Anatomic factors associated with recurrent pregnancy loss

Anatomic uterine defects appear to predispose women to reproductive difficulties, including first- and second-trimester pregnancy losses, higher rates of preterm labor and birth, and abnormal fetal presentation. These anatomic abnormalities can be classified as congenital, including müllerian and diethylstilbestrol-related abnormalities, or acquired, such as intrauterine adhesions or leiomyomata. In women with three or more consecutive spontaneous abortions who underwent hysterosalpingography or hysteroscopic examination of their uteri, mullerian anomalies have been found in 8 to 10%. Women with mullerian anomalies may be predisposed to recurrent pregnancy loss because of inadequate vascularity to the developing embryo and placenta, reduced intraluminal volume, or cervical incompetence. The reproductive history of most women with a müllerian anomaly is poor, especially for women with a uterine septum, the most common mullerian anomaly. Recurrent pregnancy losses resulting from a uterine septum, bicornuate uterus, intrauterine adhesions, and fibroids are amenable to surgical correction. Women with müllerian anomaly and a history of second-trimester pregnancy losses may benefit from a prophylactic cervical cerclage.     

Assessing congenital uterine anomalies: the role of three-dimensional ultrasonography

Congenital uterine anomalies are associated with a range of adverse reproductive outcomes but may also be found incidentally. Their significance in women with normal reproductive histories, who do not have a history of recurrent miscarriage or infertility, has been uncertain. The absence of these data has made it difficult to understand the true significance of congenital uterine anomalies found in women with adverse pregnancy outcomes. The advent of transvaginal three-dimensional ultrasonography has enabled the accurate, non-invasive, outpatient diagnosis of congenital uterine anomalies. It has enabled large-scale screening and morphological analysis of congenital uterine anomalies.     

Congenital Uterine Anomalies and Uterine Rupture

Congenital uterine anomalies are more common than previously recognized. While many women will have no symptoms or problems, some women with congenital uterine anomalies have increased risks of adverse outcomes during pregnancy. This article presents a case study of a woman with a congenital uterine anomaly leading to spontaneous rupture of her unscarred uterus remote from term. The most common types of congenital uterine anomalies and their associated reproductive risks are reviewed. Evaluation of congenital uterine anomalies and management alternatives are discussed.     

Statistical analysis of possible causes of repeated spontaneous abortions]

The possible causes of early pregnancy failure in one thousand, three hundred and seventeen women (n = 1,317) with a history of repeated reproductive wastage were analysed and the results of treatment for each etiology were evaluated. Out of 1,200 hysterosalpingographies, 188 (15.7%) congenital uterine anomalies were detected and the degree of each uterine cavity deformity was evaluated by the X/M ratio. Metroplasty was performed on 71 women with no other causes of spontaneous abortion, and more than 84% of the post-operative pregnancy were successfully maintained. One hundred and four (n = 104, 5.5%) out of 949 couples with a high incidence of reproductive failure had either a chromosomal abnormality or normal variants in the wife and/or husband. Twelve cases (n = 12, 8.1%) had a positive analysis for anticardiolipin antibody among 148 women examined. Immunotherapy utilizing the husband's lymphocytes was indicated for four hundred and seventy three (n = 473) other couples with no other abnormalities likely to induce spontaneous abortions. This treatment brought approximately 80% of pregnancies to successful termination and 199 deliveries were recorded with this immunotherapy. The present study suggests that the causes of early pregnancy failure are complex, but that most of the causes of repetitive wastage are curable after exact diagnosis and appropriate treatment.     

Uterine factor in recurrent pregnancy loss

ObjectiveTo review the current understanding of the role the uterus plays in recurrent pregnancy loss.FindingsCongenital and acquired uterine abnormalities are associated with recurrent pregnancy loss in the first and second trimester. Relevant congenital Mullerian tract anomalies include unicornuate, didelphys, bicornuate and septate uteri. Pregnancy loss has also been associated with acquired uterine abnormalities that distort the uterine cavity such as intrauterine adhesions and submucosal myomas. Initial evaluation of women with recurrent pregnancy loss should include a uterine assessment such as a pelvic ultrasound or sonohysterography. Uterine abnormalities such as uterine septum, intrauterine adhesions and submucosal myomas may be managed surgically with operative hysteroscopy.ConclusionUterine abnormalities, both congenital and acquired, can be responsible for recurrent pregnancy loss.     

