Uterine septum
Encyclopedia
A uterine septum is a form of a congenital
malformation
where the uterine
cavity is partitioned by a longitudinal septum
; the outside of the uterus has a normal typical shape. The wedge-like partition may involve only the superior part of the cavity resulting in an incomplete septum or a subseptate uterus, or less frequently the total length of the cavity (complete septum) and the cervix
resulting in a double cervix. The septation may also continue caudally into the vagina
resulting in a "double vagina
".
by the fusion of the two mullerian duct
s. During this fusion a resorption process eliminates the partition between the two ducts to create a single cavity. This process begins caudally and advances cranially, thus a complete septum formation represents an earlier disturbance of this absorption than the incomplete form. Causes for incomplete absorption are not known.
(5%), while 0.5% were found to have a bicornuate uterus
. In contrast, in about 15% of patients with recurrent pregnancy loss anatomical problems are thought to be causative with the septate uterus as the most common finding.
, premature birth
, and malpresentation. According to the classical study by Buttram there is a 60% risk of a spontaneous abortion, this being more common in the second than in the first trimester. However, there is no agreement on this number and other studies show a lower risk. Woelfer found that the miscarriage risk is more pronounced in the first trimester.
The condition is also associated with abnormalities of the renal system. Further, skeletal abnormalities have been linked to the condition.
Helpful techniques to investigate a septum are transvaginal ultrasonography and sonohysterography
, MRI, and hysteroscopy
. More recently 3-D ultrasonography has been advocated as an excellent non-invasive method to delineate the condition. Prior to modern imaging hysterosalpingography
was used to help diagnose the uterine septum, however, a bicornuate uterus may deliver a similar image.
A septum that has not caused problems may not be removed. There is controversy whether a septum should be removed prophylactically prior to a pregnancy
or infertility
treatment.
contains a residual cranial septum that is smaller than an incomplete septum but definitions between the two conditions are not standardized, - a cause for discrepancies in the literature.
A bicornuate uterus is sometimes confused with a septate uterus as in each situation the cavity is partitioned, however, in the former case the uterine body is cranially doubled (two uterine horns) while in the latter a single uterine body is present. The former represents a malformation of incomplete fusion of the mullerian systems, and the latter of incomplete absorption. A hysterosalpingogram may not be able to distinguish between the two conditions. The differentiation, however, is important as a septum can be corrected by hysteroscopy, while a bicornuate uterus would be corrected by a metroplasty
via laparotomy
if necessary.
Congenital disorder
A congenital disorder, or congenital disease, is a condition existing at birth and often before birth, or that develops during the first month of life , regardless of causation...
malformation
Uterine malformation
A uterine malformation is a type of female genital malformation resulting from an abnormal development of the Müllerian duct during embryogenesis...
where the uterine
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
cavity is partitioned by a longitudinal septum
Septum
In anatomy, a septum is a wall, dividing a cavity or structure into smaller ones.-In human anatomy:...
; the outside of the uterus has a normal typical shape. The wedge-like partition may involve only the superior part of the cavity resulting in an incomplete septum or a subseptate uterus, or less frequently the total length of the cavity (complete septum) and the cervix
Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
resulting in a double cervix. The septation may also continue caudally into the vagina
Vagina
The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...
resulting in a "double vagina
Vaginal septum
A vaginal septum is a congenital partition within the vagina; such a septum could be either longitudinal or transverse.-Longitudinal septum – double vagina:...
".
Etiology
The uterus is formed during embryogenesisEmbryogenesis
Embryogenesis is the process by which the embryo is formed and develops, until it develops into a fetus.Embryogenesis starts with the fertilization of the ovum by sperm. The fertilized ovum is referred to as a zygote...
by the fusion of the two mullerian duct
Müllerian duct
Müllerian ducts are paired ducts of the embryo that run down the lateral sides of the urogenital ridge and terminate at the Müllerian eminence in the primitive urogenital sinus. In the female, they will develop to form the Fallopian tubes, uterus, cervix, and the upper two-third of the vagina; in...
s. During this fusion a resorption process eliminates the partition between the two ducts to create a single cavity. This process begins caudally and advances cranially, thus a complete septum formation represents an earlier disturbance of this absorption than the incomplete form. Causes for incomplete absorption are not known.
