British Jocirnal of Obstetrics and Gynaecology May 1976. Vol83. pp 389-392
PUERPERAL ULTRASONIC HYSTEROGRAPHY IN THE DIAGNOSIS OF CONGENITAL UTERINE MALFORMATIONS BY
M. J. BENNETT, Clinical Lecturer Nufield Department of Obstetrics and Gynaecology University of Oxford John Radclife Hospital, Oxford Summary Puerperal ultrasonic hysterography has been found to be a safe and simple technique. It is suggested as a screening procedure prior to radiological hysterography in patients whose recent reproductive performance suggests a diagnosis of congenital malformation of the uterus. RADIOLOGICAL hysterography is at present the accepted non-surgical method of defining the exact anatomy of congenital uterine malformations. The ultrasonic diagnosis of uterine abnormalities in the antenatal period was first reported by Heriot et a1 (1972) and has recently been confirmed (Bennett, 1975). This paper reports the preliminary results in the ultrasonic diagnosis of uterine anomalies in the puerperium and postabortal periods, as a preliminary investigation prior to confirmatory radiological hysterography.
corresponding hysterosalpingogram obtained 12 weeks later. Figure 3 demonstrates the appearance of a uterus bicornis bicollis-a baby had been delivered from the right horn by Caesarean section six days previously.
DISCUSSION The precise incidence of congenital malformations of the uterus is unknown although Hay (1958) and Semmens (1965) both estimated around 10 per cent. Despite a congenitally malformed uterus a pregnancy may be entirely normal. On the other hand, some malformations may be associated with infertility, recurrent abortion, abnormal lies, premature delivery and accidents of labour associated with these abnormalities and a fetal wastage of the order of 85 to 95 per cent has been reported (Strassman, 1962; Jones et al, 1956; Jones and Wheeless, 1968; Craig, 1973). Of paramount importance in the diagnosis of uterine anomalies is clinical awareness of their existence and of the problems most frequently associated with them. No woman should have to have two or more successive abortions before the possibility of a uterine anomaly is considered, especially as after appropriate surgical treatment, successful pregnancy rates of 90 per cent and more have been claimed (Strassman, 1952 and 1966; Craig, 1973; Gibbs, 1973).
METHODS AND RESULTS Seven patients in whom a congenital malformation of the uterus had been detected at either Caesarean section, manual exploration of the uterine cavity or evacuation following spontaneous midtrimester abortion were examined by diagnostic ultrasound at variable times in the puerperium, the earliest being the first and the latest the sixth puerperal day. The apparatus used was the Diasonagraph NE 4102 (Nuclear Enterprises). In all seven patients the presence of a fundal abnormality was easily demonstrated by this technique. The women’s total of 25 pregnancies had yielded only eight live children, of whom three were spontaneous preterm deliveries. Figure 1 demonstrates the ultrasonic appearance of a bicornuate uterus while Figure 2 shows the 3 89
Fig. 1
Fig. 2
ULTRASONIC HYSTEROGRAPHY
391
Fig. 3
FIG.1 A transverse scan through the fundus of a bicornuate uterus. FIG.2 The hysterosalpingographic appearance of the uterus shown in Figure 1 . FIG.3 Transverse scan through the body of a uterus bicornis bicollis-a baby had been delivered from the right horn six days previously by Caesarean section.
The ability of puerperal ultrasonic hysterography to demonstrate the presence of congenital abnormalities of the uterine fundus has been clearly shown. The technique of Buttery (1973), wherein saline is injected through the cervical canal to outline the uterine cavity, is unnecessary and could cause an ascending infection in the puerperium. Detailed descriptions of the various positions the fetus in the abnormal uterus is forced to adopt are to be found in the papers of Hay
(1958) and Semmens (1965). But abnormal fetal lies still only raise suspicion about the possible presence of an anomaly and confirmation rests upon manual exploration of the cavity at the time of delivery or radiological hysterography once involution has been completed. Gibbs (1973) recently suggested that abnormal uteri accounted for 3 per cent of premature deliveries but has no figures to substantiate this contention. Puerperal ultrasonic hysterography is a simple
392 BENNETT procedure. By using it to screen patients with recurrent abortions or a premature labour, it may enable one to identify those patients who should have a hysterosalpingogram at a later date and thus prevent many unnecessary X-rays. However, hysterosalpingography is still required for a precise anatomical diagnosis, and is mandatory if any form of surgical correction is contemplated. At present, ultrasonic hysterography is being used in our unit to examine all women who have a spontaneous delivery before 37 weeks. REFERENCES
Bennett, M. J. (1975) : Excerpta Medica Znternational Congress. Series No. 363, p 48.
Buttery, B. W. (1973): Lancet, 2, 595. Craig, C. J. T. (1973): South African Medicat Journal, 47, 2000. Gibbs, C. E. (1973): Clinical Obstetrics and Gynecology, 16, 159. Hay, D. (1958): Journal of Obstetrics and Gynaecotogy of the British Empire, 65, 557. Heriot, G., Zurlinden, B., and Gillet, J. Y . (1972): Journal de radiologie, d'ktectrologie et de mkdecine nuctkaire, 53, 683. Jones, H. W., Delfs, E., and Jones, G . E. S. (1956): American Journal of Obstetrics and Gynecology, 72, 865. Jones, H. W., and Wheeless, C. R. (1968): American Journal of Obstetrics and Gynecology, 104, 348. Semmens, J. P. (1965): Obstetrics and Gynecology, 24, 179. Strassman, E. 0. (1952): American Journal of Obstetrics and Gynecology, 64, 25. Strassman, E. 0. (1966): Fertility and Sterility, 17, 165.
