| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Early Pregnancy & Gynaecology Assessment Unit, King’s College Hospital, and Recurrent Miscarriage Clinic, St Mary’s Hospital, London, United Kingdom.
Address reprint requests to: Davor Jurkovic, MD, PhD, Early Pregnancy and Gynaecology Assessment Unit, King’s College Hospital, Denmark Hill, London SE5 8RX United Kingdom; E-mail: davor.jurkovic{at}kcl.ac.uk.
 |
ABSTRACT |
|---|
TOP
 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
METHODS: We studied 1089 women with no history of infertility or recurrent miscarriage who were seen for a transvaginal ultrasound scan. They were screened for uterine abnormalities using three-dimensional ultrasound. We determined prevalence of miscarriage and preterm labor in women with normal and abnormal uterine morphology.
RESULTS: We found that 983 women had a normally shaped uterine cavity, 72 an arcuate, 29 a subseptate, and five a bicornuate uterus. Women with a subseptate uterus had a significantly higher proportion of first-trimester loss (Z = 4.68, P < .01) compared with women with a normal uterus. Women with an arcuate uterus had a significantly greater proportion of second-trimester loss (Z = 5.76, P < .01) and preterm labor (Z = 4.1, P < .01). There were no other significant differences in pregnancy outcomes between women with normal and abnormal uterine morphology.
CONCLUSION: This study shows the potential value of three-dimensional ultrasound and confirmed that women with congenital uterine anomalies were more likely to have adverse pregnancy outcomes than women with a normal uterus.
Until recently, the use of invasive tests, such as laparoscopy, hysteroscopy, or hysterosalpingography, was necessary for the diagnosis of congenital uterine anomalies.1–3 The assessment of uterine morphology was therefore offered selectively to women with a history of subfertility or recurrent early pregnancy loss, which are traditionally associated with uterine abnormalities. The prevalence and clinical significance of congenital uterine anomalies in the general population thus remained largely unknown.4
In routine clinical practice, a system adopted by the American Fertility Society has been used widely to classify uterine anomalies.5 This classification, however, does not specify the diagnostic methods or criteria that should be used to diagnose uterine anomalies. The diagnosis is thus solely based on the subjective impression of the clinician performing the test. The anomalies are classified into six groups, but there is no requirement to assess the severity of uterine defect within each group (Table 1
).
|
In this study we used three-dimensional ultrasound to perform a detailed analysis of uterine morphology in a group of women at low risk of congenital uterine anomalies. The purpose was to establish whether the presence of a uterine anomaly was associated with higher risk of miscarriage and preterm labor. We also investigated whether there was correlation between the degree of uterine distortion measured on ultrasound scan and the history of miscarriage and preterm labors.
|
MATERIALS AND METHODS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
). Exclusion criteria were ongoing pregnancy, history of infertility or recurrent miscarriage, presence of uterine fibroids that distorted the uterine cavity, and previous hysterectomy or myomectomy.
|
A history was taken and clinical examination was performed by the attending physician. A conventional B-mode two-dimensional transvaginal ultrasound scan was performed using a 7.5-MHz probe (Combison 530 3-D Voluson, Kretztechnik, Austria). The longitudinal axis of the uterus, from isthmus to fundus, was first defined. A series of parallel transverse sections was then done starting from the internal os to the top of the uterine fundus. When there was any duplication or splitting of the endometrial echo, congenital anomalies were suspected, and a three-dimensional ultrasound scan was used to determine the diagnosis. The technique of three-dimensional ultrasound has been described previously.10 Briefly, the uterus was visualized in the longitudinal plane, and a three-dimensional volume was generated by the automatic sweep of the mechanical transducer. The volumes were analyzed online using the technique of planar reformatted sections. With this technique it is always possible to obtain the coronal view of the uterus, which is usually lying perpendicular to the ultrasound beam. The analysis of uterine morphology was performed in a standardized plane using interstitial portions of the Fallopian tubes as reference points (Figures 1 and 2). Congenital uterine anomalies were classified in accordance with the American Fertility Society Classification5 (Table 1
). In addition, in each case the distance was measured between the midpoint of the line joining the two internal tubal ostia and the distal tip of fundal indentation or uterine septum (Figures 1 and 2).
|
|
2 test, and Pearson bivariate correlation coefficient was calculated to investigate the association between fundal morphology and reproductive outcome. |
RESULTS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Of 1089 women who were included into final data analysis, 983 had a normally shaped uterine cavity, and 106 had uterine anomalies (72 arcuate, 29 subseptate, and 5 bicornuate uteri). There was no significant association between the indication for referral and diagnosis of uterine anomalies (Table 2), but women with a normally shaped uterus were significantly older than women with an arcuate (t = 4.14, P < .01) or subseptate uterus (t = 2.97, P < .01) (Table 3).