Post-abortion hysteroscopy: a method for early diagnosis of congenital and acquired intrauterine causes of abortions

Objective

Recurrent pregnancy loss is often defined as three or more consecutive pregnancy losses but there are no strict criteria for initiation of investigations after a miscarriage. We compared the frequency of uterine anomalies diagnosed by hysteroscopy following one, two and three or more miscarriages.

Study design

In our study 151 patients underwent diagnostic hysteroscopy following a missed or an incomplete abortion. Uterine septum, subseptum, arcuate uterus, and uterine hypoplasia are classified as congenital uterine anomalies and polyps, synechia, and submucous myomas are classified as acquired uterine abnormalities.

Results

151 Patients were enrolled in the study. The pregnancy numbers of the patients varied between 1 and 12. Sixty nine (46%) of the patients had one miscarriage, 42 (28%) had two miscarriages and 40 (26%) had three or more miscarriages. Diagnostic hysteroscopy revealed normal uterine cavity in 61.1% of the patients, congenital uterine anomalies in 20.4% and acquired uterine pathologies in 18.5%. Among the congenital anomalies, 14 (9.3%) were uterine septum, 10 (6.6%) were subseptate uterus, 4 (2.6%) were arcuate uterus and 3 (1.9%) were uterine hypoplasia. Among acquired abnormalities 14 (9.3%) were uterine synechia, 12 (7.9%) were endometrial polyps, and 2 (1.3%) were submucous myoma. Among patients who had one miscarriage 64.1% had a normal uterine cavity, 18.2% had congenital abnormalities and 17.7% had acquired uterine pathologies. Of patients with two miscarriages, 52% had a normal uterine cavity, 21.9% had congenital anomalies and 26.1% had acquired uterine pathology. In the three or more miscarriage group, 58.4% had normal uterine cavity, 25.3% had congenital anomalies, and 16.3% had acquired uterine pathology. We did not find any statistically significant difference between the number of miscarriages and pathologic diagnostic hysteroscopy findings.

Conclusions

Post-abortion office hysteroscopy is a simple and efficient tool in the early diagnosis of congenital and acquired uterine pathologies. Diagnostic hysteroscopy can be performed after the first miscarriage in order to determine congenital and acquired uterine pathologies, with regard to the patient's age and anxiety level.     

Management of Reproductive Tract Anomalies

Reproductive tract malformations are rare in general population but are commonly encountered in women with infertility and recurrent pregnancy loss. Obstructive anomalies present around menarche causing extreme pain and adversely affecting the life of the young women. The clinical signs, symptoms and reproductive problems depend on the anatomic distortions, which may range from congenital absence of the vagina to complex defects in the lateral and vertical fusion of the Müllerian duct system. Identification of symptoms and timely diagnosis are an important key to the management of these defects. Although MRI being gold standard in delineating uterine anatomy, recent advances in imaging technology, specifically 3-dimensional ultrasound, achieve accurate diagnosis. Surgical management depend on the type of anomaly, its complexity and the proper embryological interpretation of the anomaly and involves multiple specialties; thus, patients should be referred to centres with experience in the treatment of complex genital malformations.     

Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening.

OBJECTIVE: To determine reproductive outcomes in women with congenital uterine anomalies detected incidentally by three-dimensional ultrasound. 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 (Zeta = 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 (Zeta = 5.76, P <.01) and preterm labor (Zeta = 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.     

