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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 4  |  Page : 217-221

An ultrasonographic assessment to document the prevalence of various congenital uterine anomalies and their probable clinical outcome in the Eastern Uttar Pradesh region: A prospective study


1 Associate Professor, Department of Anatomy, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Assistant Professor, Department of Anatomy, Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India
3 Additional Professor, Department of Anatomy, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Associate Professor, Department of Radiodiagnosis, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission18-Aug-2022
Date of Decision24-Sep-2022
Date of Acceptance28-Sep-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Anamika Gaharwar
Department of Anatomy, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_142_22

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  Abstract 


Background: Uterine anomalies arise from abnormal fusion of paramesonephric ducts or failure of apoptosis of septum between two ducts leading to abnormal division of the uterine cavity. Initial dearth of universal standard diagnosis was the reason for the improper reporting of the data associated with prevalence of uterine developmental anomalies. But now various authors have reported the prevalence of uterine anomalies using standard diagnostic techniques. The objective of the study was to assess the prevalence of various uterine congenital anomalies among women of reproductive age (15–45 years) with no previous uterine pathology. Methodology: An ultrasound was utilized to take a transabdominal sonographs of both longitudinal and transverse planes from the supine position of participants who were made to consume 500–1000 mL of water to promote diuresis for the duration of the scan. Scans were then interpreted. Results: From a study of 200 participants whose mean age group fell around 30 ± 8 years, 140 of the women were parous and 60 were nulliparous. Twelve of the participants displayed anomalies that included bicornuate, arcuate, and septate. Five cases of the bicornuate uterus (2.5%), four arcuate uterus (2.0%), and three septate uterus (1.5%) were noted. Conclusion: From a sample size of 200, the occurrence of uterine anomalies is 6%, with no cases of uterine agenesis or a hypoplastic uterus.

Keywords: Arcuate uterus, bicornuate uterus, septate uterus, uterine anomalies


How to cite this article:
Gaharwar A, Pandey P, Pasricha N, Sthapak E, Narayan S. An ultrasonographic assessment to document the prevalence of various congenital uterine anomalies and their probable clinical outcome in the Eastern Uttar Pradesh region: A prospective study. Natl J Clin Anat 2022;11:217-21

How to cite this URL:
Gaharwar A, Pandey P, Pasricha N, Sthapak E, Narayan S. An ultrasonographic assessment to document the prevalence of various congenital uterine anomalies and their probable clinical outcome in the Eastern Uttar Pradesh region: A prospective study. Natl J Clin Anat [serial online] 2022 [cited 2023 Feb 6];11:217-21. Available from: http://www.njca.info/text.asp?2022/11/4/217/359873




  Introduction Top


The development of female reproductive system is a very complex process. Any developmental defect during this process will lead to the congenital malformation or anomaly. It is well established that these anomalies happen due to the error in the three known developmental phases of paramesonephric duct namely, organogenesis phase, fusion phase, and the septum resorption phase.[1] It is well known that uterine anomalies decreases fertility and increases abortion and preterm birth rates. Globally, many studies have reported the prevalence of congenital anomalies in different ethnicities. Our aim is to provide data of these anomalies in the Eastern Uttar Pradesh region of India.

The most common uterine developmental anomalies are bicornuate uterus, arcuate uterus, septate uterus, hypoplastic uterus, and uterine agenesis. A systematic assessment of studies found that 6.7%of the general population has congenital uterine anomalies, whereas 7.3% of infertile women have uterine anomalies. Recurrent pregnancy loss affects 12% of women.[2] The actual prevalence of uterine anomalies has not been studied before, due to the invasive techniques that low-risk participants do not see the need to undergo an examination. This leads to an imbalance in a single approach and a universal population/sample.[3] Despite the fact that a variety of methods are available leading to the detection of various uterine anomalies, ultrasound (USG) is the most widely accepted method of gynecological assessment. Diagnostic ultrasound is uncomplicated, less time-consuming, accurate, harmless, and noninvasive procedure. Its main advantage is that it does not cause the dangers associated with ionizing radiation. Therefore, it is proved to be safe investigation for all ages. Moreover, it has likewise diminished the requirement for pelvic assessment under sedation and other intrusive systems. Hence, in this study, we employed USG technique to assess the prevalence of uterine anomalies in Indian nationals of reproductive age.


