BICORNUATE UTERUSType of Müllerian duct anomaly (Type IV, ASRM Classification)Caused by incomplete lateral fusion of the Müllerian ductsTwo separate but communicating endometrial cavities and a single uterine cervix.

Incidence- 0.1-0.5% of women (Possibly underestimated) Obstetric complications-

Live birth rate 63% Abortion rate- 28% Preterm labour- 20% Malpresentation- 40-50% Recurrent pregnancy loss- ?May be associated

CASE DETAILS Name- Mrs. S GAge- 27 yrs

P 0+0+2+0Chief complaint- Repeated spontaneous pregnancy lossesOne at 12th week (2006), Another at 14th week (2007)

WORK UP PROFILEHospital A

Done for infertility work up (Married in 1999)

2001- HSG Bicornuate uterus with B/L spillage 2001- Diagnostic laparoscopy Bicornuate uterus Dye test bilaterally positive

WORK UP PROFILE (Contd.)Hospital B

(for repeated pregnancy loss)2009- Blood investigations

Thyroid profile TSH- 2.28 mU/LfT4- 12.6 pmol/LfT3- 6.8 pmol/L

Blood sugar FBS- 92 mg/dlPPBS- 108 mg/dl

Blood Group O +ve

APLA screening Anti-Cardiolipin IgM- NegativeAnti-Cardiolipin IgG- NegativeLupus Anticoagulant- Negative

TORCH screening Negative

Karyotyping 46,XX

WORK UP PROFILE (Contd.)Hospital B

2009- USG Bicornuate uterus

2010- Repeat laparoscopy Bicornuate uterus, both of equal size Dye test B/L positive

2010- Ovulation induction planned 100 mg clomiphene citrate daily from D3-D7 of the cycle

CONCEIVED After 2 cycles of Ovulation Induction

LMP- 26.01.2011EDD- 02.11.2011

Antenatal work up- (On 1st visit) Weight- 52 kg BP- 110/72 mm Hg Hb- 12.8 g/dl PPBS- 86 mg/dl Blood group- O +ve VDRL- Nonreactive PPTCT- Nonreactive HBsAg- Nonreactive

ULTRASOUND SCAN(06.06.2011)

GA as per LMP- 18 wk 4 d

Bicornuate gravid uterus with triplet pregnancyLeft Horn- Twin fetuses (F1 & F2) And a single posterior placenta Right horn- Single fetus (F3) And a posterior placenta Liqour- Adequate AGA- 17 weeks 4 days.

F1 (Left horn) F3 (Right horn)

F2 (Left horn)

Placenta Placenta of left horn of right horn

The lady continued the pregnancy

FOLLOW UP ANTENATAL CARE

GA 20 wk 24 wk 28 wk

Weight (Kg) 60 63 65

BP (mm Hg) 110/68 120/76 116/72

Hb (g/dl) 11.4 10.8 11.0

PPBS (mg/dl) 90 104 88

TSH (mU/L) 3.28

fT4 (pmol/L) 12.8

fT3 (pmol/L) 4.6

FOLLOW UP USG(24.08.2011)

GA as per LMP- 29 wk 6 d

Left Horn Right HornFetuses F1 F2 F3EFW (Kg) 1.2 0.8 1.3AGA 28 wk 5

d26 wk 2 d

29 wk 2 d

Presentation Cephalic

Cephalic Cephalic

Liqour Adequate AdequatePlacenta Single, posterior Posterior

In A MidnightShe attended the

EMERGENCY

At GA 31 wk 2 d (03.09.11) C/O- Abdominal pain O/E- Active labour (Os 6 cm dilated)Labour events- Apparently uneventful Delivered- Vaginally Two Male babies BW 1.4 Kg and 0.9 kg respectively Both Cried after birth 3rd stage- Delivery of a single placenta No excessive haemorrhage.

Thus, the F1 & F2 along with the placenta present in the left horn were delivered (Confirmed by Labour Room USG)

Patient showed no evidence of labour after this episode, even on prolonged waiting

Os gradually got reduced in size Cervix started to reform

MANAGEMENT PLAN

Expectant management was contemplatedAim- To continue the F3 baby in the Right horn as long as possible Oxytocics withheld Breast feeding discouraged Both babies sent to NICU as LBW babies Both babies expired within 7 days due to sepsis Mother kept in close observation Antenatal steroids administeredWeekly scanning to monitor fetal growth

Follow up conditions- Satisfactory Follow up USG- Involuting left horn Normally growing fetus in right horn Investigations- Hb- 10.2 g/dl PPBS- 102mg/dl Rest of the days of hospital stay- Uneventful

On One Fine MorningAt GA 36 wk 3 days (09.10.2011)

She developed PRETERM LABOUR

Emergency CAESAREAN SECTION

was doneIndication- Dribbling

with unfavourable cervix

Delivered- Single Female baby BW- 2.7 kg Cried at birth3rd stage- Single placenta delivered UneventfulOxytocics administered

F3 was delivered thirty six days thirty six days after the delivery of the two other fetuses.

THE ULTIMATE AWARD

Post-partum period- UneventfulExclusive breast feeding- EncouragedAt the time of discharge- Both the mother and baby were healthyPost-natal visit- At the end of 6 wk Both mother and baby doing well

Uniqueness of this case

Rarity of presentationHas not been described earlier in the literature

Long interval between delivery of two sets of fetuses THIRTY SIX DAYS

The longest known intertwin delivery interval is 153 days A case report of delayed delivery of 99 days in a triplet pregnancy was also presented

Successful outcome

Raises a controversy regarding

an established concept

Normal contraction wave originates from uterine pacemakers, located at uterine end of the fallopian tubes, that spreads throughout the uterus, depolarizing the whole organ *

*Caldeyo-Barcia and Poseiro (1960) Seitchik (1981) Young and Zhang (2004)

CONCLUSIONPregnancy in bicornuate uterus needs

special supervison,especially in a case of multifetal

gestation

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