What is an Intrauterine Septum?
The intrauterine septum is a malformation of the uterus, in which the uterus is divided into two halves (hemipubs) by a septum of various lengths. Patients with an intrauterine septum account for 48-55% of all cases of genital malformations. In the general population, a septum in the uterus occurs in approximately 2-3% of women.
Pathogenesis during the Intrauterine Septum
The uterus is formed from mylerian ducts. As a result of sewage and reverse resorption of the median septum (usually by the 19-20th week of gestation), a single uterine cavity is formed, otherwise the median septum is preserved.
Symptoms of the Intrauterine Septum
Women with a septum in the uterus mainly suffer from miscarriage and less often with infertility. In the first trimester of pregnancy, the risk of miscarriage in patients with a septum in the uterus is 28-60%, in the second trimester – approximately 5%. In patients with an intrauterine septum, preterm labor, violations of uterine contractility during childbirth, abnormal fetal position are noted. Possible negative effects of septum on the course of pregnancy:
- insufficient volume of the uterus (the partition prevents the increase in the size of the fetus);
- isthmic-cervical insufficiency (often combined with uterine septum);
- implantation of the embryo on the avascular septum, which is not able to support its adequate development.
Most often, these disorders occur with a full septum in the uterus.
Data on the frequency of infertility with intrauterine septum are inconsistent. Most authors believe that in patients with an intrauterine septum, the ability to conceive does not decrease compared with the norm. According to other authors, primary infertility occurs in 21-28%, secondary – in 12-19% of women with an intrauterine partition.
Patients with a septum in the uterus often have dysmenorrhea and abnormal uterine bleeding.
Approximately 50% of women with an intrauterine septum are capable of conceiving and carrying pregnancy and uterine malformations in them are detected by chance during examination for another disease.
Diagnosis of Intrauterine Septum
As a rule, the septum in the uterus is diagnosed either by examination for miscarriage (metrosalpingography) or by curettage of the uterus. In clinical practice, various methods of investigation are used to diagnose intrauterine septa.
Hysterosalpingography. Opinions of various authors regarding this method are contradictory. The method allows to determine only the internal contours of the uterus, and the external contours are not visible and there may be an error in determining the type of uterine defect. With hysterosalpingography, it is difficult to differentiate the septum in the uterus and the two-horned uterus. A.M. Siegler (1967) noted that hysterographically, in the double-horned and double uterus, the halves of the cavities have an arched (convex) middle wall and the angle between them is usually greater than 90. On the contrary, with a partition, the middle walls (straight) and the angle between them is usually less than 90 °. In practice, even with these criteria, errors in the differential diagnosis of uterine malformations are possible. The diagnostic accuracy of hysterosalpingography in the diagnosis of uterine malformation is 50%.
Ultrasound. The septum in the uterus is not always detected and is defined on the echogram as a thin-walled structure, going in the anteroposterior direction, it seems that the uterus consists of two parts. Most researchers believe that, according to ultrasound, it is almost impossible to distinguish the two-horned uterus from the complete or incomplete septum in the uterus. Hydrosonography is the most informative, when against the background of the expanded uterus, the septum is easily identified, its thickness and length can be determined.
In recent years, work has emerged on the use of ultrasound devices with a three-dimensional image, which make it possible to diagnose intrauterine septa with maximum accuracy (91-95%).
When ultrasound of the uterus in patients with suspected intrauterine partition, an examination of the kidneys is necessary to exclude anomalies of their development.
Endoscopic research methods. The most complete information about the malformation of the uterus can be obtained with a combination of hysteroscopy and laparoscopy.
Conducting parallel two endoscopic methods is necessary due to the fact that the hysteroscopic picture with the two-horned uterus and intrauterine septum is identical. Laparoscopy allows not only to clarify the type of uterine malformation (external contours of the uterus), to assess the status of the uterus, pelvic peritoneum, but also to correct the pathological processes in the abdominal cavity. In addition, laparoscopy can be a method of monitoring the course of hysteroscopic surgery when dissecting the intrauterine septum.
In patients with an intrauterine septum, the laparoscopic picture can have several options: the uterus can be expanded in diameter or have a whitish strip running in the sagittal direction, and a slight retraction in this area; one half of the uterus may be larger than the other, and sometimes the uterus is of normal size and shape.
Hysteroscopy is used to clarify the form of the defect, and for its surgical correction.
During hysteroscopy, the intrauterine septum is defined as a strip of triangular tissue of various thickness and length dividing the uterine cavity into two hemi-cavities, with one mouth of the fallopian tube being determined in each of them.
Hysteroscopy under direct visual control is sometimes difficult, since the entrance to the second hemi-hollow can open at an angle. During diagnostic hysteroscopy, it is possible to determine the thickness and extent of the septum. The septum may be complete, reaching the cervical canal, and incomplete. More often the partition is longitudinal, from I to 5-6 cm long, but transverse partitions can also occur. The longitudinal septum can be defined as a triangle, the base of which is thickened and located in the bottom of the uterus. Rarely are septa in the cervical canal. When the hysteroscope is located at the level of the internal os in the cervical canal, two dark holes are seen, separated by a whitish stripe. If the septum is thick, difficulties may arise in its differentiation with the two-horned uterus. If a hysteroscope with a full septum immediately falls into one of the cavities, the diagnosis may be erroneous, so you should remember the guidelines – the mouths of the fallopian tubes. If only one mouth of the tube is visible, it is necessary to exclude a malformation of the uterus. More accurately determine the type of malformation of the uterus, especially with a thick and full septum, can be combined with hysteroscopy with hysterosalpingography and laparoscopy.
Additional research methods. Magnetic resonance tomography and spiral X-ray computer tomography are highly informative in diagnosing malformations of the uterus. They allow you to specify the diagnosis in difficult cases at the examination stage and to avoid the use of invasive diagnostic methods. However, these methods, due to their high cost and inaccessibility in our country, have not yet found wide application.
Treatment of Intrauterine Septum
Surgical treatment of the intrauterine septum, according to many authors, should be carried out only in cases of pronounced impairment of reproductive function. According to others, immediately after the intrauterine septum is detected, the patient should be offered metroplasty without waiting for complications.
Currently, the method of choice for treating an intrauterine septum is dissecting it under visual control through the transcervical route through a hysteroscope. The septum can be dissected using an endoscopic scissors (with a thin partition) or with the help of a hysteroresectoscope (with a thick, wide vascularized septum). Perhaps the use of a laser.
When the uterus is fully septum, which passes into the cervical canal, it is recommended to preserve the cervical part of the septum to prevent secondary isthmic-cervical insufficiency.
Most authors recommend that after dissection of the wide intrauterine septum, in order to quickly epithelialize and reduce the likelihood of synechia formation at the site of the dissection of the septum, it is necessary to prescribe estrogens (estrogen 2 mg daily or in the first phase) for 2-3 months.
Forecast. Transhysteroscopic dissection of the intrauterine septum is a gentle and low-impact surgery that does not leave a scar. In the future, possible birth through the natural birth canal. The frequency of normal labor, according to various authors, after a hysteroscopic dissection of the intrauterine septum is 70-85%. However, in the literature there are references to uterine ruptures during pregnancy after both complicated (uterine perforation) and uncomplicated hysteroscopic metroplasty. It is necessary to remember about the thinning of the uterus after such an operation.