A Case Study Of Mullerian Anomaly
Patient History
- A 17 Year old girl was admitted to our hospital on 26/9/23 with c/o -severe pelvic pain on & off since few months.
- She HAD MENARCHE AT AGE OF 15 YEARS WITH REGULAR PERIODS OF CYCLE LENGTH 30 DAYS MENSES FOR 4-5DAYS WITH MODERATE FEW AND G/W SEVERE DYSMENORRHEA NOT RELIEVED BY NSAIDS FOR PAST 3 MONTHS.
- SHE ALSO COMPLAINT OF RADIATING PAIN TO LEFT THIGH SINCE 6 MONTHS AND WAS GETTING EVALUATED AND TREATED FOR THIGH PAIN.
- THIS PERSISTENT SPASMODIC PELVIC PAIN WAS CAUSING REPEATED ABSENTEEISM FROM SCHOOL AND AFFECTING HER DAILY ROUTINE.
- SHE THEN DEVELOPED A TENDER LUMP IN LEFT ILAC FOSSA FOR WHICH A USG WAS DONE WHICH REPORTED A CYSTIC MASS WITH UNICORNUATE UTERUS.
Patient Findings
- LMP - 20/9/23
- PAST CYCLE REGULAR
- PH/FH – NS
- GENERAL EXAM – WERE NORMAL
- SEC SEXUAL CHARACTERISICS WERE WELL DEVELOPED
- LOCAL EXAM –S/O- TENDER MASS IN LEFT ILIAC FOSSA
Evaluation
- Investigation -
- routine lab - was nomal
- MRI ABDOMEN PELVIS : WAS DONE ON THE SAME DAY 26/9/23
- WELL DEFINED THICK WALLED CYSTIC AREA (42 X 37MM)
- CLOSELY ABUTTING THE UTERUS ,THE CYST DISTENDED WITH COLLECTION & NOT
- COMMUNICATING WITH MAIN UTERINE CAVITY ,LATERALLY CYSTIC AREA
- COMMUNICATED WITH A DILATED TUBULAR STRUCTURE OF 7.1 X 5.1 X 3.5 CM IN SIZE.
Evaluation
- meri abdomen pelvis : was done on the same day 26/9/23
- WELL DEFINED THICK WALLED CYSTIC AREA (42 X 37MM)
- CLOSELY ABUTTING THE UTERUS ,THE CYST DISTENDED WITH COLLECTION & NOT COMMUNICATING WITH MAIN UTERINE CAVITY ,LATERALLY CYSTIC AREA
- COMMUNICATED WITH A DILATED TUBULAR STRUCTURE OF 7.1 X 5.1 X 3.5 CM IN SIZE.
- A RIGHT UNICORNUATE UTERUS SEEN BOTH OVARIS ARE NORMAL NO URINARY TRACT ANOMALY.
- IMPRESSION:- ESHRE / ESGE CLASSIFICATION – CLASS U4a UETRINE ANOMALY
- A RIGHT UNICORNUATE UTERUS WITH LEFT RUDIMENTORY HORN , NON COMMUNICATING WITH THE MAIN CAVITY WITH HAEMATOMETRA AND LEFT HEMATOSALPHINX
- SO THE DECISION FOR AN OPERATIVE LAPROSCOPY WAS TAKEN.
- CONSENT OF BOTH PARENTS WAS OBTAINED FOR HEMIHYSTERECTOMY TO RELIEF HER OF PAIN.
- SHE WAS PREPARED FOR LAPROSCOPY FOR THE NEXT DAY WITH ALL HER PREOP INVESTIGATIONS IN PLACE.
LEFT HAEMATOSLPINX WAS SEEN ATTACHED TO DISTENDED RUDIMENTARY HORN
RIGHT UNICORNUATE UTERUS WITH NORMAL APPREARING RIGHT ADNEXA COULD BE SEEN LEFT OVARY APPEARED NORMAL
LEFT ROUND LIGAMENT WAS CUT. UV FOLD CUT AND BLADDER PUSHED DOWN. THEN RUDIMENTARY HORN WAS RESECTED AFTER VASOPRESSIN INJECTION.
THE RAW BED WAS SUTURED IN TWO LAYERS. LEFT ROUND LIGAMENT AND OVARIAN PEDICLE ATTACHED TO THE CORNUAL END OF UNICORNUATE UTERUS. THERE WERE NO ENDOMETRIOTIC SPOTS IN PELVIS
SPECIMEN WAS REMOVED BY PIECEMEAL MORCELLATION
ANATOMY RESTORED
CASE DISCUSSION :
- POST OP PERIOD WAS UNEVENTFUL , DISCHARGED 3 DAYS POST SURGERY
- CONGENITAL UTERINE MALFORMATION OCCURS IN 1-10% OF GENERAL POPULATION
- UNICORNUATE UTERUS WITH NON COMMUNICATING RUDIMENTARY HORN IS A RESULT OF INCOMPLETE FUSION OF THE PAIRED MULLERIAN DUCTS.
- BASIC OBJECTIVE OF SUCH A SURGERY IS TO BRING PAIN RELIEF AND MAINTENANCE OF REPRODUCTIVE HEALTH.
- THE GYNAECOLOGICAL SEQUELAE,POTENTIAL FERTILITY AND OBSTETRIC CHALLENGES WERE COUNSELLED BECAUSE A UNICORNUATE UTERUS IS MUCH SMALLER THAN A TYPICAL UTERUS AND HAS ONLY ONE FALLOPIAN TUBE. SO THEY ARE PRONE TO MISCARRIAGES,PRETERM LABOUR,INCOMPETENT OS AND LOW LIVE BIRTH RATE