Uterus Didelphys with Longitudinal Vaginal Septum: Normal Delivery

A 21 year old, Rhesus negative Primigravida referred in view of severe preeclampsia with uterine didelphys. She had regular cycles and no history of menstrual disturbances in the past. She was married for 10 months, spontaneous conception and no dyspareunia. Booked at 6weeks, had conceptional folate, Iron and calcium supplementation. No history of early pregnancy bleeding or threatened preterm labour. She was diagnosed to have uterine didelphys or bicornuate uterus by early scans.


Introduction
Pregnancy in uterine didelphys is a relatively rare condition and the mode of delivery in these patients is unclear. Uterine didelphys is not an indication for caesarean section. We report a case of uterus didelphys who had a vaginal delivery.

Case Report
A 21 year old, Rhesus negative Primigravida referred in view of severe preeclampsia with uterine didelphys. She had regular cycles and no history of menstrual disturbances in the past. She was married for 10 months, spontaneous conception and no dyspareunia. Booked at 6weeks, had conceptional folate, Iron and calcium supplementation. No history of early pregnancy bleeding or threatened preterm labour. She was diagnosed to have uterine didelphys or bicornuate uterus by early scans.
Was started on anti hypertensive and bloods for PIH profile sent. We did an ultrasound which showed a Single live fetus, cephalic presentation, IUGR with normal doppler flow. EFW: 2190 gms. Pelvic examination: Longitudinal vaginal septum, two cervices, pregnancy in the left uterus.
After discussion labour was induced in view of her severe preeclampsia. As the Bishop's score was unfavorable -prostaglandins were used. Patient had continuous CTG monitoring from the onset of uterine contractions in view of IUGR and preeclampsia. We had cross matched 1 unit of packed cell in view of mild anemia and bearing in mind the possibility of vaginal septal laceration at birth. She delivered after 8 hrs 30 min, 15 min of second stage. During second stage the vaginal septum stretched and small cut at the area of maximal stretch given, and the whole septum got lacerated at the delivery of the head with the episiotomy. Baby weight 2.36 kg, boy with good APGAR score. 3 rd stage actively managed. Uterus well contracted. Cervices were normal. Septum completely lacerated, minimal oozing from the lacerated septal edges-settled on pressure and vicryl sutures. Episiotomy sutured. Estimated blood loss was 150 ml.

Discussion
Uterine didelphys is also known as a duplicated uterus. Almost all have double vagina-longitudinal vaginal septum. Incidence is 1 in 3000 [1]. Relatively uncommon it remains a challenge for the obstetrician especially at delivery.
The etiology of uterine didelphys is unknown. It is an embryological abnormality resulting from the failure of fusion of the Mullerian ducts, causing full uterine development to erroneously occur bilaterally.
They are usually asymptomatic. It may present with dysmenorrhoea or dyspareunia. A patient not had intercourse may just complain of difficulty in insertion of a tampon or bleeding during menstruation with a tampon. Dypareunia may be a presenting symptom with intercourse especially in a transverse vaginal septum.
Diagnosis is mainly by pelvic examination -double vagina and double cervix.
Pregnancy losses, Malpresentations, IUGR are some of the complications during pregnancy.
Multiple pregnancies are very rare. The usual presentation is twins in each horn separately. Majority of Multiple pregnancies with uterine didelphys have preterm labour. But delivery interval between twins might vary from days to weeks. Incidence of triplets in uterine didelphys is 1 in 25 million [5]. The first case of viable triplets was reported in UK in 2006.

Conclusion
Vaginal delivery is not contraindicated in uterine didelphys with longitudinal vaginal septum. Although the caesarean section rate is 82% vaginal delivery is still a possibility with maternal and fetal monitoring and proper vigilance.

Disclosure of Interest
There is no conflict of interest to declare

Contribution to Authorship
The author was directly involved in the care and management of the patient. Also collaborated on the content of the paper and approved with the final outcome.

Details of Ethics Approval
No ethical approval was required for this paper.

Funding
No funding was obtained from external sources to promote this paper. The author confirms that the permission of the patient involved was obtained prior to submission of this case report for publication.