Keywords : missed abortion, Robert’s uterus, hemihysterectomy
Anomalies of the mullerian duct present in a variety of forms like menstrual abnormalities, infertility, recurrent pregnancy loss, preterm labor, malpresentation and increased incidence of cesarean section. Septate uterus is the most common uterine anomaly and is associated with very poor reproductive outcome. Hysteroscopic metroplasty substantially improve the obstetric performance.
Robert, a French gynecologist in 1969 first described a rare variant of septate uterus. Where the septum is complete and one of the hemicavity is blind and non communicating1. Most of these patients present with menstrual fluid retention and dysmenorrhea 1. However, pregnancy in the blind hemicavity is rare and previously only one such case has been reported2.
Miss D, 21 year old, second gravida, presented in the obstetric outdoor with amenorrhea of 8 weeks and an ultrasound report revealing missed abortion. She underwent two failed attempts of suction and evacuation by a private practitioner before reporting to our institute. Her menstrual cycles were regular with average flow but associated with dysmenorrhea since menarche. She had a normal delivery 1½ years back. Her antenatal, intranatal and postnatal periods were uneventful. Her general condition was good. On vaginal examination uterus was soft and asymmetrically enlarged to 10 weeks size with single cervix. There was no vaginal septum. Ultrasonography showed bicornuate uterus with missed abortion of 8 weeks gestation (Figure 1). The patient was admitted on 12.12.04 with
provisional diagnosis of pregnancy in non communicating horn of the uterus and a laparotomy was performed. At laparotomy on 15.12.04 the uterus was asymmetrically enlarged to 10 weeks size, more on the left side which contained the pregnancy. Both the tubes and the ovaries were normal. There was a single cervix. An incision was given in left hemicavity and products sucked out. The right hemicavity was communicating with the cervix and spill was seen on chromopertubation only through the right fallopian tube. The left hemicavity was blind. After left hemihysterectomy the left side of the uterine wall was reconstructed. The left tube was ligated and the left ovary preserved. Postoperative period was uneventful. The patient was discharged in 24.12.04. Latest follow up 6 months after the surgery showed that the patient had regular menstruation.
Characteristics of Robert’s uterus are (i) primary dysmenorrhea (ii) discordance between normal laparoscopic appearance and the hysterographic appearance of unicornuate uterus and (iii) the absence of anomalies of the urinary system3. Pregnancy, an uncommon presentation in Robert’s uterus could be due to transperitoneal migration of a sperm. Though there was no evidence of endometriosis, on laparotomy a decision was taken for hemihysterectomy to arrest the future occurrence of the same. Six months following the surgery the patient is doing well and we hope for an uneventful obstetric outcome in future pregnancy.
