Female genital tract congenital malformations and the applicability of the ESHRE/ESGE classification: a systematic retrospective analysis of 920 patients

Perinatal outcomes of twin pregnancies in women with a unicornuate uterus

OBJECTIVE

A unicornuate uterus is a type of Müllerian anomaly and is associated with adverse pregnancy outcomes. However, the perinatal outcomes of twin pregnancies in women with a unicornuate uterus remain unknown, and previous studies on women with a unicornuate uterus have focused mostly on those with singleton pregnancies. This research aimed to investigate the perinatal outcomes of twin pregnancies in women with a unicornuate uterus.

METHODS

From January 2013 to December 2022, 283 women with a unicornuate uterus, including 21 with twin pregnancies (Group A), 262 with singleton pregnancies (Group B), and 105 with twin pregnancies and a normal uterus (Group C) were enrolled in this study and gave birth at West China Second University Hospital, Sichuan University. General characteristics and perinatal outcomes were retrospectively analysed using SPSS version 22.0.

RESULTS

Among the 21 women with twin pregnancies and a unicornuate uterus, 20 (95.2%) had dichorionic diamniotic twins, and 1 (4.8%) had monochorionic diamniotic twins. Seventeen patients (81.0%) conceived by in vitro fertilization-embryo transfer (IVF-ET), and 4 patients (19.0%) conceived naturally. The mean gestational age at delivery was 33.8 ± 5.7 weeks, and 19 patients (90.5%) underwent caesarean section. The twin group (A) had significantly higher rates of preterm premature rupture of membranes (38.1%, 8/21), preterm delivery (85.7%, 18/21) (preterm delivery was defined as a birth occurring after 28 weeks and before 37 completed weeks of gestation), and neonatal intensive care unit (64.3%, 27/42) admission than Groups B and C (p < 0.05). Moreover, the live birth weight in Group A (1931.7 ± 535.2 g) was lower than that in Groups B and C (p < 0.001).

CONCLUSION

The incidence of complications and the risk of adverse perinatal outcomes in women with twin pregnancies and a unicornuate uterus are greater than those in women with singleton pregnancies and a unicornuate uterus and women with twin pregnancies and a normal uterus. Thus, maternal and foetal monitoring during pregnancy should be strengthened to achieve good outcomes.

Prevalence of Septate Uterus in a Large Population of Women of Reproductive Age: Comparison of ASRM 2016 and 2021, ESHRE/ESGE, and CUME Diagnostic Criteria: A Prospective Study

In this study, we aimed to assess and compare the prevalence of septate uterus using the diagnostic criteria of the ESHRE-ESGE, ASRM 2016, ASRM 2021, and CUME classifications. This prospective observational study included 977 women of reproductive age. Each participant underwent a transvaginal ultrasound, and a 3D volume of the uterus was obtained for further analysis. Offline assessment of the uterine coronal plane was conducted to measure uterine wall thickness, fundal indentation length, and indentation angle. The diagnosis of a septate uterus was determined according to the criteria of the ESHRE-ESGE, ASRM, and CUME classifications. The prevalence of septate uterus was then calculated and compared across these classifications. The ESHRE-ESGE classification identified 132 women (13.5%) with a septate uterus. The 2016 ASRM classification identified nine women (0.9%), with an additional nine women falling into a grey zone. The 2021 ASRM classification identified fourteen women (1.4%), with eleven women in the grey zone. The CUME classification identified 23 women (2.4%). The prevalence of septate uterus was significantly higher when using the ESHRE-ESGE criteria compared to the 2016 ASRM [relative risk (RR): 7.33 (95% CI: 4.52-11.90)], the 2021 ASRM [RR: 5.28 (95% CI: 3.47-8.02)], and the CUME [RR: 5.94 (95% CI: 3.72-8.86)] (p < 0.001). Our findings indicate that the ESHRE-ESGE criteria result in a significantly higher prevalence of septate uterus compared to the ASRM and CUME criteria. The ASRM 2016 criteria may underdiagnose more than half of the cases.

Perinatal outcomes of women with Müllerian anomalies

PURPOSE

To investigate the perinatal outcomes of singleton pregnant women with Müllerian anomalies (MuAs).

METHODS

A retrospective cohort study was conducted on singleton pregnant women with MuAs who delivered at the West China Second University Hospital between January 1, 2009 and December 31, 2020.