先天性子宫异常矫正手术对女性生育结局的影响

先天性子宫异常在女性生殖系统发育异常中最为常见,易导致不良妊娠及产科结局,对女性生理心理上造成了严重的影响.近年来,宫腔镜、腹腔镜等微创手术在纵隔子宫、双角子宫、单角子宫及残角子宫、T型子宫、苗勒管发育不良等先天性子宫异常患者矫正中的应用越来越广泛,逐渐取代了以往的传统手术,成为先天性子宫发育异常治疗的主要方法.宫腔镜...     

Female genital anomalies affecting reproduction

OBJECTIVE: A multitude of female congenital anomalies are uncommon. However, their impact on reproduction can be profound. The aim of this review is to remind the practicing physician of the clinically relevant embryology and summarize the studies that look at the impact of such various anomalies on a woman's fecundity. We review particular surgical therapies that possibly may improve fertility in such women. DESIGN: Review and critique of available studies in which particular surgical therapies were done and whether they truly improved fertility in these women with congenital reproductive anomalies. RESULTS: Clear evidence demonstrates that uterine septum resection is effective in women with demonstrated recurrent pregnancy losses. Arcuate uterus has little impact on reproduction. Other studies fail to definitively show that surgical correction will improve pregnancy retention or fertility except for specifically indicated clinical scenarios. CONCLUSIONS: The practicing reproductive specialist should have working knowledge of evidence-based therapeutic options for women with reproductive congenital anomalies. A summary chart has been devised to clearly associate embryologic structures with normal adult derivative as well as anomalous structures.     

先天性子宫畸形患者辅助生殖技术助孕结局分析

目的:探讨先天性子宫畸形对女性生育能力的影响及先天性子宫畸形患者行辅助生殖技术(ART)助孕后的妊娠情况。方法:回顾分析我院2004年1月至2011年6月收治的145例子宫畸形行体外受精/卵胞浆内单精子显微注射和胚胎移植(IVF/ICSI-ET)患者的临床资料。随机抽取同期子宫形态正常的不孕患者198例作为对照组,比较两组患者的助孕情况及妊娠结局。结果:(1)子宫畸形组的年龄、获卵数、移植胚胎数、子宫内膜厚度与对照组比较,均无统计学差异;(2)145例子宫畸形患者行248个胚胎移植周期,妊娠89例共96个周期,患者临床妊娠率61.38%(89/145),移植周期临床妊娠率38.71%(96/248),足月产占55.21%(53/96)。与对照组比较,不同类型子宫畸形组临床妊娠率、多胎妊娠率、平均孕周及新生儿出生体重差异均无统计学意义;(3)双角+双子宫流产率较高(43.75%),与对照组比较差异显著(P<0.05),其余各组差异均无统计学意义;(4)子宫畸形组的胎膜早破及低出生体重儿发生率分别为20.29%、31.87%,均显著高于对照组(P<0.05)。结论:先天性子宫畸形患者行ART助孕后妊娠率良好,但妊娠期胎膜早破及低出生体重儿发生率明显增高。     

The reproductive performance of women before and after metroplasty

Nineteen women with congenital uterine anomalies underwent metroplasty. Prior to surgical correction of the uterine malformation, 44 of their 45 (98%) pregnancies had ended with a spontaneous abortion, and no woman had a living child. Following metroplasty, only 4 of 18 (22%) pregnancies aborted, and 12 of the 14 (86%) women attempting pregnancy had a living child. There were no unusual intraoperative or postoperative complications. Metroplasty procedures can be performed safely, and are associated with excellent reproductive outcomes.     

Congenital malformations of the uterus: the role of ultrasound

Congenital uterine anomalies in women often do not cause any symptoms, except when there is an obstruction of the uterine outflow tract, which occurs infrequently. Patients with congenital uterine anomalies often go undetected or are only discovered incidentally during an evaluation for something else. Consequently, it is difficult to determine the prevalence of congenital uterine anomalies in the general population, and it appears more frequently in certain populations, namely in those with recurrent pregnancy loss or infertility. This paper will review the pathogenesis of congenital uterine anomalies and the standard classification for these anomalies. We will focus on ultrasound and other diagnostic modalities (hysterosalpingogram, laparoscopy with hysteroscopy, and magnetic resonance imaging). We will compare the accuracy and differences between these diagnostic techniques. With the development of three-dimensional ultrasound, the diagnosis of congenital uterine anomalies can be made accurately, effectively, and with less invasiveness than with other procedures. We will briefly review the treatments and pregnancy outcomes in these different anomalies.     

