Undiagnosed Uterine Didelphys in a Multiparous Somali Woman with Two Previous Cesarean Sections

Introduction

Uterine didelphys (UD) develops from failure of fusion of the paired Müllerian ducts, resulting in two uterine horns and creating two noncommunicating cavities. Each uterine cavity has a fallopian tube, but may or may not have its own cervix. Of all Müllerian anomalies, UD comprises 8%–10%, and has an incidence of one in 3000 women. A single vaginal canal is rarely encountered.^1–4

UD is known to be accompanied by renal anomalies, which are often unilateral and right-sided, 15%–25% of the time.^1–4Although this anomaly can be detected by ultrasound examination at any trimester of pregnancy, this may not occur in underdeveloped countries where diagnostic tools are unavailable or extremely limited. Somali is an example of one such countries where many pregnant women may not have the chance to see an obstetrician until delivery or have to give birth at home, even without the help of a midwife.

Case Presentation

A 31-year-old pregnant woman (gravida 5, para 4) was referred to the obstetrics department of a tertiary health-care center in Mogadishu, Somalia because of a suspected abdominal pregnancy and a 2-day history of severe lower abdominal pain. On the morning of presentation, she had visited a health-care clinic with a complaint of severe lower abdominal pain, where she had her first ultrasound examination during pregnancy. An initial diagnosis of abdominal pregnancy was made. At the current presentation, she did not remember her last menstrual bleeding and did not report any problems with her four prior full-term pregnancies, which ended up with normal vaginal deliveries in the first two and cesarean sections for the latter two. No information could be elicited from the patient concerning her previous cesarean sections.

Physical examination was unremarkable except for abdominal pain on palpation. Uterine contractions were present on a nonstress test. Pelvic examination showed a soft and 2 cm dilated cervix. Transabdominal ultrasonography revealed two adjacent uteri, one of which was empty (Figure 1, arrow) and the other bearing a fetus of approximately 1100 g at 28 weeks and 1 day of gestational age, with cephalic presentation and severe oligohydramnios (Figure 1). Magnetic resonance imaging substantiated ultrasonographic findings of the two uteri, with a single fetus in the left one having cephalic presentation, findings consistent with intrauterine pregnancy (Figure 2, arrow). A diagnosis of UD was made.

Figure 1 Transabdominal ultrasound showing two adjacent noncommunicating uteri (arrows), one of which is empty and the other is bearing a fetus.

Figure 2 Magnetic resonance image showing two adjacent noncommunicating uteri (arrows), one of which is empty and the other is bearing a fetus.

On the same day of presentation and after administration of betamethasone, due to the very severe lower abdominal pain of the patient and severe oligohydramnios of the fetus, the patient underwent emergency cesarean section under general anesthesia, and a 980 g male baby was delivered. His 1- and 5-min APGAR scores were 4 and 5, respectively. The newborn was transferred to the newborn intensive care unit for postnatal care. The mother had an uneventful postoperative course and was discharged home on the second postoperative day in very good condition. Given her background of poor health-seeking behavior and the three cesarean sections she had undergone, the patient was counseled about appropriate ways of contraception other than a uterine device.

Discussion

Although UD can be diagnosed with ultrasonography at any time, particularly during pregnancy, it may easily go unnoticed in underdeveloped countries like Somalia, where women have been particularly unlucky amid a host of adverse conditions, including lack of security throughout the country because of ongoing civil war, resource-limited health-care facilities, and transportation difficulties, as well as poverty. This case also emphasizes the shortcomings of the health-care system, particularly with regard to obstetric policies and services and the training and experience of obstetricians.

The current case had a history of two deliveries with cesarean section, yet her anomaly had been missed. Moreover, at the time of presentation to another clinic with severe lower abdominal pain, the anomaly was not suspected on ultrasonography and the clinical picture was mistaken for abdominal pregnancy. Documentation of UD has mainly been reported in women before pregnancy or during examinations for their first pregnancy.^1,5 Conversely, as with our case, reports of UD have been rare in women whose diagnosis has been missed before or during previous pregnancies and cesarean section deliveries.⁶

Conclusion

This case exemplifies how difficult life is for women living in an underdeveloped and resource-limited country like Somalia. Apart from the UD anomaly being undiagnosed, many women experience their pregnancies without even seeing an obstetrician and deliver their babies at home without medical support. Apart from providing the necessary education and training to all parties concerned, ie, patients and obstetricians, it should be noted that a great majority of problems encountered in underdeveloped countries are of international nature and thus cannot be solved without international cooperation and collaboration.