OK, here's how to tell the difference between a bicornuate uterus and a septate uterus using transvaginal ultraound. Most of the photos below are taken in the sagittal plane, which the plane running from front to rear dividing the body into right and left halves. (Actually, some of the photos are parasagittal views, which are in planes parallel to the sagittal plane, but to the right or left of the midline. See here for an explanation of these planes: http://en.wikipedia.org/wiki/Sagittal_plane). Both these patients had HSGs that showed a duplicated uterine cavity (see previous post for more about how HSGs look in these patients).
Patient #1 (septate uterus): To the left of the midline, a normal uterus is seen. Arrows mark the endometrium. The cervix is off the screen in the upper left. The top of the uterus is in the lower right.
This is a midline (sagittal) view. The uterus is visible, but no endometrium is seen, because we are in the plane of the uterine septum. A cursor in the lower right of the photo marks the top of the uterus.
Moving the probe to view the right side of the uterus, the endometrium reappears.
Rotating the transvaginal probe 90 degrees to give a coronal view of the top of the uterus, we see two endometria contained within a single myometrium, confirming that this is a septate uterus.
Patient #2 (bicornuate uterus). View left of the midline. Normal uterus with endometrial stripe seen. Top of uterus on the right of the screen.
Sagittal (midline) view. No uterus seen. This is a bicornuate uterus.
Right parasagittal view. The uterus reappears (and there is a gestational sac in this side of the uterus).
Patient #1 (septate uterus): To the left of the midline, a normal uterus is seen. Arrows mark the endometrium. The cervix is off the screen in the upper left. The top of the uterus is in the lower right.
This is a midline (sagittal) view. The uterus is visible, but no endometrium is seen, because we are in the plane of the uterine septum. A cursor in the lower right of the photo marks the top of the uterus.
Moving the probe to view the right side of the uterus, the endometrium reappears.
Rotating the transvaginal probe 90 degrees to give a coronal view of the top of the uterus, we see two endometria contained within a single myometrium, confirming that this is a septate uterus.
Patient #2 (bicornuate uterus). View left of the midline. Normal uterus with endometrial stripe seen. Top of uterus on the right of the screen.
Sagittal (midline) view. No uterus seen. This is a bicornuate uterus.
Right parasagittal view. The uterus reappears (and there is a gestational sac in this side of the uterus).
6 comments:
My name is Christina and I am a reasonably healthy 30 year old. I have recently been diagnosed with a probable bicornuate uterus. My current GYN is suggesting a laproscopy to confirm this. I have already had an HSG. The radiologist is pretty certain that this is the correct diagnosis. My insurance however will not cover a laproscopy for a birth defect for 18 months. You mentioned that MRI can also be used to diagnose this problem. I was wondering how accurate this is and is it a good alternative to the surgery. I understand that if it is a septum instead that I will require surgery to correct that issue. Any suggestions?
As outlined in my blog, a well-performed transvaginal ultrasound can differentiate between a bicornuate and a septate uterus.
I don't believe one can differentiate these by an HSG.
Maybe you should see me, or someone else who has some expertise in this area.
mps
Dr. Steinkampf:
I must first say that it was a pleasure meeting you. You were very informative about the diagnosis you have give me. You have given my husband hope and the means to fullfill our dreams! We are looking forward to continuing our treatment and promise to send pictures of what we hope will be a very happy healthy (soon to be) baby in the near future!
Hi Dr. Steinkampf....
It just wanted to let you know that after 3 rounds of clomid we are currently expecting a baby in October 2013. Just 3 months after visiting your office for the first time. Thank you so much for all your help and will send pictures as soon as possible :)
Dr. Steinkampf,
I have a complete bicornuate uterus as confirmed via MRI and later during the c-section to deliver my first child at 25 weeks. I had a cerclage placed at 11 weeks, and I credit it with getting my daughter to a much better place for viability (my preterm labor began at 22 weeks). I understand that a bicornuate doesn't necessarily mean all pregnancies will end at this point, but I can't help but think odds are not in my favor. My mother also has a bicornuate and lost 3 pregnancies between my birth and my younger brother's several years later. At what point is metroplasty a serious consideration (My husband and I want more children)? My daughter is 2 now, and she is defying the odds everyday. However, she is extremely delayed, has multiple therapies, a gtube, etc etc., and she needs both my husband and I to be on our A game to get through our days. I don't know that our family could handle months of bed rest or another 5 month NICU stay.. I guess I don't know where to go for guidance. None of our options seem ideal.. Just trying again seems irresponsible, metroplasty is generally discouraged from what I have read, and surrogacy is incredibly expensive. I would love for my daughter to have a sibling, but I just don't see how we get there. I am 32 and feel like time is slipping away. This may not be something you can address, but thank you for letting me air my concerns.
Dear Humphreys,
I just reviewed the literature on surgical treatment of the bicornuate uterus, and I still could not find any studies with meaningful outcome data. The papers out there come from Poland or India. Here is a published comment to the authors of one such paper which I think sums up the current state of knowledge about this subject:
"The whole principle of unifying a didelphic uterus or a bicornuate uterus is very debatable, and there are no data about the outcome of pregnancy after such unification, except in one case that the investigators cited. The situation here is completely different from a septate uterus, where the septum is removed and there are data in the literature to support the validity of this procedure for patients with recurrent miscarriages because of the septate uterus."
So I still can't recommend such surgery. One bit of good news is that, in my experience, women who suffer a preterm delivery often carry their next pregnancy longer.
mps
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