-081 Lublin, (Collegium Maximum), Poland, Tel: +4-881-532-5365; E-mail: wdowiakartur@gmail.com.

Citation: Wdowiak A, Filip M, Wdowiak A, Sorochynskyy I (2017) A Case Report of Recurrent Miscarriages in Patient with a Bicornuate Uterus with a Septum. Andr Gyn Rep 1(1): 102.

 

Abstract

 

A description of this case may be taken into consideration in further discussions on the therapeutic process of couples treated for infertility with established uterine abnormalities. It is not known which of the elements of applied therapy proved to be the most effective. Undoubtedly, the problem of reproduction in women with bicornate uterus will require further research in the future, possibly including other than the establishment of uterine pathomechanisms leading to the occurrence of miscarriages.

Keywords: Bicornuate uterus; Recurrent miscarriages; Pregnancy

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Introduction

 

Uterine anomalies are among the most common congenital abnormalities of the female reproductive system, with a prevalence of 2–4% in the general population [1,2]. During embryonic development, the uterus is formed out of the two paramesonephric (Mullerian) ducts. Uterine malformations most commonly result from incomplete fusion of the two Mullerian ducts, which normally occurs between 6th and 22nd weeks of pregnancy. If the Mullerian ducts fail to fuse altogether, a bicornuate uterus is formed [3]. Clinical symptoms of congenital reproductive malformations, if any, mostly occur at reproductive age, and include recurrent pain or recurrent pregnancy loss. Concurrent congenital urinary tract anomalies are often found.

Currently, the etiopathogenesis of uterine malformations is considered to involve multiple factors, including abnormal Mullerian regression factor production within the embryonic gonads, local absence of estrogen receptors within the Mullerian ducts, teratogenic factors interfering with the normal development of Mullerian ducts into target structures, abnormal apoptosis resulting from BCL2 gene mutation, abnormal activity of genes broadly involved in embryogenesis (WT1, PAX2, HOXA7, HOXA13, and PBX1), and abnormal activity of the WNT4 gene that belongs to a family of genes regulating cell and tissue growth and differentiation during development [4,5].

The bicornuate uterus of the current classification system, developed in 1988 by the American Fertility Society (AFS), belongs to Group IV [6]. Reports of the incidence of this defect are inconsistent. Knowledge about the fertility of women with bicornuate uterus and course of pregnancy is based on a relatively small number of cases and is ambiguous [2,7,10]. This raises the need for further analysis of reports on this anatomical abnormality in women seeking progeny and their pregnancy in order to further systematize knowledge in this area.

The present case report discusses the case of a patient with a bicornuate uterus, who after six miscarriages got pregnant, as a result of natural conception, terminated by caesarean section at 36 weeks gestation.

Case Report

 

The patient aged 34, in 2011 reported to a gynecological clinic in the 6th of pregnancy with a bleeding from the genital tract. All previous six pregnancies ended in a miscarriage between 7th and 9th week of pregnancy. The patient was not treated for other chronic diseases, had normal BMI, did not smoke, and no harmful factors were found in her workplace. The patient was menstruating regularly every 28 days and menstrual periods were painful and abundant. The thyroid-stimulating hormone level was normal (1.3 micro U/ml). Trombophilia and CMV infection were excluded. The results of the infertility workup were as follows: serum AMH: 4.5 ng/mL; LH: 5.2 IU/L; FSH: 7.5 IU/L; PRL: 10 ng/mL. The serum glucose level was normal.

Her partner was aged 35 years, had a BMI 24.9, was non-smoker with no history of hazardous alcohol consumption, and used no medications. Two spermograms revealed normospermia according to the 2010 criteria of the World Health Organization.

Pelvic examination at the first visit showed that the stem of the uterus was enlarged. During the ultrasound examination, a single live pregnancy corresponding to the 6th week of pregnancy measurements was found. In addition, a hematoma of 1.5×2 cm was reported in the internal mouth of uterus (Figure 1). The patient was administered the following: Duphaston (dydrogesterone) 10 mg 3×2, Luteina (progesteronum) 50 mg 3×2, Hydroxyzine 10 mg 2×1, Estrofem (oestradiol) 2 mg 1×1, Encorton (prednisone) 10 mg in the morning and 5 mg in the evening and Acard (acetylsalicylic acid) 75 mg 1×1.

Figure 1: Ultrasound scan of 6 weeks pregnancy.

