Decreased Foetal Movements Secondary to Uterine Septum: A Case Reoprt and Proposed Algorithm of Management

Abstract

A 25-year-old female second gravida with one live deliver with previous one lower segment caesarean section at 36 weeks six days pregnancy reported to the emergency with chief complaint of decreased foetal movements for the past two weeks. Patient perceived 3-4 foetal movements per day in last two weeks.On examination her vitals were normal. Her systemic examination revealed no positive abnormal finding. On per abdominal examination uterine height was corresponding to term pregnancy and foetal heart rate was regular, cardiotocography was done which showed accelerations of foetal heart rate coinciding with foetal movements, indicating healthy foetus with normally functioning autonomic nervous system. However, patient was not able to feel any movement during the cardiotocography. In view of this and to rule out additional risk factor, ultrasonography was undertaken. Ultrasonography revealed amniotic fluid volume of 15, expected baby weight of 3.1 kilogram and manning score of 10/10.Patient was unsatisfied after sonographic confirmation of foetal well being saying that the movements are not good enough as earlier. This was followed by repeated admissions for the same complaint three times a week.Similar complaint of decreased foetal movement was also present in her previous pregnancy. At that time she was induced with three doses of dinoprostone gel 0.5 mg which was followed by syntocinon augmentation. However, she had undergone lower segment caesarean section due to foetal distress but she was not informed about the uterine anomaly at that time.Keeping a track of foetal movement and responding to change in movement as first line of defence against still birth and perinatal hypoxia, decision was taken to induce the patient with dinoprost gel at 37 weeks four days after well informed patient consent. After receiving two doses at eight hour interval, patient was taken up for lower segment caesarean section in view of non reassuring cardiotocography. Peroperative findings revealed partial uterine septum. Birth weight of the foetus was 3.1 kg with APGAR score of 6,8,10 at 0, 1, and 5 minute respectively. Both mother and baby were healthy in post operative period. DISCUSSIONIncidence of mullerian duct anomaly is 1-3% in women.[1] Literature have reported septate uterus as one of the most common types of mullerian anomaly [1]. Uterine septum may be incomplete in which wedge-like partition may involve only the superior part of the cavity. Less frequently, it may involve the whole length of the uterine cavity (complete septum) or even cervix leading to morphologically double cervix. This septation may also continue into the vagina resulting in a double vagina. Serosal surface of the uterus is usually normal but less commonly may have a groove or indurations.[1] Congenital uterine anomaly has been well established as cause of infertility and recurrent pregnancy loss [2]. However, only few studies [2,3] have reported the adverse pregnancy outcome of mullerian anomaly in third trimester which include pre term labour, pre ter...

The impact of congenital uterine abnormalities on pregnancy and fertility: a literature review

“…Uterine septum anomaly increases the risk of obstetrical complications, recurrent miscarriage ( Nouri et al , 2010 ) , infertility ( Nouri et al ., 2010 ; Seet et al ., 2015 ) , preterm birth, fetal malpresentation, and miscarriage before six months ( Seet et al ., 2015 ) , in addition to reducing the rate of clinical fertilization success ( Table 1 ) ( Chan et al ., 2011a ) . Two mechanisms with suggested associations with spontaneous miscarriage are decreased septum vascular supply and an abnormal overlying endometrium, resulting in abnormal implantation ( Ali et al ., 2017 ; Freud et al ., 2015 ) . Müllerian malformations, including septate uterus, are among the several possible underlying causes of persistent decreased fetus movement.…”

“…Müllerian malformations, including septate uterus, are among the several possible underlying causes of persistent decreased fetus movement. Repeated differential diagnostic evaluations are especially important when the fetus is diagnosed as healthy in examinations ( Ali et al ., 2017 ) . A complete septate uterus may be confused with uterus didelphys, especially in the presence of a duplicated cervix and a longitudinal septum in the vagina ( Patton et al ., 2004 ) .…”

Uşaqlığın anadangəlmə qüsurlarının rolu vaxtından əvvəl doğuş halında

“…V tip: Arakəsməli uşaqlıq (Septate uterus). Bu tip uşaqlıq qüsuru ikibuynuzlu uşaqlıq və yəhərvari uşaqlıqdan daha tez-tez rast gəlinən (35%) uşaqlıq qüsurudur [21]. Belə qadınların uşaqlığı iki boşluğa bölünür, çünki dölün inkişafı zamanı median arakəsmə qismən və ya tamamilə reabsorbsiya edilməmişdir (şəkil 7).…”

“…Uşaqlıq dibindən başlayaraq uşaqlıq boynunun ön və ya arxa daxili arakəsmədən (uşaqlığın qismən və ya tam arakəsmədən) uşaqlıq boynunun xarici dəliyinə (serviks arakəsməli tam atakəsmə) qədər uzana bilər də ya uşaqlıq yolunun yuxarı hissəsinə (serviks və vaginal arakəsmə ilə tam uşaqlıq arakəsmə). Uşaqlıq arakəsmənin qüsuru mamalıq fəsadları riskini artırır, xüsusən də vaxtından əvvəl doğuş, dölün qeyri-düz gəlişi və altı aya qədər düşük [21]. Spontan düşüklə bağlı olduğu düşünülən iki mexanizm damar arakəsmənin qan təcizatının azalması və arakəsmə üzərində anomal implantasiyaya səbəb olan anormal endometriumdur [21].…”

“…Uşaqlıq arakəsmənin qüsuru mamalıq fəsadları riskini artırır, xüsusən də vaxtından əvvəl doğuş, dölün qeyri-düz gəlişi və altı aya qədər düşük [21]. Spontan düşüklə bağlı olduğu düşünülən iki mexanizm damar arakəsmənin qan təcizatının azalması və arakəsmə üzərində anomal implantasiyaya səbəb olan anormal endometriumdur [21]. Müller inkişafının qüsurlar, o cümlədən arakəsməli uşaqlıq daxil olmaqla, dölün hərəkətliliyinin davamlı azalmasının bir neçə mümkün əsas səbəblərindən biridir.…”