|
). When proportions of reproductive outcomes were calculated for each woman, those with a subseptate uterus had a significantly higher proportion of first-trimester losses than women with a normal uterus (Z = 4.68, P < .01). Women with an arcuate uterus had a significantly higher proportion of second-trimester losses (Z = 5.76, P < .01) and more preterm labor (Z = 4.1, P < .01) than women with a normal uterus. There was no difference in other adverse pregnancy outcomes between women with normal and abnormal uterine morphology. There was no correlation between the depth of fundal indentation in arcuate uteri and percentage of first-trimester miscarriages (r = -0.18, P = .126), second-trimester miscarriagse (r = 0.1, P = .398), or preterm labor (r = -0.63, P = .6). In women with a subseptate uterus, the first-trimester miscarriage rate appeared to decrease with increasing length of uterine septum, but this finding did not reach statistical significance (r = -0.46, P = .702). Furthermore, there was no correlation between septum length and second-trimester miscarriage (r = 0.211, P = .273) or preterm labor (r = 0.117, P = .298).
|
DISCUSSION |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Few studies have investigated reproductive outcome in an arcuate uterus. All studies were retrospective and included mostly women with a history of infertility. Two studies reported no increase in adverse pregnancy outcomes, with live-birth rates of 83–86%.11,12 A third study, however, found successful pregnancy outcomes in only 45% of women with an arcuate uterus.14 In our study, women with an arcuate uterus had significantly more second-trimester losses and preterm labor than women with a normal uterus. Term deliveries occurred in 64% of pregnancies.
The differences between the results of our study and previous reports almost certainly reflect differences in study design. Although almost all previous studies investigated women with history of recurrent pregnancy loss or infertility, we studied women considered to be at low risk of having an anomalous uterus. The outcomes of previous pregnancy would therefore be expected to be better in our study population. Comparisons between different studies are hampered not only by the differences in study populations, but also by differences in diagnostic methods and criteria used to differentiate between various types of uterine anomalies. Both hysterosalpingograhy and hysteroscopy are limited to the assessment of the uterine cavity and are unable to differentiate reliably between the subseptate, arcuate, and bicornuate uterus.15,16 Even when these methods are combined with laparoscopy the diagnosis relies on the subjective impression of the clinician rather than strict diagnostic criteria. With that approach, subtle differences in uterine morphology cannot be assessed, and the only way to describe uterine anomalies is by using a simplified classification system.
Diagnostic ultrasound has an important advantage of being noninvasive and thus applicable for studies of a low-risk population. Two-dimensional ultrasound is a sensitive method for detection of uterine anomalies.17,18 However, it provides only a limited view of the uterine fundus and therefore cannot reliably differentiate between arcuate, bicornuate, and subseptate uteri.19 Three-dimensional ultrasound overcomes those limitations by providing a coronal view of the uterus, which can rarely be seen by conventional two-dimensional ultrasound.8 The coronal view enables the clinician to examine both the endometrial cavity and uterine fundus, thus providing all information necessary for a complete assessment of uterine morphology. The examination is performed in a standardized plane using interstitial portions of the Fallopian tubes as the reference point, which enables quantitative description of uterine morphology. In addition, three-dimensional volumes can be stored on disk and re-examined later, which facilitates audit and independent verification of the diagnosis.6–8
Measurements of uterine septum and other features of uterine anomalies enable comparisons to be made between the degree of uterine distortion and reproductive outcomes. That information could improve our understanding of the mechanisms of pregnancy failure in women with congenital uterine anomalies and the assessment of risk in future pregnancies. However, in this study the depth of fundal distortion in the arcuate uterus did not correlate with the number of previous pregnancy losses. With a subseptate uterus, the risk of miscarriage decreased with increasing septum length, but the result did not reach statistical significance.
This surprising finding could be explained in several ways. Assuming that the risk of miscarriage is proportional to the length of the uterine septum, then women with longer septa would be more likely to present with a history of recurrent pregnancy loss. By choosing to study a low-risk population, we might have excluded women with longer septa, which could have created a false impression of negative correlation between the length of septum and pregnancy loss. However, it is likely that shorter septa are associated with higher miscarriage risk. This could be explained by the increased vascularity of longer uterine septa, which are better equipped to support pregnancy.20 To resolve this uncertainty, it will be necessary to study uterine morphology in women with a history of recurrent miscarriage.
