An Atypical Outcome Of Multifoetal Gestation In Bicornuate Uterus
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This paper was presented at the Annual Conference of Bengal Obstetric and Gynaecological Society (BOGSCON) 2012 held at ECOHUB Conclave, Kolkata, January, 2012 and was awarded as the BEST CASE PRESENTATION (1st PRIZE)
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An Atypical Outcome Of Multifoetal Gestation In Bicornuate Uterus
- 2. BICORNUATE UTERUS Type of Müllerian duct anomaly (Type IV, ASRM Classification) Caused by incomplete lateral fusion of the Müllerian ducts Two separate but communicating endometrial cavities and a single uterine cervix.
- 3. 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
- 4. CASE DETAILS Name- Mrs. S G Age- 27 yrs P 0+0+2+0 Chief complaint- Repeated spontaneous pregnancy losses One at 12th week (2006), Another at 14th week (2007)
- 5. WORK UP PROFILE Hospital 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
- 6. WORK UP PROFILE (Contd.) Hospital B (for repeated pregnancy loss) 2009- Blood investigations Thyroid profile TSH- 2.28 mU/L fT4- 12.6 pmol/L fT3- 6.8 pmol/L Blood sugar FBS- 92 mg/dl PPBS- 108 mg/dl Blood Group O +ve APLA screening Anti-Cardiolipin IgM- Negative Anti-Cardiolipin IgG- Negative Lupus Anticoagulant- Negative TORCH screening Negative Karyotyping 46,XX
- 7. 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
- 9. CONCEIVED After 2 cycles of Ovulation Induction LMP- 26.01.2011 EDD- 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
- 10. ULTRASOUND SCAN (06.06.2011) GA as per LMP- 18 wk 4 d Bicornuate gravid uterus with triplet pregnancy Left 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.
- 11. F1 (Left horn) F3 (Right horn) F2 (Left horn)
- 12. Placenta Placenta of left horn of right horn
- 13. The lady continued the pregnancy
- 14. 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
- 15. FOLLOW UP USG (24.08.2011) GA as per LMP- 29 wk 6 d Left Horn Right Horn Fetuses F1 F2 F3 EFW (Kg) 1.2 0.8 1.3 AGA 28 wk 5 d 26 wk 2 d 29 wk 2 d Presentation Cephalic Cephalic Cephalic Liqour Adequate Adequate Placenta Single, posterior Posterior
- 16. In A Midnight She attended the EMERGENCY
- 17. 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)
- 18. Patient showed no evidence of labour after this episode, even on prolonged waiting Os gradually got reduced in size Cervix started to reform
- 19. MANAGEMENT PLAN
- 20. Expectant management was contemplated Aim- 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 administered Weekly scanning to monitor fetal growth
- 21. 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
- 22. On One Fine Morning At GA 36 wk 3 days (09.10.2011) She developed PRETERM LABOUR
- 23. Emergency CAESAREAN SECTION was done Indication- Dribbling with unfavourable cervix
- 26. Delivered- Single Female baby BW- 2.7 kg Cried at birth 3rd stage- Single placenta delivered Uneventful Oxytocics administered F3 was delivered thirty six daysthirty six days after the delivery of the two other fetuses.
- 28. Post-partum period- Uneventful Exclusive breast feeding- Encouraged At the time of discharge- Both the mother and baby were healthy Post-natal visit- At the end of 6 wk Both mother and baby doing well
- 29. Uniqueness of this case
- 30. Rarity of presentation Has 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
- 31. 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)
- 32. CONCLUSION Pregnancy in bicornuate uterus needs special supervison, especially in a case of multifetal gestation