Hemolytic anemias during pregnancy and the reproductive years

Anemia is a common phenomenon in women during the reproductive years. In pregnancy, it is associated with an increased incidence of maternal-fetal morbidity and mortality. The approach to the investigation of anemic women suspected of having hemolytic anemia of either congenital or acquired etiology is the subject of this article. Various conditions in the pregnant women can have hematologic consequences for the newborn infant; these conditions include sensitization to fetal blood cells, infections, drug ingestion and the possession of genes for hereditary hemolytic disorders, which may be transmitted to the fetus. Because several forms of hemolytic anemias are hereditary or are caused by an altered gene, genetic consultation is important.     

Uterine arteriovenous malformations: a rare but serious cause of vaginal bleeding

Arteriovenous malformations (AVMs) of the uterus are rare. They may either be congenital or acquired. They can cause life-threatening haemorrhage and should therefore be considered in all premenopausal women presenting with severe vaginal bleeding, especially those with a previous history of uterine curettage. We report on six women aged between 20 and 26 years of age, all of whom presented with heavy vaginal bleeding 1 week to 12 months postuterine curettage. All of our patients had undergone surgical termination of pregnancy within the preceding 12 months. Grey-scale transvaginal ultrasound and colour Doppler are diagnostic. The latter shows characteristic patterns of turbulent high systolic velocity flows with low resistance indices. Pelvic angiograms and magnetic resonance imaging are also useful diagnostic tools. Until recently, hysterectomy was the only treatment available. Currently the preferred choice appears to be uterine artery embolisation, which allows fertility to be retained. Embolisation was successfully used in three of our patients. Two were managed conservatively, and one of our patients has had a hysterectomy following failed embolisation. Curettage can provoke catastrophic bleeding and must be avoided. In conclusion, the AVMs are a potential cause of catastrophic vaginal bleeding in premenopausal women. Early diagnosis is based on a high index of suspicion and is confirmed by characteristic colour Doppler imaging findings. Typically, there is a history of previous uterine curettage.     

The significance of hysteroscopic treatment of congenital uterine malformations

Hysteroscopic surgery replaced abdominal metroplasty and is today the treatment of choice for congenital uterine malformations. This is not just because of its reproductive results, which are comparable to those achieved with the abdominal approach, but mainly because of several post-operative benefits (reduced morbidity, convalescence and costs, and no scar tissue on the abdominal and uterine walls), improved reproductive performance (no reduction in uterine volume, shorter interval to conception after operation) and the mode of delivery (avoiding Caesarean section). Decisions on when and how to treat uterine septa, in relation to the type of malformation, are discussed. In particular, indications for treatment have been broadened to include not only the septate uterus associated with adverse reproductive outcome, but also patients before any potential obstetric accidents, especially in those with declining fecundity (>35 years), with reproductive problems (unexplained infertility) and before assisted reproductive techniques, as well as in women with no actual desire of pregnancy. Two types of hysteroscopic treatment are available: resectoscopic and office hysteroscopic surgery. The indications for resectoscopic surgery are broad-based septa and complete septa with single or double cervix. The resectoscope allows an excellent continuous flow system, providing continuous washing of the uterine cavity and a clear view, removing bubbles and debris during the procedure. However, an exact measurement of fluid balance must be performed to avoid excessive fluid intravasation. Laparoscopic or sonographic monitoring is mandatory. Treatment of limited-based small septa whose apex is easily visible can be achieved with an outpatient approach using office mini-hysteroscopic surgery and the vaginoscopic technique. The intra-operative check of the fundus is performed by ultrasonography. No preparation of the endometrium is required, except for large, broad-based septa, and hormonal therapy and intrauterine devices are not utilized post-operatively. The post-operative follow-up consists of a hysteroscopic check performed 1-3 months after surgery.     

