Bicornuate Uterus: Unusual Management

o Mrs XYZ
o 25 y
o P0L0A1; history of spontaneous abortion at 14 weeks 2 years earlier
o Now anxious to concieve
o Both cornua in the lower half were close together simulating a septate uterus.
o In the upper part, they were further apart. A hysteroscopic metroplasty was done and both cavities were enlarged. Lower half of the uterine cavities were unified by cutting the adjoining myometrial tissues of both the horns using a traditional Karl Storz monopolar resectoscope. After the procedure the clip shows how the uterine horns on laparoscopy have come closer.
o An intra uterine device (after removing copper) was inserted and she was put on sequential hormones. She is scheduled for a 2nd look hysteroscopy after her next period
o The bicornuate uterus results from incomplete fusion of the utero-vaginal horns at the level of the fundus and accounts for approximately 10% of Mullerian duct anomalies
o It is common to get confused between a septate and a bicornuate uterus. The gold standard for diagnosing is laparoscopy and hysteroscopy. Hysteroscopic septoplasty is now considered the gold standard management for septate uterus.
o Laparoscopic/ Laparotomic metroplasty for a bicornuate uterus is the standard management all over the world. This requires great surgical skill.
Practical Tips:
o When the uterine horns are close together, the intervening mantle of myometrium simulates a septum. This can then be cut and the cavities unified. The above clip clearly shows this. This thus gives us another option for management of such anomalies.
o Individual enlargement of each bicornuate uterine horn when they are far apart is another option in order to enlarge the cavity to make it suitable for housing a pregnancy.