Vaginal Delivery after External Cephalic Version in Woman with Partial Uterine Septum: Case Report
A septate uterus is a uterus divided by a longitudinal band of tissue that may extend from the uterine fundus partially or completely to the cervix. A septate uterus is clinically significant because it has been shown to be associated with adverse pregnancy outcomes including spontaneous abortion, preterm delivery, and malpresentation.
Kristen E. Park et al presented a case of a woman with a large partial uterine septum and primary infertility who conceived naturally and had two full-term vaginal deliveries. Both vaginal deliveries were achieved after ECVs performed for breech presentation.
Case Presentation
The patient initially presented as an 18-year-old nulligravida with a chief complaint of 2 years of infertility and a known uterine septum. Gynecological history was significant for menarche at the age of 13, regular monthly menses, and a history of treated chlamydia.
On examination, she was 165 cm tall and weighed 58 kg with a BMI of 21 kg/m2. Her vital signs were normal. Transvaginal ultrasound revealed a uterus measuring 7:1 cm length × 8:1 cm width × 4:6 cm depth with normal appearing ovaries. On 3D transvaginal ultrasound, the uterine septum had a 2 cm deep indentation with an angle of 65°. A hysterosalpingogram showed two uterine cornua with normal appearing and patent fallopian tubes. Laboratory studies were unremarkable.
She conceived her first pregnancy spontaneously 2 months after the hysterosalpingogram was performed. Part of the uterine septum could be seen on an 18-week obstetrical ultrasound performed in this first pregnancy. During her first pregnancy, she was diagnosed with preeclampsia with severe features at 37 weeks of gestation at an outside hospital. An ECV was performed, followed by induction of labor and an uncomplicated vaginal delivery.
The patient then conceived her second pregnancy spontaneously 4 months after her first delivery. She received prenatal care by an outside clinic that did not offer ECVs and was referred to the obstetrical triage unit for the procedure.
On presentation to the hospital, she was a 20-year-old gravida 2 para 1 at 37 weeks and 6 days of gestational age with confirmed breech presentation and a posterior placenta.
The estimated fetal weight by ultrasound was 3003 grams, and maximum vertical amniotic fluid pocket was 5.7 cm. Risks and benefits of an ECV were discussed with the patient, and consent was obtained.
At 38 weeks and 0 days, an ECV was performed in the operating room under epidural anesthesia with administration of 0.25 mg subcutaneous terbutaline. The fetus was in frank breech position with the fetal head in the maternal right upper quadrant and back facing up and to the maternal left. The fetal rump was elevated out of the pelvis while pressure was simultaneously applied to the fetal head to direct it towards the pelvis.
The ECV was successful on the second attempt, and anti-D immune globulin was administered after the procedure. After the ECV, the patient was discharged home and scheduled to return for induction of labor at 39 weeks 0 days. When she returned for induction of labor, breech position was again observed by ultrasound.
An epidural was placed, ECV was performed again in the operating room easily and without complications, and the patient was transferred to labor and delivery for induction of labor. During labor, the patient was diagnosed with preeclampsia with severe blood pressures and started on magnesium sulfate for seizure prophylaxis.
A singleton male in cephalic position was delivered vaginally at 39 weeks 2 days of gestation weighing 3510 grams with Apgar scores of 8 at 1 minute and 9 at 5 minutes. After delivery of the fetus and placenta, there were retained membranes that did not deliver with gentle traction. Manual uterine exploration revealed membranes firmly adhered in the right cornu which was felt to have contracted around the membranes holding them in place. The membranes were removed manually with traction. Manual uterine exploration afterwards revealed a thick uterine septum consistent with previous 3D TVUS and hysterosalpingogram findings. The postpartum course was uncomplicated, and another dose of anti-D immune globin was administered on postpartum day 2 since the infant was Rh positive. The mother and infant were both discharged on postpartum day 2.
Septate uteri constitute roughly 35% of congenital uterine abnormalities, making them the most common type of Mullerian anomaly. In spite of this, there is still much debate surrounding its pathophysiology, diagnosis, and treatment. In cases of breech presentation and a septate uterus, there are no specific guidelines for management.
In summary, the authors presented a case of a woman with an unresected large partial uterine septum who had two term vaginal deliveries after ECVs. Although septum resection has been shown to reduce the risk of obstetrical complications, more information is needed on how septum size and shape impacts these risks. Although more studies that include women with uterine abnormalities are needed to create guidelines, this case suggested that a large partial uterine septum should not be considered a contraindication to ECV.
Source: Kristen E. Park, Nicole L. Vestal, Michael S. Awadalla, and Sharon A. Winer; Hindawi Case Reports in Obstetrics and Gynecology Volume 2021
DOI: https://doi.org/10.1155/2021/9912271