  Methodology Top


Subjects

In this study, we included a total of 200 women of reproductive age (15–45 years) belonging to Indian ethnicity. As the prevalence of uterine anomalies varies (as stated in the introduction part) among the general population and among females who are seeking assisted reproductive treatment, Menstruating women, women with any type of uterine disease, women who had undergone a hysterectomy, and also the women who were undergoing IVF were all excluded from the study. In this study, 70% of females were nulliparous, whereas 30% were parous. The study was conducted at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, after obtaining the approval from ethics committee (IEC-84/20).

Ultrasound condition

Our study included unmarried females as well, who were not comfortable in undergoing a transvaginal ultrasound so did not consented for the same. Therefore, to maintain the consistency of the findings, an transabdominal ultrasound was used. The scans were captured using a commercially available real-time ultrasound machine (Philips, Simpson using a 6–13 Mhz frequency probe by a radiologist. To avoid inherent air interference between the transducer and the anterior abdominal wall and skin, an acoustic gel and a 3.5MHz sector transducer were used as the coupling medium. Before the scanning procedure, all participants were asked to drink approximately 500–1000 ml of water to aid in diuresis and to hold urine until the scanning was completed. Congenital malformations of the female genital tract are defined as deviations from normal anatomy which result from embryological maldevelopment of the paramesonephric ducts. They represent common benign conditions with a prevalence of 4%–7%. The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA (CONgenital UTerine Anomalies), with the goal of developing a new updated classification system. This classification is the ESHRE/ESGE classification system based on the anatomy of the female genital tract. Anomalies are classified into the following main classes, including uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus [Figure 1]; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemiuterus; U5, aplastic uterus; U6, for still unclassified cases. Main classes have been then divided into subclasses which include anatomical varieties with clinical significance. Class U0 incorporates all cases with a normal uterus. The dysmorphic uterus is divided into T-shaped and infantilis types. Septate uterus has partial and complete subtypes. Bicorporeal uterus is also divided into partial and complete. Hemiuterus has two subtypes, namely, rudimentary horn with cavity a (communicating or not) and rudimentary horn without cavity/aplasia (no horn). A plastic uterus has rudimentary horn with cavity (bi- or unilateral) and rudimentary horn without cavity (bi- or unilateral)/aplasia. Class U0 incorporates all cases with normal uterus. Class U1 or dysmorphic uterus includes all cases with normal uterine outline but with an abnormal shape of the uterine cavity which excludes septa. Class I is further subdivided into three categories – Class U1a or T-shaped uterus characterized by a narrow uterine cavity due to thickened lateral walls with a correlation between 2/3 uterine corpus and 1/3 cervix, Class U1b or uterus infantilism characterized also by a narrow uterine cavity without lateral wall thickening but an inverse correlation of 1/3 uterine body and 2/3 cervix, and Class U2 or septate uterus incorporates all cases with normal fusion and abnormal absorption of the midline septum. Septate is defined as the uterus with a normal outline and an internal indentation at the fundal midline exceeding 50% of the uterine wall thickness. This indentation is characterized as septum and it could divide the uterine cavity partly or completely. Class U2 or septate uterus incorporates all cases with normal fusion and abnormal absorption of the midline septum. Septate is defined as the uterus with normal outline and an internal indentation at the fundal midline exceeding 50% of the uterine wall thickness. This indentation is characterized as septum and it could divides partly or completely the uterine cavity. Class U3 or bicorporeal uterus incorporates all cases of fusion defects. As bicorporeal is defined the uterus with an abnormal fundal outline; it is characterized by the presence of an external indentation at the fundal midline exceeding 50% of the uterine wall thickness. This indentation could divide partly or completely the uterine corpus. Class U3 is further divided into two subclasses according to the degree of the uterine corpus deformity – Class U3a or partial bicorporeal uterus characterized by an external fundal indentation partly dividing the uterine corpus above the level of the cervix and Class U3b or complete bicorporeal uterus characterized by an external fundal indentation completely dividing the uterine corpus up to the level of the cervix. Class U4 or hemiuterus incorporates all cases of unilateral formed uterus. Hemiuterus is defined as unilateral uterine development; the contralateral part could be either incompletely formed or absent. Class U4 is further divided into two subclasses depending on the presence or not of a functional rudimentary cavity – Class U4a or hemiuterus with a rudimentary (functional) cavity characterized by the presence of a communicating or non-communicating functional contralateral horn and Class U4b or hemiuterus without rudimentary (functional) cavity characterized either by the presence of nonfunctional contralateral uterine horn or by aplasia of the contralateral part. The presence of a functional cavity in the contralateral part is the only clinically important factor for complications, such as hematocavity or ectopic pregnancy in the rudimentary horn or hematoma cavity, and treatment (laparoscopic removal) is always recommended even if the horn is communicating. Class U5 or aplastic uterus incorporates all cases of uterine aplasia. It is a formation defect characterized by the absence of any fully or unilaterally developed a uterine cavity. Class U5 is further divided into two subclasses depending on the presence or not of a functional cavity in an existent rudimentary horn – Class U5a or aplastic uterus with rudimentary (functional) cavity characterized by the presence of bi- or unilateral functional horn and Class U5b or aplastic uterus without rudimentary (functional) cavity characterized either by the presence of uterine remnants or by full uterine aplasia. Class U6 is kept for still unclassified cases.[4]
Figure 1: Ultrasound showing normal uterus

