A Tale of Two Cesarean Hemi-Hysterectomies

Background: Congenital uterine anomalies (CUA) result from abnormal formation, differentiation, fusion or reabsorption of the Müllerian ducts during fetal life1. Complete fusion failure of bilateral Mullerian (paramesonephric) ducts between the 6th and the 11th week of gestation results in uterine didelphys2. Morphologically, uterine didelphys presents with two separate uterine horns or a double uterus with two separate cervices. Each uterine horn is linked to one fallopian tube and one ovary3. The prevalence of CUA in the general population varies from 0.06 to 38%4. The population prevalence of didelphys uterus is between 0.3% and 5%5. Most CUA are asymptomatic, but they can be associated with adverse pregnancy outcomes. Studies have shown that women with unification defects are at increased risk of preterm labor, growth restriction and fetal malpresentation2. There still is insufficient evidence on the efficacy and safety of surgical interventions in CUA, regarding improvement of reproductive performance. Case Report:29 y.o. G3P0212 female with a PMHx of rheumatoid arthritis, celiac disease, and depression on Prozac. Patient presented at 7w5d for her initial prenatal appointment. • Ultrasound confirmed a didelphys uterus with an intrauterine pregnancy in the left horn of the uterus. • Patient was admitted to L&D at 36w3d gestation due to an intractable headache and was diagnosed with pre-eclampsia with severe features (HA). • The patient underwent primary cesarean section during which she experienced significant uterine atony requiring multiple medications, hysterotomy reopening, and a B lynch suture. • While in recovery, the patient experienced continued uterine atony with symptomatic hypotension. She was taken back to the OR and underwent a supracervical hemi-hysterectomy of the left uterine horn. • Following the procedure, the patient was found to be in DIC, underwent massive transfusion protocol in the OR, and recovered in the ICU. • The patient was discharged on post operative day #6. Patient presented at 12w2d for her initial prenatal appointment for an IUI conception. • Ultrasound confirmed an intrauterine pregnancy in the remaining (right) horn of the uterus. • Pregnancy was complicated by fetal VSD, IUGR, and polyhydramnios. • Patient underwent scheduled repeat cesarean section at 36w6d. • The patient experienced uterine atony, received multiple uterotonic medications, and underwent supracervical hemi- hysterectomy of the remaining uterine horn (right). • The patient recovered well and was discharged on post-operative day #4. Dicussion: Currently, there is insufficient evidence regarding the effectiveness of surgical interventions in improving reproductive outcomes for congenital uterine anomalies (CUA). The primary aim of managing CUA is to address anatomical distortions of obstructive anomalies to alleviate symptoms and prevent reproductive complications. Recent systematic reviews and meta-analyses have indicated that while uterine didelphys does not significantly increase the incidence of infertility or miscarriage, it is linked to a higher risk of preterm delivery, preterm premature rupture of membranes, fetal malpresentation, and fetal growth restriction. Studies suggest that up to 82.3% of women with Müllerian uterine anomalies require cesarean deliveries, regardless of the clinical indication2. It remains uncertain whether factors such as suboptimal myometrial contractions or reduced uterine muscle mass, stemming from abnormal embryonic development, contribute to labor dystocia. In our case, our patient elected for a primary cesarean section due to worsening preeclampsia symptoms and the concern for a long induction process. Given her obstetrical history, it was recommended that she undergo a repeat cesarean section for her next delivery. This report adds to the limited literature on pregnancies following hemihysterectomy, for which there has only been ten documented cases since 19471. Most of these pregnancies resulted in live births (82%), but preterm deliveries occurred in 37% of cases1. Comparatively, a larger study of women with didelphys uterus showed a lower live birth rate (56%) and a higher preterm delivery rate (43%)7. Recent findings indicate that preterm delivery rates for didelphys uterus are significantly higher than those post-hemihysterectomy (66.7% vs. 44.4%)1. While our case demonstrates a successful live birth post-hemihysterectomy, the preterm delivery rate should be interpreted cautiously due to various influencing factors, including multiple pregnancies. Each clinical situation involving uterine anomalies must be evaluated and managed individually, considering both the potential benefits and the risks of adverse outcomes. Awareness of the associated obstetric risks, particularly the heightened likelihood of preterm labor and the high rate of cesarean deliveries, is crucial for optimizing prenatal care and preparing for potential delivery complications.