Successful outcome of multifetal pregnancy in a single horn of a bicornuate uterus : A case report

Abnormal fusion of the mullerian ducts during embryological life result in a variety of congenital uterine malformations. These anomalies are estimated to occur in 0.1% to 3% of women but it may be under estimate as often it goes undetected. Most studies report that 15% to 25% of women with such congenital uterine abnormalities have problem with fertility and reproduction. They are often associated with miscarriage, premature rapture of membrane, preterm labour and mal presentation.


Successful outcome of multifetal pregnancy in a single horn of a bicornuate uterus: A case report
Herath H.m.J.N a , Suhajanan T. b

INTrODucTION
Abnormal fusion of the mullerian ducts during embryological life result in a variety of congenital uterine malformations.These anomalies are estimated to occur in 0.1% to 3% of women but it may be under estimate as often it goes undetected.Most studies report that 15% to 25% of women with such congenital uterine abnormalities have problem with fertility and reproduction.They are often associated with miscarriage, premature rapture of membrane, preterm labour and mal presentation.bicornuate uterus is a type of congenital anomaly of mullerian duct, characterized by their incomplete lateral fusion.As per American society of reproductive medicine classification it belongs to type IV mullerian duct abnormality.In this type there are two separate but communicating endometrial cavities and a single uterine cervix1.
Multiple pregnancy in a bicornuate uterus is uncommon and even if it is occurs, successful outcome of pregnancy is unusual.We present a case of twin pregnancy in a single horn of a bicornuate uterus.

cASe rePOrT
Mrs. b a 27 years old G2P1C0 mother presented to Teaching Hospital Anuradhapura for her booking visit with the history of Positive urine HCG report at her 4+6 weeks of period of amenorrhea, she was investigated for secondary subfertility following a first trimester miscarriage and during laparoscopy she was found to have a bicornuate uterus with complete separation of two horns at cervical junction, right sided tubal patency was demonstrated and in left side tubal patency could not demonstrated.She conceived following ovulation induction with clomifine citrate.
At her booking visit trans vaginal ultrasound scan was carried out and two gestational sac was noted in the left horn of the uterus, gestational sac diameter was compatible with period of amenorrhea but there were no fetal poles noted Routine antenatal investigations shows full blood counts WbC 11800/ml, with 68% of neutrophils, 28% of lymphocytes,3% of eosinophils and hemoglobin concentration was 12.3g/dl with platelet count 211000/ ml, blood grouping and Rh was O positive VDRL non-reactive and HIV1/11 negative PPbS was 86mg/dl Repeated Trans vaginal ultrasound scan at 7week of gestation revealed a live dichorionic diamniotic twins in the left horn of the uterus and cavity of right horn was empty with decidual changes in the endometrium.She was treated with Low molecular weight heparin 20mg/daily for 14 days, proluten depot injection one vial weekly for four weeks and duphastone and low dose aspirin.

a MBBS, MD, MRCOG (UK) Consultant obstetrician and Gynaecologist b MBBS (Registrar, Obstetrics & Gynaecology Teaching Hospital Anuradhapura
She was given iron and calcium supplements.At 26th weeks of gestation she complaint of mild lower abdominal pain and she was advised to get admitted to the ward for further monitoring.She also diagnosed to have a 2x 1.5 cm left sided breast lump at her left sided breast and fibro adenoma was diagnosed following fine needle aspiration and surgical intervention was planned after the delivery.
Anomaly scan at 20th week was normal.At 26th week of gestation, she developed two premature uterine contractions and was treated with tocolytics.
Serial scan carried out at 28th and at 31 weeks revealed asymmetrical intra uterine growth restriction with reduced liquor volume.She also treated for urinary tract infection following culture and AbST.Her OGTT was within normal limits.She went into preterm labour at 32 weeks and 3 days and caesarean section was carried out following I/M dexamethasone 12.5mg two doses.babies were weighing 1360 and1400 grams.They were kept in the special care baby unit high and handed over to the mother after 48hours.Her intra operative and post-operative periods were uneventful.

Figure 1 Laparoscopic views of the bicornuate uterus
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