Prevalence
Most studies are based on populations of women who have experienced a pregnancy loss and thus do not address the issue of the prevalence in the general population. A screening study by Woelfer at al. of women without a history of reproductive problems found that about 3% of women had a uterine septation; the most common anomaly in their study was an arcuate uterusUterine malformation
A uterine malformation is a type of female genital malformation resulting from an abnormal development of the Müllerian duct during embryogenesis...
(5%), while 0.5% were found to have a bicornuate uterus
Uterine malformation
A uterine malformation is a type of female genital malformation resulting from an abnormal development of the Müllerian duct during embryogenesis...
. In contrast, in about 15% of patients with recurrent pregnancy loss anatomical problems are thought to be causative with the septate uterus as the most common finding.
Clinical presentation
The condition may not be known to the affected individual and not result in any reproductive problems; thus normal pregnancies may occur. However, it is associated with a higher risk for miscarriageMiscarriage
Miscarriage or spontaneous abortion is the spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving independently, generally defined in humans at prior to 20 weeks of gestation...
, premature birth
Premature birth
In humans preterm birth refers to the birth of a baby of less than 37 weeks gestational age. The cause for preterm birth is in many situations elusive and unknown; many factors appear to be associated with the development of preterm birth, making the reduction of preterm birth a challenging...
, and malpresentation. According to the classical study by Buttram there is a 60% risk of a spontaneous abortion, this being more common in the second than in the first trimester. However, there is no agreement on this number and other studies show a lower risk. Woelfer found that the miscarriage risk is more pronounced in the first trimester.
The condition is also associated with abnormalities of the renal system. Further, skeletal abnormalities have been linked to the condition.
Diagnosis
A pelvic examination may reveal a double vagina or double cervix that should be further investigated and may lead to the discovery of a uterine septum. In most patients, however, the pelvic examination is normal. Investigations are usually prompted on the basis of reproductive problems.Helpful techniques to investigate a septum are transvaginal ultrasonography and sonohysterography
Gynecologic ultrasonography
Gynecologic ultrasonography or Gynecologic sonography refers to the application of medical ultrasonography to the female pelvic organs, specifically the uterus, the ovaries, the Fallopian tubes, as well as the bladder, the adnexa, the Pouch of Douglas, and any findings in the pelvis of relevance...
, MRI, and hysteroscopy
Hysteroscopy
Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention .-Method:...
. More recently 3-D ultrasonography has been advocated as an excellent non-invasive method to delineate the condition. Prior to modern imaging hysterosalpingography
Hysterosalpingography
Hysterosalpingography is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. It entails the injection of a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification...
was used to help diagnose the uterine septum, however, a bicornuate uterus may deliver a similar image.
Management
A septum can be resected with surgery. Hysteroscopic removal of a uterine septum is generally the preferred method as the intervention is relatively minor and safe in experienced hands. A follow-up imaging study should demonstrate the removal of the lesion.A septum that has not caused problems may not be removed. There is controversy whether a septum should be removed prophylactically prior to a pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
or infertility
Infertility
Infertility primarily refers to the biological inability of a person to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term...
treatment.
Differential diagnosis
Other forms of uterine malformation need to be considered in the work-up for uterine septum. An arcuate uterusArcuate uterus
The arcuate uterus is a form of a uterine anomaly or variation where the uterine fundus displays a concave contour towards the uterine cavity. Normally the fundus of the uterus is straight or convex on anterior-posterior imaging but in the arcuate uterus it dips into the cavity and may form a small...
contains a residual cranial septum that is smaller than an incomplete septum but definitions between the two conditions are not standardized, - a cause for discrepancies in the literature.
A bicornuate uterus is sometimes confused with a septate uterus as in each situation the cavity is partitioned, however, in the former case the uterine body is cranially doubled (two uterine horns) while in the latter a single uterine body is present. The former represents a malformation of incomplete fusion of the mullerian systems, and the latter of incomplete absorption. A hysterosalpingogram may not be able to distinguish between the two conditions. The differentiation, however, is important as a septum can be corrected by hysteroscopy, while a bicornuate uterus would be corrected by a metroplasty
Metroplasty
Metroplasty is plastic surgery or reconstructive surgery on the uterus.The technique tactile cold scissor metroplasty is a useful, safe, and effective backup procedure for hysteroscopic metroplasty....
via laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
if necessary.