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Two uteri and one cervix – operated laparoscopically for abnormal post-menopausal bleeding

Two uteri and one cervix – operated laparoscopically for abnormal post-menopausal bleeding
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Background

A 56-year-old female patient presented at the Department of Gynaecology at the CK Birla Hospital®, Gurugram. She presented with chief complaints of post-menopausal bleeding. After extensive examination and investigations, it was
discovered that the patient had a double uterus.

Uterus didelphys or double uterus is a rare anomaly. It accounts for 8% of all female reproductive tract congenital anomalies. It occurs in 0.3% of the total population.

Repeated miscarriages, mid-trimester abortions, cervical incompetence, preterm labour or stillbirth are a few of the poor obstetric outcomes in females with a double uterus. In addition, these abnormalities are often associated with abnormal positions of kidneys such as pelvic kidney or single kidney.

Patient history

The patient reported having birthing and pregnancy complications in the past. She lost her first child after preterm labour. The pregnancy must have occurred in the smaller, less developed uterus, which could not provide space and nutrition to the developing foetus. And due to a weak uterus (womb), intrauterine death of the baby occurred, which is a very common complication with uterine abnormalities.
Her second and third pregnancies were in the more developed left uterus, which carried till 9 months. However, vaginal delivery was not possible. Hence, both the deliveries were caesarian sections through a vertical incision on the abdomen.

Investigations

  • The diagnosis of the double uterus was not made even during cesarean sections. Our gynaecological care team, led by Dr Aruna Kalra, examined the patient when she presented with postmenopausal bleeding. On clinical examination, the uterus was found to have deviated to the left, and a mass was palpable in the right adnexa. Ultrasonography revealed the patient to have a double uterus attached to a single cervix opening in a single vagina.
  • The exact diagnosis was confirmed with an MRI scan. Further examination reported that both the uteri had an endometrial lining of 9 & 9.4 mm each. In addition, left horn of the uterus had an endometrial polyp, which resulted in postmenopausal bleeding.
  • The team also performed a hysteroscopic D&C (Dilation and Curettage) – a procedure to diagnose abnormal bleeding from the uterus. Detailed histopathology further reported benign endometrium.
  • The condition led the patient to experience another episode of postmenopausal bleeding in a few months.

Treatment indicated

  • As per the findings of the investigations, the patient was recommended total laparoscopic hysterectomy with bilateral salpingo-oophorectomy.
  • The removal of the uteruses with fallopian tubes and ovaries was taken to prevent any cancerous/malignant growth in future.
  • Total laparoscopic hysterectomy is a procedure in which the surgeon removes the uterus using a thin, lighted tube called the laparoscope. It is a minimally invasive technique. Bilateral salpingo-oophorectomy is a surgical intervention to remove the fallopian tubes and ovaries.
  • The surgical team anticipated challenges during the surgery due to distorted anatomy and the previous two vertical caesarian sections.

Procedure

  • The surgeons, led by Dr Aruna, carefully dissected extensive intraabdominal adhesions between the omentum and anterior abdominal wall and urinary bladder with the anterior wall of the uterus.
  • It was discovered that the right uterus lay horizontally hidden behind the bladder peritoneum in front and rectal adhesions behind. Between two uterine bodies, a bridge attachment of the peritoneum was covering the cervix. On one side, the fallopian tube and ovaries were attached to the left uterine body. On the other, the fallopian tube and ovary were attached to the less developed right uterine body.
  • The surgeons started by dissecting the urinary bladder down. Next, the right horn of the uterus was dissected away from the urinary bladder and rectum to visualise the right uterine vessels and right ureter. The rectovesical fold of the peritoneum hid the bridge between the two uterine bodies.
  • An intricate dissection to protect the urinary bladder anteriorly and the rectum posteriorly was carried out.
    Once both the uterine bodies were dissected away from the bladder and rectum, bilateral ligaments were clamped and cut till the vaginal vault.
  • Two uterine bodies with one cervix and both ovaries and fallopian tubes were taken out.
  • Post which, the surgeons closed the vaginal vault. They further checked the bladder integrity with methylene blue. Since there was no blood loss, no suction was required.
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