Our findings might fuel the controversy about the appropriate treatment of women with subseptate uterus.21,22 Although there seems to be general consensus that metroplasty should be offered to all women with subseptate uterus and history of recurrent miscarriage,13 it is not known whether the treatment should be offered to women with an incidental diagnosis as well. Because our data show that such women have a reasonable chance of successful pregnancy, elective excision of septum would be difficult to justify.
In a low-risk population, the routine use of three-dimensional ultrasound cannot be justified at present. However, this technology will facilitate further research into congenital uterine anomalies and improve our understanding and treatment of these conditions. In women with a history of recurrent miscarriage or infertility, where an association between congenital uterine anomaly and adverse reproductive outcomes is likely to be stronger, three-dimensional ultrasound is more cost-effective and accurate than invasive diagnostic procedures.5 Therefore we believe that three-dimensional ultrasound is the method of choice for the evaluation of uterine morphology in high-risk women.
We confirmed the association between congenital uterine anomalies and early and late pregnancy losses. However, there are significant differences in miscarriage rates between low-risk and high-risk populations, which should be taken into account when considering surgical correction of uterine anomalies. The value of surgery is not known, and there is an urgent need to test available interventions in prospective randomized controlled trials.
|
Footnotes |
|---|
Received March 27, 2001. Received in revised form July 24, 2001. Accepted July 26, 2001.
|
REFERENCES |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
2. Patton PE. Anatomic uterine defects. Clin Obstet Gynecol 1994;37:705–21.[Medline]
3. Fayez JA, Mutie G, Schneider PJ. The diagnostic value of hysterosalpingography and hysteroscopy in infertility investigation. Am J Obstet Gynecol 1987;156:558–60.[Medline]
4. Ashton D, Amin HK, Richrart RM, Neuwirth RS. The incidence of asymptomatic uterine anomalies in women undergoing transcervical tubal sterilization. Obstet Gynecol 1988;72:28–30.
5. The American Fertility Society. The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, mullerian anomalies and intrauterine adhesions. Fertil Steril 1988;49:944–55.[Medline]
6. Wu MH, Hsu CC, Huang KE,. Detection of congenital mullerian duct anomalies using three-dimensional ultrasound. J Clin Ultrasound 1997;25:487–92.[Medline]
7. Raga F, Bonilla-Muscoles F, Blanes J, Osbourne NG. Congenital mullerian anomalies: Diagnostic accuracy of three-dimensional ultrasound. Fertil Steril 1996;65:523–8.[Medline]
8. Jurkovic D, Geipel A, Gruboeck K, Jauniaux E, Natucci R, Campbell S. Three-dimensional ultrasound for the assessment of uterine anatomy and detection of congenital anomalies: Comparison with hysterosalpingography and two-dimensional ultrasonography. Ultrasound Obstet Gynecol 1995;5:233–7.[Medline]
9. Jurkovic D, Gruboeck K, Tailor A, Nicolaides KH. Ultrasound screening for congenital uterine anomalies. Br J Obstet Gynaecol 1997;104:1320–1.[Medline]
10. Jurkovic D, Aslam N. Three-dimensional ultrasound for diagnosis of congenital uterine anomalies. In: Merz E. 3-D ultrasound in obstetrics & gynaecology. Philadelphia: Lippincott Williams & Wilkins, 1998:27–9.
11. Raga F, Bauset C, Remohi J, Bonilla-Muscoles F, Pellicer A. Reproductive impact of congenital uterine anomalies. Hum Reprod 1997;12:2277–81.
12. Acien P. Reproductive performance of women with congenital uterine malformations. Hum Reprod 1993;8: 122–6.
13. Homer HA, Li TC, Cooke ID. The septate uterus: A review of management and reproductive outcome. Fertil Steril 2000;73:1–4.[Medline]
14. Tulandi T, Arronet GH, McInnes RA. Arcuate and bicornuate uterine anomalies and infertility. Fertil Steril 1980; 34:362–4.[Medline]
15. Reuter KL, Daly DC, Cohen SM. Septate versus bicornuate uteri: Errors in imaging diagnosis. Radiology 1989; 172:749–52.
