British Journal of Radiology (2005) 78, 952-953
© 2005 British Institute of Radiology
doi: 10.1259/bjr/37756141
Two cases of uterine septum with intrauterine device
E Dikensoy, MD
1
I Kutlar, MD
2
A Gocmen, MD
2 and
C R Graves, MD
1
1 Vanderbilt University, Department of Obstetrics and Gynecology, Nashville, TN 37235, USA and 2 Gaziantep University, Obstetrics and Gynecology, Gaziantep, Turkey
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Abstract
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Intrauterine devices (IUDs) have been used worldwide for contraception for decades. They are easily deployed, inexpensive and one of the most reliable contraceptive methods. Though ease of placement is such that they are frequently placed by midwives in the outpatient setting in developing countries, some complications due to its misplacement occasionally can occur. We present two cases with unknown uterine septum in which IUDs were placed without prior ultrasound examination of the pelvis. We conclude evaluation of the pelvis by ultrasound prior to placement of IUDs in women with a history of breech presentation, preterm labour, or recurrent miscarriage may be helpful in identifying uterine anomalies that make IUD placement unsuitable.
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Introduction
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Intrauterine contraceptive devices (IUDs) have been used in gynaecological practice for decades. IUDs constitute approximately 13% of all contraceptives used with a failure rate of 1–3% [1, 2]. There are various risk factors for the failure of the IUD referrable to the IUD itself (composition of the IUD, duration of use, role of the IUD position), or to the characteristics of the woman (age, uterus position, endometrial cavity length and drug use) [3].
A uterine septum is the most common mullerian duct anomaly and results from partial or complete failure of resorption of utero-vaginal septum after fusion of the paramesonephric ducts [4–6]. The uterine septum is associated with the worst obstetric outcome of the mullerian anomalies, with overall premature birth rates ranging from 9% to 33%, and fetal survival rates of 10% to 75%. Morphological narrowing of the endometrial capacity by the septum has been implicated as the cause of poor outcomes [7].
We present two patients with an unknown uterine septum in the setting of IUD use.
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Case reports
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Patient 1
A 23-year-old, married Caucasian woman presented for 8 days of delayed menstruation. She had an IUD placed without pelvic ultrasound evaluation 1 year prior to presentation. Her past medical history was remarkable only for a cesarean section at 36 weeks pregnancy for breech presentation 2 years previously. Upon initial physical examination, the cervix appeared normal without any sign of an IUD. Transvaginal ultrasound revealed one uterine fundus with two uterine cavities, and the uterine fundal contour was minimally indented (Figure 1
). A gestational sac approximately 20 mm in size (about 5 weeks pregnancy) was identified in the right portion of the cavity. An IUD was identified in the left portion of the cavity. Her pregnancy course was uncomplicated and at 35 weeks and 5 days of the pregnancy, she was admitted to the hospital for labour contractions and back pain. Cesarean section was performed under general anaesthesia, during which correction of the uterine septum was also performed without complication.
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Figure 1. Transvaginal ultrasound of patient 1: one uterine fundus with two uterine cavities, a gestational sac approximately 20 mm was seen in the right portion of the cavity, and an intrauterine device was seen in the left portion of the cavity.
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Patient 2
A 25-year-old married, Caucasian woman presented for a routine pap smear. Her past medical history included pre-term labour at 28 weeks and a spontaneous abortion 4 and 2 years ago, respectively. Her past medical history was otherwise unremarkable. She had an IUD placed 1 year ago without pelvic evaluation by transvaginal ultrasound. At physical examination, the string of the IUD was visualized and the cervix appeared normal. The transvaginal ultrasound examination showed one uterine fundus with two uterine cavities and a flat uterine fundal contour. The IUD was identified to be in the left portion of the uterine cavity (Figure 2).
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Figure 2. Transvaginal ultrasound of patient 2: one uterine fundus with two uterine cavities and the intrauterine device was seen in the left portion of the uterine cavity.
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Discussion
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We present two cases of uterine septum in which an IUD was placed without prior pelvic evaluation by transvaginal ultrasound. The first patient had a cesarean section for breech presentation 2 years prior to the admission. Although an IUD had been placed 1 year prior to presentation, pregnancy was not prevented as the IUD was placed into the left side of the cavity. The second patient had a history of pre-term labour at 28 weeks of and a spontaneous abortion at 6 weeks. A possible mullerian anomaly was the first consideration. Transvaginal ultrasound revealed one uterine fundus with two uterine cavities and minimal indentation of the uterine fundal contour compatible with a uterine septum.
The presence of a uterine septum is associated with some the of poorest reproductive outcomes. The prevalence of septae in the patients who have had recurrent spontaneous abortions (usually three or more) has been reported to be 26–94%. The prevalence of premature birth rates associated with uterine septum has been reported to be 9–33% [3].
Accurate classifying of uterine anomalies by transvaginal ultrasound is 85–92% [3].
Transabdominal ultrasound may be useful in making the diagnosis of a uterine septum, especially in pregnant women. It is essential that imaging focus not only on conventional sagittal and transverse imaging of the pelvis, but also include orthogonal images along the long axis of the uterus to characterize the external uterine contour [8].
With a sensitivity of 100% and specificity of 80%, transvaginal ultrasound allows a better assessment in the diagnosis of uterine septum than transabdominal ultrasound. This superiority may be due to the avoidance of subcutaneous fat and the use of higher-frequency probes when performed by transvaginal means. Furthermore, transvaginal ultrasound may involve the saline infusion sonohysteroscopy [3]. A uterine septum appears as a convex, flat myometrial septum dividing the uterine cavity, the proximal part of which possesses an echographic texture indicative of myometrium merging into hypoechoic fibrous tissue distally when viewed by transvaginal ultrasound [9].
We conclude that ultrasound evaluation of the pelvis prior to IUD placement in women with a history of breech presentation, preterm labour, or recurrent miscarriage can be helpful in detecting patients with uterine abnormalities in whom IUD use is not suitable for contraception.
Received for publication December 21, 2004.
Revision received February 19, 2005.
Accepted for publication April 14, 2005.
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References
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Abstract
Introduction
