CASE DISCUSSION

Mayan, Mercurio, Murillo

BSN 2-A
 Case Presentation
A 27-year-old nulligravida attending infertility clinics and on serial follicular monitoring conceived
after intrauterine insemination. Earlier transabdominal ultrasound had revealed no remarkable abnormalities
in the uterus or adenexa. After 6 weeks of conception she presented with bleeding per vaginum and was
clinically diagnosed as threatened abortion. An urgent ultrasound was asked for and since the patient was
on empty bladder, a direct transvaginal ultrasound was performed, which could only pick up a healthy
gestational sac with a live fetus of 6 weeks gestation and a closed internal os. Due to persistent bleeding per
vaginum a repeat ultrasound a day later, via the transabdominal route revealed two gestational sacs-one in
each horn of a previously undetected bicornuate uterus. The sac on the left side was empty and showed
features of sac separation. In order to protect the healthy pregnancy a D & E was avoided, 4 weeks later a
repeat transabdominal ultrasound showed features of an incompetent os in the form of herniation of the
membranes and shortening of the cervical canal. An encirclage was performed and the pregnancy continued
normally till 34 weeks after which a healthy baby was delivered by caesarean section.
 Pathophysiology
■ The female genital tract is formed in early embryonic life when a pair
of ducts develops. These paramesonephric or mullerian ducts come
together in the midline and fuse into a Y- shaped canal. The open
upper ends of this structure lead into the peritoneal cavity and the
unfused portions become the uterine tubes. The fused lower portion
forms the uterovaginal area.

■ A uterine malformation is the result of an abnormal development of

the Mullerian ducts during embryogenesis. A bicornuate uterus is
formed during embryogenesis. The fusion process of the upper part of
the Mullerian ducts (Paramesonephric ducts) is altered. As a result, the
caudal part of the uterus is normal while the cephalo part is bifurcated.
Clinical Manifestations

■ The most common symptomatic presentation is early pregnancy loss and

cervical incompetence.
■ Infertility is not usually a problem with this type of malformation
because implantation of the embryo is not impaired.
■ Dysmenorrhea is there due to cryptomenorrhea (pent up menstrual blood
in rudimentary horn).
■ Menorrhagia is present due to increased surface area in the bicornuate
uterus.
 Nursing Management/ Responsibilities
1. Goal: minimize physical/psychological stress during labor/birth. 3. Goal: continuous monitoring of maternal/fetal status and progress
through labor:
Assist woman in coping effectively:
To identify early signs of dysfunctional labor, fetal distress; facilitate
a. Reinforce relaxation techniques. prompt, effective treatment of emerging complications.
b. b. Support couple’s effective coping techniques/mechanisms. 4. Goal: minimize effects of complicated labor on mother, fetus.
a. Position change: lateral Sims’—to reduce compression of inferior
vena cava.
2. Goal: emotional support.
b. Oxygen per mask, as indicated.
a. Encourage verbalization of anxiety/fear/ concerns.
c. Institute interventions appropriate to emerging problems (see
b. Explain all procedures—to minimize anxiety/fear, encourage specific disorder).
cooperation/participation in care.
Evaluation/outcome criteria:
c. Provide quiet environment conducive to rest.
1. Woman has successful birth of viable infant.
2. 2. Maternal/infant status stable, satisfactory.
Surgical Management
■ In women who are diagnosed with a septate or bicornuate uterus:
1. Surgical correction of the uterus (metroplasty) is the recommended treatment.
2. If the surgeon is not absolutely confident of the diagnosis prior to surgery, then
it is advised that a laparoscopy should be performed as the first step to confirm.
3. During a septate uterus correction surgery, the septum can usually be removed
by hysteroscopy while the patient is still under anesthesia.
4. However, if the external appearance of the uterus is “rabbit-eared” suggesting a
bicornuate uterus, surgical correction is performed by laparotomy (open
abdominal surgery).
Diagnostic Testing
■ In the case of a suspected congenital uterine factor,
1. Hysterosalpingogram(HSG) test, is often used to help diagnose.
2. Another type of test used is a sonohysterogram which is done by injecting a small amount of
sterile water or saline and looking at the uterus by a transvaginal ultrasound. It is performed in
the office and is not usually very uncomfortable. This particular ultrasound technique will often
allow the physician to see separate uterine cavities and may also allow them to see if the
uterine abnormality maybe from a septate uterus (SU) or a bicornuate uterus (BU). 
3. MRI- May help confirm anatomy by showing a deep (>1 cm) fundal cleft in the outer uterine
contour and an intercornual distance of >4 cm. The uterus demonstrates normal 
uterine zonal anatomy. 
4. Transabdominal ultrasound
5. Transvaginal Ultrasound
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE OUTCOME
Subjective: Acute pain r/t STG: Independent:   Goal met. After 2hrs of
“the pain is disruption of skin After 1-2hr of     nursing intervention, the
unbearable,” as and tissue nursing intervention, - Established rapport. -T o have a good nurse-client relationship patient verbalized pain
verbalized by the secondary to patient will verbalize     decreased from a scale of 8/10
patient. cesarean section. decrease intensity of - Monitored vital signs. - To establish a baseline data – 3/20 as evidenced by
  pain from 8/10 to     (-) facial grimace
Objective: 3/10. - Assessed quality, characteristics, severity- To establish baseline data for comparison (-) guarding behavior.
-Pain scale= 10/10   of pain. in making evaluation and to assess for Frequent small talks with
-Teary eyed   possible internal bleeding. significant others
-(+) guarding    
behavior - Provided comfortable environment - Calm environment helps to decrease the
-(+) facial grimace   anxiety of the patient and promote of
-Irritable   decreasing pain.
-Pale palpebral  
conjunctiva -Instructed to put pillow on the abdomen - To check for diastasis recti and protect
-Skin warm to touch when coughing or moving. the area of the incision to improve comfort.
-V/S taken as   And to initiate nonstressful muscle-setting
follows:   techniques and progress as tolerated,
BP= 110/80   based on the degree of separation.
PR= 80    
RR= 22  - Instructed patient to do deep breathing - To promote circulation, prevent venous
T= 37.6 and coughing exercise. stasis, prevent pressure on the operative
    site.
   