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  Results Top


Patients' demographics and clinical details

A total of 200 women of the age group 15–45 years (mean age group of 30.27 ± 7.70 years) were checked for the parity of the uterus examination, in which 60 were 15–25 years age, 84 were 26–35 years age, and 56 were 36–45 years age. Parous types are represented in [Figure 2].
Figure 2: Frequency chart of participants on basis of uterine parity

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Ultrasonography

All patients in the sample size received transabdominal sonography for evaluation of uterine anomalies in the supine position in both longitudinal and transverse planes. Congenital uterine anomalies were detected in 12 cases, that is 6% of the participants. IIn which, five were partial bicornuate uterus [Figure 3], four were moderate arcuate uterus [Figure 4], and three were partial septate anomalies [Figure 5] there were no cases of hypoplastic uterus and uterine agenesis [Table 1].
Figure 3: Ultrasound showing bicornuate uterus

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Figure 4: Ultrasound showing arcuate uterus

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Figure 5: Ultrasound showing septate uterus

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Table 1: Frequencies of congenital uterine anomalies observed in 6% of the participants

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  Discussion Top


The results of this study showed the total prevalence (6%) of all the congenital uterine anomalies diagnosed in the selected female population in this study turned out higher than previously reported percentages such as 0.17%–4.3%[5] and the more recent 5.5% but lower than a report from a systematic review claiming that 6.7% of women had presented with a uterine anomaly.[2] Similarly, various studies claim different anomalies to be the highest prevailing such as arcuate uteri,[3] and canalization defects[5] which does not reflect the data from this study that shows bicornuate uterus to be the most prevalent.
Table 2: A Comparative Analysis of Congenital Uterine Anomalies in Different Ethnicities

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Uterine anomalies are associated with infertility, recurrent miscarriages, premature birth, malpresentation of the fetus, and fetal development limitation in the case of problems. Uterine anomalies are associated with a different degree of adverse consequences. Women with canalization defects, such as septate or partial septate uteri, had the poorest reproductive performance, according to a systematic review of 3805 women.[3] These women had lower conception rates and an increased risk of first-trimester miscarriage, preterm birth, and fetal malpresentation at delivery, the study found. Women with a septate uterus have poorer outcomes throughout their pregnancies as compared to those with a partial septate uterus, according to research.[6] Bicornuate, unicornuate, and didelphic uteri appear to reduce fertility but lead to more serious of unfavorable birth outcomes.[7]

