British Journal of Obstetrics und Gynaecology Koveniber 1990, Vol. 97, pp. 1033-1045

Transvaginal ultrasound for diagnosis of uterine malformations M. N. NASRI, M. E. SE'TCHELL, T. CHARD Summary. Uterine malformations were detected in 8 of 300 patients (3%) refcrred for transvaginal ultrasound scan (TVS) for different indications. Six of them h a d a partially septate uterus and two had a uterus didelphys. As uterine malformations can b e associated with both sterility and reproductive failure, we suggest that t h e study of uterine morphology and structure could be a part of routine TVS examination.

Congenital malformations of the uterus caused by mullcrian duct fusion defects include uterus didelphys, bicornuate uterus and septate uterus. Only 25% of patients with these conditions have reproductive problems, mostly associated with uterine septa, which cause a high rate of prcgnancy loss (Buttram rt ml. 1979, Jones 1981). Because many of these malformations are clinically silent, their true prevalence is difficult to ascertain but it has been reported to be between 0.1% and 1% (DeCherney 1984). There is an increase in urological anomalics associatcd with uterine malformations. Mercer et al. (1981) reported a figure as high as 20% for the associated occurrence of renal anomalies. As a general rule, the more severe the uterine malformation, the greater is the likelihood of a coexisting urological anomaly. The aim of this study was to assess the frequency of uterine anomalies in a group of gynaecological patients with the usc of transvaginal ultrasound scanning (TVS),

rcferrcd to thc ultrasound scan unit in the gynaecology department at St Bartholomew's Hospital for TVS. The indications for scanning are shown in Tablc 1. The scan was performed with the paticnt supine and with the bladder empty. The probe was covered with a sterile lubricated condom and inserted into the mid-vagina. Images of the uterine body, fundus, and the cervix were obtained in the antero-posterior and transverse planes. The following data were recorded: (i) the external shape of the uterus; (ii) the presence and grade of the endometrial layer; (iii) the presencc of a median endo-uterine septum at any point along its longitudinal axis. The adnexal areas and the posterior cul-de-sac were also identified. Ultrasound examinations were performed using an ALOKA SSD-620 machine, with a 5MHz vaginal probe giving a 60" angle view. Each examination took 5 to 10 min.

Patients and methods

The study included 300 women who wcre St Bartholomew's Hospital, West Smithfield, London EClA 7BE M. N . NASRI Clinical Research Fellow Department of Obstetrics and Gynaecology of Depirtment

M. E. SETCHELL Heud

Department of Reproductive Physiology, St Bartholomen's Hospital Medical School T. CHARD Professor

Correspondence: M. N. Nasri, Academic Unit of Obstetrics and Gynaecology, Thc London Hospital Medical College, London E l 2AD

Results

A partial uterine septum was found in six women (2%) (Fig. 1). The uterine cavity was clcarly seen in all six, cspecially in the four patients with thick endometrium characteristic of the luteal phase of the menstrual cycle (Nicolini et al. 1987). There was an increase in the transverse diameter of the uterus in five of the six women with partial septa; the external uterine morphology was normal in four and difficult to assess in two. Tn two patients a complete uterus didelphys

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M . N . Nasii et al.

Fig. 2. Transvaginal ultrasound scan of a transverse section of the uterus (doublc image) showing two endometrial hemicavitics (arrowheads) with a septum bctwecn the inner margins (didelphic uterus).

girl with pelvic pain in whonl urography showed a large left kidney and no right kidney (HSG wa? not dune). Table 2 summarizes the clinical details of the eight patients with uterine malformations.

Discussion This i s the first study in which TVS has been used to detect uterine malformations in a largely unselected group of gynaccological patients. Previous ultrasound studies focused mainly on congenital abnormalities of the uterus during pregnancy and the pucrpcrium (Jones el id. 1980), with isolated reports on nonpregnant patients (Valdes et al. 1984). Although physical examination may reveal an obvious malformation, more often the diagnosis is made in the course of curettage, hysterosalpingography, hysteroscopy or laparoscopy. This Table 1 . Indications for transv-aginal ultrasound

Indication Fig. 1. Tramvaginal ultrasound scan showing serial transvcrse sections of the uterus indicating a septatc uterus, between 1 and 2. (a) close to the cervix, (b) mid-cavity, and (c) close to fundus.

was diagnosed (Fig. 2). One was a 13-year-old woman with menorrahgia in whom hysterosalpingography (HSG) confirmed the diagnosis and intravenous urography showed no functioning left kidney, with compensatory hypertrophy of the right kidney. The other was an 18-year-old

Pelvic pain Ahnormal utcrinc bleeding Pelvic mass Pi-cgiiancy complications Infertility and cycle tracking Dysmenorrhea Dyspareunia Lost intrauterine device EndomeLriosis Total

Numhcr

70 61 56 36 21 18

to 8 7 300

Tramvaginal US and uterine malfornzaticiii

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Table 2. Clinical details of eight women with uterine malformations detected a t transvaginal ultrasound scanning

(TVS) No.