RESULTS

Four hundred fifty-seven cases of MuAs were identified, with an incidence of 0.40%. The most common anomaly was a septate uterus (38.7%). Compared to the control group, the MuAs group had significantly higher incidences of perinatal complications, including preterm deliveries (PTDs) (27.4 vs. 9.8%, P < 0.001), preterm premature rupture of membranes (PPROM) (29.1 vs. 22.5%, P = 0.001), malpresentation (34.4 vs. 5.6%, P < 0.001), abruptio placentae (4.6 vs. 1.2%, P < 0.001), placental accreta/increta (19.7 vs. 11.8%, P < 0.001), and uterine rupture (2.8 vs. 1.6%, P = 0.035). The rates of in vitro fertilization and embryo transfer (IVF-ET), foetal growth restriction (FGR), and low birth weight were also significantly higher in the MuAs group (8.3 vs. 4.5%, P < 0.001; 2.6 vs. 0.9%, P = 0.001; 3.1 vs. 1.7%, P = 0.033, respectively). In the MuAs group, the incidence of PPROM was high in cases with unicornuate uterus (31.5%), and malpresentation was as high as 42.4 and 37.0% in cases with septate and didelphys uteri, respectively.

CONCLUSION

The data suggest that pregnancy with MuAs may increase adverse perinatal outcomes, which calls for intensive supervision during pregnancy and delivery to reduce maternal and foetal complications. Individualized considerations should be emphasized according to the different categories of MuAs in pregnancies.

The Overview of Anatomical Variations and Congenital Anomalies of the Uterine Tubes and Their Impact on Fertility

Anatomical variations and congenital anomalies of the uterine tubes (UTAVsCAs) are rare conditions, which are often undiagnosed, or accidentally diagnosed upon imaging, laparotomy, laparoscopy for unrelated condition, or during the Cesarean section. UTAVsCAs are often asymptomatic, but their clinical relevance lies in their possibly adverse impact on fertility. Since their rare occurrence, they are usually published as case reports. The most typically described are: agenesis of the uterine tubes (UTs), accessory UT (UT duplication), accessory UT ostium, and paratubal cysts (e.g. the hydatid cyst of Morgagni). UTAVsCAs are classified into an umbrella category of Müllerian duct anomalies (MDAs) which comprises anomalous development of all the organs developing from the paramesonephric (Müllerian) ducts, i.e., UTs, uterus and upper portion of the vagina. Interestingly, most of the classification systems of MDAs discuss solely the uterine and vaginal anomalies, while the UTs are often utterly ignored. This probably originates from the fact that UTs are no longer interesting for many clinicians as they think of UTs as superfluous organs whose function can be easily replaced in the in vitro fertilization (IVF) laboratory. Indeed, the modern reproductive medicine has been helping enormously with the conception of infertile couples. In many instances, the UTs are in fact successfully bypassed and a “test-tube” baby is born. Nevertheless, the UTs are still absolutely unique in providing suitable environment for fertilization and early embryo development - processes that hasn´t been still completely understood. This fact could partially explain why the success rate of IVF is “only” around 30-50 % depending on age. Therefore, the research of the UTAVsCAs is still clinically relevant in the context of reproductive medicine and should not be omitted from research endeavors.

Reassessment of Surgical Procedures for Complex Obstructive Genital Malformations: A Case Series on Different Surgical Approaches

The objective of this case series was to describe different uterus-preserving surgical approaches and outcomes in patients with complex obstructive Müllerian duct malformation caused by cervical and/or vaginal anomalies. A retrospective analysis was performed including patients undergoing uterovaginal anastomosis (n = 6) or presenting for follow-up (n = 2) at the Department for Gynecology at the University of Tuebingen between 2017 and 2022. Uterovaginal anastomosis was performed with a one-step combined vaginal and laparoscopic approach (method A), a two-step/primary open abdominal approach with primary vaginal reconstruction followed by abdominal uterovaginal anastomosis after vaginal epithelization (method B) or an attempted one-step approach followed by secondary open abdominal uterovaginal anastomosis due to reobstruction (method A/B). Patients presented at a mean age of 15 years. Two patients were treated by method A, four by method B and two by method A/B. Functional anastomosis was established in seven of eight patients, with normal vaginal length in all patients. Concerning uterovaginal anastomosis, the primary open abdominal approach with or without previous vaginal reconstruction seems to have a higher success rate with fewer procedures and should be implemented as standard surgical therapy for complex obstructive genital malformations including the cervix.