PUERPERAL ULTRASONIC HYSTEROGRAPHY IN THE DIAGNOSIS OF CONGENITAL UTERINE MALFORMATIONS BY
M. J. BENNETT, Clinical Lecturer Nufield Department of Obstetrics and Gynaecology University of Oxford John Radclife Hospital, Oxford Summary Puerperal ultrasonic hysterography has been found to be a safe and simple technique. It is suggested as a screening procedure prior to radiological hysterography in patients whose recent reproductive performance suggests a diagnosis of congenital malformation of the uterus. RADIOLOGICAL hysterography is at present the accepted non-surgical method of defining the exact anatomy of congenital uterine malformations. The ultrasonic diagnosis of uterine abnormalities in the antenatal period was first reported by Heriot et a1 (1972) and has recently been confirmed (Bennett, 1975). This paper reports the preliminary results in the ultrasonic diagnosis of uterine anomalies in the puerperium and postabortal periods, as a preliminary investigation prior to confirmatory radiological hysterography.
corresponding hysterosalpingogram obtained 12 weeks later. Figure 3 demonstrates the appearance of a uterus bicornis bicollis-a baby had been delivered from the right horn by Caesarean section six days previously.
DISCUSSION The precise incidence of congenital malformations of the uterus is unknown although Hay (1958) and Semmens (1965) both estimated around 10 per cent. Despite a congenitally malformed uterus a pregnancy may be entirely normal. On the other hand, some malformations may be associated with infertility, recurrent abortion, abnormal lies, premature delivery and accidents of labour associated with these abnormalities and a fetal wastage of the order of 85 to 95 per cent has been reported (Strassman, 1962; Jones et al, 1956; Jones and Wheeless, 1968; Craig, 1973). Of paramount importance in the diagnosis of uterine anomalies is clinical awareness of their existence and of the problems most frequently associated with them. No woman should have to have two or more successive abortions before the possibility of a uterine anomaly is considered, especially as after appropriate surgical treatment, successful pregnancy rates of 90 per cent and more have been claimed (Strassman, 1952 and 1966; Craig, 1973; Gibbs, 1973).
METHODS AND RESULTS Seven patients in whom a congenital malformation of the uterus had been detected at either Caesarean section, manual exploration of the uterine cavity or evacuation following spontaneous midtrimester abortion were examined by diagnostic ultrasound at variable times in the puerperium, the earliest being the first and the latest the sixth puerperal day. The apparatus used was the Diasonagraph NE 4102 (Nuclear Enterprises). In all seven patients the presence of a fundal abnormality was easily demonstrated by this technique. The women’s total of 25 pregnancies had yielded only eight live children, of whom three were spontaneous preterm deliveries. Figure 1 demonstrates the ultrasonic appearance of a bicornuate uterus while Figure 2 shows the 3 89
Fig. 1
Fig. 2
ULTRASONIC HYSTEROGRAPHY
391
Fig. 3
FIG.1 A transverse scan through the fundus of a bicornuate uterus. FIG.2 The hysterosalpingographic appearance of the uterus shown in Figure 1 . FIG.3 Transverse scan through the body of a uterus bicornis bicollis-a baby had been delivered from the right horn six days previously by Caesarean section.
The ability of puerperal ultrasonic hysterography to demonstrate the presence of congenital abnormalities of the uterine fundus has been clearly shown. The technique of Buttery (1973), wherein saline is injected through the cervical canal to outline the uterine cavity, is unnecessary and could cause an ascending infection in the puerperium. Detailed descriptions of the various positions the fetus in the abnormal uterus is forced to adopt are to be found in the papers of Hay
(1958) and Semmens (1965). But abnormal fetal lies still only raise suspicion about the possible presence of an anomaly and confirmation rests upon manual exploration of the cavity at the time of delivery or radiological hysterography once involution has been completed. Gibbs (1973) recently suggested that abnormal uteri accounted for 3 per cent of premature deliveries but has no figures to substantiate this contention. Puerperal ultrasonic hysterography is a simple
392 BENNETT procedure. By using it to screen patients with recurrent abortions or a premature labour, it may enable one to identify those patients who should have a hysterosalpingogram at a later date and thus prevent many unnecessary X-rays. However, hysterosalpingography is still required for a precise anatomical diagnosis, and is mandatory if any form of surgical correction is contemplated. At present, ultrasonic hysterography is being used in our unit to examine all women who have a spontaneous delivery before 37 weeks. REFERENCES
Bennett, M. J. (1975) : Excerpta Medica Znternational Congress. Series No. 363, p 48.
Buttery, B. W. (1973): Lancet, 2, 595. Craig, C. J. T. (1973): South African Medicat Journal, 47, 2000. Gibbs, C. E. (1973): Clinical Obstetrics and Gynecology, 16, 159. Hay, D. (1958): Journal of Obstetrics and Gynaecotogy of the British Empire, 65, 557. Heriot, G., Zurlinden, B., and Gillet, J. Y . (1972): Journal de radiologie, d'ktectrologie et de mkdecine nuctkaire, 53, 683. Jones, H. W., Delfs, E., and Jones, G . E. S. (1956): American Journal of Obstetrics and Gynecology, 72, 865. Jones, H. W., and Wheeless, C. R. (1968): American Journal of Obstetrics and Gynecology, 104, 348. Semmens, J. P. (1965): Obstetrics and Gynecology, 24, 179. Strassman, E. 0. (1952): American Journal of Obstetrics and Gynecology, 64, 25. Strassman, E. 0. (1966): Fertility and Sterility, 17, 165.