 

In the following weeks, the bleeding decreased and the hematoma absorbed about 10 nd weeks of pregnancy. In 12 wg steroid medications were discontinued, and after 14 wg gestagens and estrogens. About 30 nd there was a symptom of preterm labor and the patient was hospitalized. The termination of pregnancy was performed at 35 nd by caesarean section due to no progress in childbirth. During the cesarean section, a septum was found in the uterus. The baby weighed 2470 g, anatomically normal and gained eight points in APGAR scale. After 10 days in hospital, the mother and the baby were discharged in good condition.

One year later, the patient became pregnant for the 8th time, did not take any medication, and the pregnancy ended in miscarriage at 10 t.c. After another pregnancy loss, the patient underwent partial resection of the septum during hysteroscopy. Despite this, further attempts to get pregnant were unsuccessful. Hysterosalpingography (HSG) was performed on the patient, showing a bicornuate uterus with a septum and an adhesion in the left corner (group IVa) (Figure 2).

Figure 2: Fluoroscopic examination of the Bicornuate uterus.

 

The whole therapeutic process was carried out according to the choice of the patient by different doctors. The first author led the seventh pregnancy to 25 wg and made HSG.

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Discussion

 

Scientific reports of such rare malformations as uterine malformations are very scarce, so it is difficult to determine the effect of bicornate uterus on woman's fertility. Scientists lacked a group on which to conduct professional and full-scale research. In the Chinese study "Clinical analysis of 225 women with congenital uterine malformation", Zhonghua et al. found that, in women with bicornate uterus during pregnancy, complications related to urinary tract, recurrent miscarriages and premature birth are unavoidable [11]. Similar results were obtained by Raga et al. [2] and Gruszka et al. [7]. They observed that fertility was lower in women suffering from uterine defects, and miscarriages were more frequent. In addition, Raga et al. [2] observed a higher incidence of uterine defects in women with reduced fertility compared to those who did not have any uterine defects.

The issue of multiple miscarriages described in our patient would seem to be related to abnormalities of uterine structure and obstetric problems mentioned by these authors. However, only the use of immune system treatment, coagulation disorders and supplementation of gestagens and estrogens has led to a successful termination of pregnancy. This allows saying that the earlier miscarriages were not caused solely by anomaly of the construction of female genital organs, but also by other abnormalities of implantation of pregnancy.

Autoimmune disorders are undoubtedly the cause of habitual miscarriage in certain women [12]. The exact number is unknown, but we know they are responsible for miscarriages in the early stages of pregnancy. It is estimated that only 10% of miscarriages are clinically apparent [13]. We know many autoimmune factors are responsible for implantation and maintenance of pregnancy. Women with abnormal function of the endometrium on the basis of autoimmune changes due to a relatively high number of pregnancies may appear fertile, but, in fact, the number of miscarriages is significant [14]. Researchers have discovered a tremendous amount of endometrial and blastocyst secretion factors that can cause miscarriage. These include interleukin-1 and 2 (IL-1 and IL-2), leukemia inhibitory factor (LIF), insulin-like growth factor I and II (IGF I and insulin-like IGF II Growth factor I and II, colony stimulating factor 1 (CSF-1), transforming growth factors (TGF-α and TGF-β, transforming growth factor α and β), hepatocyte growth factor HGF, hepatocyte growth factor, fibroblast growth factor (FGF), heparin-binding epidermal growth factor (HBFE), hypoxia-1 (HIF-1, hipoxia inducible factor) and vascular endothelial growth factor (VEGF) [15].

It is worth noting that the patient in the seventh pregnancy, which ended in delivery at 35 t.c, took medication – including gestagens. Progesterone is one of the most important immunosuppressive factors in pregnancy. Absence or deficiency of progesterone plays an important role in habitual and spontaneous miscarriages [16]. Researchers have demonstrated the importance of progesterone preparations in the treatment of symptoms that threaten miscarriage [17]. In the case of habitual miscarriage, the additional and beneficial effect of progesterone in the prophylaxis of subsequent pregnancy losses is an immune modulating effect with a number of protective factors for pregnancy [16]. Currently, the Polish Gynecological Society recommends progesterone supplementation from the very beginning of pregnancy until the 16th week of pregnancy in each patient with habitual miscarriages [18].

According to the researchers, luteal insufficiency concern 23%–50% of women with recurrent miscarriages. In fact, there is no clear evidence of the efficacy of administering gestagens in the prevention of miscarriage. The meta-analysis of the studies conducted by Haas et al. [19] indicates only the possible benefit of such treatment in women with three or more miscarriages [19,20].

Coagulation disorders are also a cause of habitual miscarriage and also predispose to preeclampsia [21]. Supplemented with acetylsalicylic acid, it was also perhaps one of the factors that prevented miscarriage [17].

Conflict of Interest

 

The authors declared there is no conflict of interest.

References

 

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Copyright: © 2017 Wdowiak A, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.