16. Sheth SS, Sonkawde R. Uterine septum misdiagnosed on hysterosalpingogram. Int J Gynaecol Obstet 2000;69: 261–3.[Medline]
17. Nicolini U, Bellotti M, Bonazzi B, Zamberletti D, Candiani GB. Can ultrasound be used to screen uterine malformations? Fertil Steril 1987;47:89–93.[Medline]
18. Fedele L, Ferrazzi E, Dorta M, Vercellini P, Candiani GB. Ultrasonography in the differential diagnosis of "double" uteri. Fertil Steril 1988;50:361–4.[Medline]
19. Pellerito JS, McCarthy SM, Doyle MB, Glickman MG, DeCherney AH. Diagnosis of uterine anomalies: Relative accuracy of MR imaging, endovaginal sonography and hysterosalpingography. Radiology 1992;183:795–800.
20. Dabirashafi H, Bahadori S, Mohammed K, Alavi M, Moghadami-Tabrizi N, Zandinejad K, et al. Septate uterus: New idea on the histological features of the septum in this abnormal uterus. Am J Obstet Gynecol 1995;171: 105–7.
21. Kirk EP, Choung CJ, Coulam CB, Williams TJ. Pregnancy after metroplasty for uterine anomalies. Fertil Steril 1993;59:1164–8.[Medline]
22. Propst AM, Liberman RF, Harlow BL, Ginsburg ES. Complications of hysteroscopic surgery: Predicting patients at risk. Obstet Gynecol 2000;96:517–20.
This article has been cited by other articles:
|
|
 |
|
  S. H. Saravelos, K. A. Cocksedge, and T.-C. Li Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal Hum. Reprod. Update, June 6, 2008; (2008) dmn018v1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. V. Ghate, M. M. Crockett, B. K. Boyd, and E. K. Paulson Sonohysterography: Do 3D Reconstructed Images Provide Additional Value? Am. J. Roentgenol., April 1, 2008; 190(4): W227 - W233. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. D. Deutch and A. Z. Abuhamad The Role of 3-Dimensional Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of Mullerian Duct Anomalies: A Review of the Literature J. Ultrasound Med., March 1, 2008; 27(3): 413 - 423. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. C. Mueller, H. K. Hussain, Y. R. Smith, E. H. Quint, R. C. Carlos, T. D. Johnson, and J. O. DeLancey Mullerian Duct Anomalies: Comparison of MRI Diagnosis and Clinical Diagnosis Am. J. Roentgenol., December 1, 2007; 189(6): 1294 - 1302. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. H. Y. Ng, C. C. W. Chan, O. S. Tang, W. S. B. Yeung, and P. C. Ho Endometrial and subendometrial vascularity is higher in pregnant patients with livebirth following ART than in those who suffer a miscarriage Hum. Reprod., April 1, 2007; 22(4): 1134 - 1141. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. F. Andreotti, A. C. Fleischer, and L. E. Mason Jr Three-dimensional sonography of the endometrium and adjacent myometrium: preliminary observations. J. Ultrasound Med., October 1, 2006; 25(10): 1313 - 1319. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Jauniaux, R. G. Farquharson, O. B. Christiansen, N. Exalto, and On behalf of ESHRE Special Interest Group for Earl Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage Hum. Reprod., September 1, 2006; 21(9): 2216 - 2222. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Z. Abuhamad, S. Singleton, Y. Zhao, and S. Bocca The z technique: an easy approach to the display of the midcoronal plane of the uterus in volume sonography. J. Ultrasound Med., May 1, 2006; 25(5): 607 - 612. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. R. Benacerraf, C. B. Benson, A. Z. Abuhamad, J. A. Copel, J. S. Abramowicz, G. R. DeVore, P. M. Doubilet, W. Lee, A. S. Lev-Toaff, E. Merz, et al. Three- and 4-Dimensional Ultrasound in Obstetrics and Gynecology: Proceedings of the American Institute of Ultrasound in Medicine Consensus Conference J. Ultrasound Med., December 1, 2005; 24(12): 1587 - 1597. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Weiss, E. Shalev, and S. Romano Hysteroscopy may be justified after two miscarriages Hum. Reprod., September 1, 2005; 20(9): 2628 - 2631. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Monteagudo, I. Strok, S. Greenidge, and I. E. Timor-Tritsch Quadruplet Pregnancy: Two Sets of Twins, Each Occupying a Horn of a Septate (Complete) Uterus J. Ultrasound Med., August 1, 2004; 23(8): 1107 - 1111. [Full Text] [PDF]
|
|
|
|
|
|
R. Salim, L. Regan, B. Woelfer, M. Backos, and D. Jurkovic A comparative study of the morphology of congenital uterine anomalies in women with and without a history of recurrent first trimester miscarriage Hum. Reprod., January 1, 2003; 18(1): 162 - 166. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