- Provided diversionary activities. Initiate - Relieves pain felt by the patient
ankle pumping, active lower extremity
ROM, and walking
 
Collaborative:-
- Administer analgesic as per doctor’s
order.
 
Effects on Reproduction
Pregnancies in a bicornuate uterus are usually considered high-risk and require
extra monitoring because of association with poor reproduction potential.

A bicornuate uterus is associated with increased adverse reproductive outcomes like:

■ Recurrent pregnancy loss

■ The reproductive potential of a bicornuate uterus is usually measured by live birth

rate (also called fetal survival rate).

■ Preterm birth
Effects on Reproduction
■ With a 15 to 25% rate of preterm delivery. Often the reason that a pregnancy may not reach full-
term in a bicornuate uterus is that the baby begins to grow in either of the protrusions at the top. A
short cervical length seems to be a good predictor of pre-term delivery in women with a bicornuate
uterus.

■ Malpresentations (breech birth or transverse presentation)

■ A breech presentation occurs in 40-50% pregnancies with a partial bicornuate uterus and not at all
(0%) in a complete bicornuate uterus.

■ Deformity

■ The off-spring of mothers with a bicornuate uterus are at high risk of "deformities and disruptions"
and "malformations."7-10
Conclusion
■ A bicornuate uterus, the most common congenital uterine anomaly, though a rare condition, is
associated with many gynecological and reproductive morbidities and can impact a woman's
reproductive capabilities.
■ Pregnancies in a bicornuate uterus are usually considered high-risk and require extra monitoring
because of their association with poor reproduction potential. The condition is associated with an
increased rate of spontaneous abortion, though the miscarriage rate is lower with a bicornuate
uterus than with a separate uterus. That is probably because the blood supply to the midline
indentation is better.
■ Premature labour, a breech presentation, and/or a retained or trapped placenta are also common
complaints with a bicornuate uterus. Precise antenatal diagnosis is important in order to ensure
appropriate management. It should be diagnosed before the pregnancy occurs or, at the latest
before rupture occurs, and should be treated through immediate surgery,as boththe baby as well as
the mother can be saved by doing emergency Caesarean Section. When a mullerian anomaly is
identified, the woman should be counselled about reproductive prognosis, pregnancy outcomes,
and evidence-based management.