Presenting symptom

1. 2. 3.

Menorrahgia Pelvic pain Uyspareunia Late period Intermenstrual blecding Pelvic mass Pelvic pain Infertility and hirsutism

1. 5. 6.

7. 8.

Age (years)

Parity

TVS findings

33 18 23

PO+ I PO+O P1+0 P2t1 PO+O PO+O PO+O PO+O

IJterus didelphys Uterus didelphys Septate uterus Septate uterus Septate uterus Septate uterus Septate uterus Septate uterus

29 34 19 25 26

study suggests that the prevalence oP uterine inalformations may be higher than previously rcportcd. The most common abnormality identified was the partially septate uterus, which is one 01 the leading anatomical causes of repeated first-trimester pregnancy loss (Rock et al. 1985). Patients with a maliormed uterus may benefit from an open or hysteroscopic metroplasty operation (Capraro et al. 1968, DeCherney 1983). Transvaginal ultrasound scanning may replace HSG as an initial screening test for uterine malformations, to be followed by more invasive procedures, such as hysteroscopy, laparoscopy, or HSG only in the small number of patients with ultrasonically demonstrated abnormalities. A useful additional outcome of screening for uterine abnormalities is the detection of coexisting urological anomalies (Morgan et al. 1987). It is of potential benefit for a woman to be aware that she has asymptomatic unilateral renal agenesis, as this information could be lifc saving in certain circumstances. Whenever possible, TVS should be recorded in the luteal phase of the menstrual cycle, because the cndomctrium is then thicker and almormalities can be more clearly identified. TVS is a safe, comparatively noninvasive procedure which can be used to screen for morphological abnormalitics of the uterus in the general population. as well as in patients with a history of recurrent pregnancy loss. The study of uterine shape and dimensions could bccomc a routine part of gynaecological ultrasound examination. References Buttram V. C. Jr. & Gibbons W. E. (1979) Mullerian

anomalies: a proposed classification (an analysis of 134 cases). berfil Steril32, 40.46. Capraro V. J . . Chuang J . T. & Randall C. L. (1968) Iniprovcd fetal salvage after metroplasty. Ubstet Gyriecol31,97-103. DeCherney A . H. & Dlugi A. M. (19x4) Uterine factors in reproductive feilure. In Progress in Ohstetrics 6:Gynuecology (J. Studded). Vol. 4.Churchill Livingstone. Edinburgh, pp. 302-321. DeCherney A . H. & Polan M. L. (1983) Hysteroscopic management of intrauterine lcsions and intractable utcrinc blccding. Ohstet Gyriecol 61, 392-397. Joncs H. W. Jr. (1Y81) Kcproductive impairment and the malfornicd utcrus. Ferfil S l e d 36, 137-148. Joncs 7.. B., Fleischcr A. C., Daniel1 J. F., Lindsey A . M. 8r James A. E. (1980) Sonographic characteristics of congcnital uterine abnormalities and associated pregnancy. JCU 8,435-437. Mercer C . A , , Long W. N. &Thompson .I. D. (1981) Uterine unification; indication and technique. Clin Ubstet Gyriecol24, 1199-1216. Morgan M. A,, Thurnau G. R . & Smith M. L. (1987) Uterus didelphys with unilateral hematocolpos, ipsilateral renal agtinesis and menses: a case report and literature review. .I Reprod M e d 32,47-58. Nicolini IJ.,Rellotti M., Bonazzi B.. Zambcrletti D. & Candiani G. B. (1987) Can ultrasound be uscd to screen uterine malformation? Fertil Steril 47, 89-93.

Rock J . A . B Schlaff W. 11. (19x5) The obstetric consequences of uterovaginal anomalies. Fertil Steril 43, 681-692. Valdes C.. Malini S. & Malinak L. R. (1984) Ultrasourtd evaluation of female genital tract anomalies: A review of 64 cases. Am J Obstet Gynecol 149. 285-292. Received I Febrrtury 1990 Accepted 16 Muy 1990

Transvaginal ultrasound for diagnosis of uterine malformations.

Uterine malformations were detected in 8 of 300 patients (3%) referred for transvaginal ultrasound scan (TVS) for different indications. Six of them h...
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