An arcuate uterus is an endometrial fundus indentation. It is the most frequent paramesonephric duct abnormality, affecting 3.9% of the general population.[8],[9] Contrary to high-risk controls, an arcuate uterus is associated with lower birth weight and intrauterine growth retardation. This shows that an arcuate uterus is more than just a sign of a high-risk pregnancy.[10] According to one meta-analysis investigations have also revealed that nearly one-third of individuals (165 out of 522) with a septate uterus have concurrent intrauterine adhesions, with a prevalence of approximately 31.6% in patients with a septate uterus.[11] The assumption is that these anomalies have a direct prevalence status in reproductive defects, which has been overlooked due to a lack of evidence in the past.[12] The prevalence, on the other hand, may vary depending on the ethnic group and the history of reproductive issues.


  Conclusion Top


In the present study, five cases of the bicornuate uterus (2.5%), four arcuate uterus (2.0%), and three septate uterus (1.5%) were noted among 200 participants. The knowledge of prevalence of various uterine anomalies will aid the gynecologist and radiologist dealing with cases of infertility.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bermejo C, Martínez Ten P, Cantarero R, Diaz D, Pérez Pedregosa J, Barrón E, et al. Three-dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging. Ultrasound Obstet Gynecol 2010;35:593-601.  Back to cited text no. 1
    
2.
Saravelos SH, Cocksedge KA, Li TC. Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: A critical appraisal. Hum Reprod Update 2008;14:415-29.  Back to cited text no. 2
    
3.
Chan YY, Jayaprakasan K, Zamora J, Thornton JG, Raine-Fenning N, Coomarasamy A. The prevalence of congenital uterine anomalies in unselected and high-risk populations: A systematic review. Hum Reprod Update 2011;17:761-71.  Back to cited text no. 3
    
4.
Grimbizis GF, Gordts S, Di Spiezio Sardo A, Brucker S, De Angelis C, Gergolet M, et al. The ESHRE-ESGE consensus on the classification of female genital tract congenital anomalies. Gynecol Surg 2013;10:199-212.  Back to cited text no. 4
    
5.
Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simón C, Pellicer A. Reproductive impact of congenital Müllerian anomalies. Hum Reprod 1997;12:2277-81.  Back to cited text no. 5
    
6.
Fox NS, Roman AS, Stern EM, Gerber RS, Saltzman DH, Rebarber A. Type of congenital uterine anomaly and adverse pregnancy outcomes. J Matern Fetal Neonatal Med 2014;27:949-53.  Back to cited text no. 6
    
7.
Kaur P, Panneerselvam D. Bicornuate Uterus. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560859/.  Back to cited text no. 7
    
8.
Behr SC, Courtier JL, Qayyum A. Imaging of Müllerian duct anomalies. Radiographics 2012;32:E233-50.  Back to cited text no. 8
    
9.
Niranjan R, Singh AK, Yadav A. Embryological basis of malformed female genital tract and various classifications. Natl J Clin Anat 2014;3:150-8.  Back to cited text no. 9
  [Full text]  
10.
Connolly CT, Hill MB, Klahr RA, Zafman KB, Rebarber A, Fox NS. Arcuate Uterus as an Independent Risk Factor for Adverse Pregnancy Outcomes [published online ahead of print, 2021 Oct 20]. Am J Perinatol. 2021;10.1055/a-1674-5927.  Back to cited text no. 10
    
11.
Shen M, Duan H, Chang Y, Lin Q. Prevalence and risk factors of intrauterine adhesions in women with a septate uterus: A retrospective cohort study. Reprod Biomed Online 2022;44:881-7.  Back to cited text no. 11
    
12.
Practice Committee of the American Society for Reproductive Medicine Electronic address: [email protected], Practice Committee of the American Society for Reproductive Medicine. Uterine septum: A guideline. Fertil Steril 2016;106:530-40.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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