Modern management of uterine fibroids

Uterine fibroids are the most common tumor of the reproductive tract in women of reproductive age. Although they are benign tumors that are often asymptomatic, uterine fibroids may cause debilitating symptoms in many women, such as abnormal uterine bleeding, abdominal pain, increased abdominal girth, urinary frequency, constipation, pregnancy loss, dyspareunia, and in some cases infertility. Several approaches are available for the treatment of uterine fibroids. These include pharmacologic options, such as hormonal therapies and gonadotropin-releasing hormone agonists; surgical approaches, such as hysterectomy, myomectomy, myolysis, laparoscopic uterine artery occlusion, magnetic resonance imaging-guided focused ultrasound surgery, and uterine artery embolization. The choice of approach may be dictated by factors such as the patient's desire to become pregnant in the future, the importance of uterine preservation, symptom severity, and tumor characteristics. New treatment options for uterine fibroids would be minimally invasive, have long-term data demonstrating efficacy and safety, have minimal or no incidence of fibroid recurrence, be easy to perform, preserve fertility, and be cost effective. New treatment approaches are under investigation, with the goals of being effective, safe, and less invasive.     

Clinical assessment and management of the endometrium in recurrent early pregnancy loss

Unexplained and recurrent loss of pregnancies is a heartbreaking and frustrating condition. The routine diagnostic workup for pregnancy loss includes hormonal evaluation, screening for genetic or chromosomal defects, immunologic and thrombophilic testing, and evaluation of congenital or acquired Müllerian defects. In cases of idiopathic pregnancy loss, defects in endometrial receptivity are increasingly being investigated. The role of the endometrium in pregnancy loss has historical roots but remains controversial. Exciting new directions based on microRNAs, proteomics, and epigenetics promises to keep this area of investigation both interesting and complex. With each new diagnostic and therapeutic biomarker identified comes a greater potential for diagnosis and treatment of women. The clinical assessment of the endometrium remains an important part of the investigation of couples with unexplained pregnancy loss.     

实时三维超声成像诊断子宫畸形

目的 :探讨三维超声在诊断子宫畸形中的作用及子宫畸形对妊娠的影响。方法 :对 30例子宫畸形患者及 2 0例子宫形态正常者行三维超声检查 ,并记录孕产史。结果 :30例子宫畸形中 ,纵隔子宫 14例 ,双角子宫 10例 ,双子宫 5例 ,残角子宫 1例。对子宫畸形患者三维超声成像能清晰显示子宫内部结构 ,特别是子宫腔及内膜的形态和结构。结论 :三维超声能从不同角度观察各种位置的子宫内部构造 ,显示内膜形态 ,诊断子宫畸形的准确性明显优于二维超声。     

Surgical management of congenital uterine anomalies (including indications and surgical techniques)

The prevalence of congenital uterine anomalies (CUA) is reported to be 4.3–6.7% in the general population, 3.4%–8% in the infertile population, and 12.6–18.2% of those with recurrent miscarriages. They are the result of abnormal formation, differentiation, and fusion of the Müllerian or paramesonephric ducts during fetal life.To date, various classification systems have been proposed for the categorization of CUA, but the recently introduced ESHRE/ESGE classification seems to be a new, clear, and systematic categorization, which could be the basis for clinicians to rely on when they refer to CUA and their clinical impact either generally or concerning pregnancy outcomes. CUA are apparently related to an impaired reproductive outcome, while their exact clinical impact as well as the effectiveness of their treatment remain considered controversial. Surgery is indicated in women presenting with symptoms related to specific uterine anomalies, especially in those with fertility problems. In this review, indications, surgical techniques for the repair of CUA according to their classification, and fertility and pregnancy outcomes before and after surgery will be thoroughly reviewed.