High-grade cervical dysplasia in a woman with uterine didelphys: A case report

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Simultaneous malformations of the genital and urinary tracts present a higher risk of genital cancers.

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Carcinomas of the genital tract and genitourinary malformations are separately relatively common but coexistence is rare.

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We describe a case of high-grade dysplasia in the left cervix of a woman with a uterine didelphys and urinary malformations.

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Multi-disciplinary international Project ECHO tumor boards can provide guidance in the management of difficult cases.

The combination of lower genital tract carcinomas with genitourinary malformations is a rare occurrence. The purpose of this report is to describe the case of high-grade cervical dysplasia of the left cervix of a woman with a uterine didelphys and additional urinary tract malformations.

Living-Donor Uterus Transplantation: Pre-, Intra-, and Postoperative Parameters Relevant to Surgical Success, Pregnancy, and Obstetrics with Live Births

Uterus transplantation (UTx) can provide a route to motherhood for women with Mayer–Rokitansky–Küster–Hauser syndrome (MRKHS), a congenital disorder characterized by uterovaginal aplasia, but with functional ovaries. Based on our four successful living-donor transplantations and two resulting births, this analysis presents parameters relevant to standardizing recipient/donor selection, UTx surgery, and postoperative treatment, and their implementation in routine settings. We descriptively analyzed prospectively collected observational data from our four uterus recipients, all with MRKHS, their living donors, and the two newborns born to two recipients, including 1-year postnatal follow-ups. Analysis included only living-donor/recipient pairs with completed donor/recipient surgery. Two recipients, both requiring ovarian restimulation under immunosuppression after missed pregnancy loss in one case and no pregnancy in the other, each delivered a healthy boy by cesarean section. We conclude that parameters crucial to successful transplantation, pregnancy, and childbirth include careful selection of donor/recipient pairs, donor organ quality, meticulous surgical technique, a multidisciplinary team approach, and comprehensive follow-up. Surgery duration and blood vessel selection await further optimization, as do the choice and duration of immunosuppression, which are crucial to timing the first embryo transfer. Data need to be collected in an international registry due to the low prevalence of MRKHS.

Carcinoma of the lower female genital tract in patients with genitourinary malformations: a clinicopathologic analysis of 36 cases

Background: Lower genital tract carcinomas that coexist with genitourinary malformations are rare. The aim of this study was to investigate the clinicopathologic characteristics and outcomes of patients with this rare joint condition. The aim of this study was to investigate the clinicopathologic characteristics and outcomes of these patients to analyze the associations among clinicopathologic features in this rare entity.

Methods: The medical records of patients with carcinoma of lower genital tract combined with genital tract malformations who were treated at Peking Union Medical College Hospital (Beijing, China) between January 1995 and December 2017 were retrospectively reviewed and a comprehensive literature review was performed. The correlations between variables were determined using Fisher's exact test.

Results: Thirty-six patients were identified, among whom 22 had cervical carcinoma, 10 had vaginal carcinoma, and two had carcinomas of both the cervix and vagina. The most common genital tract anomaly was uterus didelphys (n=17), and 63.9% of patients had with urinary tract malformations. Twenty-five (69.4%) had pathologically confirmed adenocarcinoma, 10 (27.8%) had squamous cell carcinoma (SCC), and 1 had adenosquamous carcinoma. Patients with urinary tract malformations developed adenocarcinoma more frequently than those without malformations (95.7% vs. 30.8% P<0.001). Compared with patients with SCC, patients with adenocarcinoma presented at a younger age (36.1 vs. 47.0 years, P=0.011), had more advanced stages disease (57.7% vs. 10.0% were in stage II-IV, P=0.022), and tended to have poorer five-year overall survival rates (75.6% vs. 100.0%, P=0.279).

Conclusions: Patients with simultaneous malformations of the genital and urinary tracts had a high probability of developing adenocarcinoma. It is recommended that rigorous gynecologic exams with Pap smears and imaging analyses be performed periodically in women with genital malformations, as they may be at a risk of genital malignancies.