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Diagnosis and Management of Mullerian Anomalies Across Differing Resource Settings: Worldwide Adaptations

  • Jennifer E. Dietrich
    Correspondence
    Corresponding author.
    Affiliations
    Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Department of Pediatrics, Baylor College of Medicine, 6651 Main St, Ste 1050, Houston, TX 77030, United States
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Published:April 27, 2022DOI:https://doi.org/10.1016/j.jpag.2022.04.007

      Abstract

      Background

      Mullerian anomalies affect 7% of reproductive age women. It is important to have a basic understanding of these conditions, given they can affect women at any stage of life and have potential impacts on fertility and pregnancy. This article seeks to review these anomalies as well as specific diagnostic pitfalls and strategies to approach these conditions in both high- and low-resource environments.

      Methods

      This review was undertaken with a PubMed focused search, using terms related to the diagnosis and management of Mullerian anomalies in many worldwide settings. Consideration was made to assess the medical resources available in low- and middle-income countries (LMICs), which could impact diagnostic and management decisions, compared with high-income countries (HICs). Concurrent medical conditions and both gynecologic and obstetric outcomes were also searched. Practice recommendations from international societies were also reviewed and compared. Finally, 4 conditions were evaluated more closely to assess management differences based on geographic locations and whether the countries were LMICs or HICs; specifically, those evaluated were lower vaginal atresia, uterovaginal agenesis, bicornuate uterus, and septate uterus.

      Discussion

      Mullerian anomalies encompass a wide variety of conditions, ranging from subtle anatomic changes without concurrent anomalies to complex conditions, associated with anomalies of the kidney or spine, which could impact the ability to manage certain conditions based on medical resources available geographically. A systematic approach and provider expertise is important for appropriate diagnosis and management, independent of geographic location. Counseling is critical for medical and surgical decision-making and might be limited or guided by the resources available in certain settings or even by existing laws.

      Conclusions

      Limited outcomes are available among patients with Mullerian anomalies in LMICs; however, the management varies based on the basic tools available to address acute needs, as well as long-term fertility and obstetric concerns. More research is needed in this population, which could help drive the importance of early diagnosis and management not only in HICs but also in LMICs, where individualization strategies are key.

      Keywords

      Background

      Mullerian anomalies are one of the most interesting conditions gynecologists will encounter and affect 7% of reproductive age women.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Obstructive reproductive tract anomalies.
      Among women with a Mullerian anomaly, approximately 15%-20% will have concurrent spinal anomalies, ∼20% could have undescended ovaries, and 30%-40% will have concurrent renal anomalies.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Obstructive reproductive tract anomalies.
      • O'Flynn O'Brien KL
      • Bhatia V
      • Homafar M
      • et al.
      The prevalence of Müllerian anomalies in women with a diagnosed renal anomaly.
      • Dietrich JE
      • Hertweck SP
      • Bond S:
      Undescended ovaries: a clinical review.
      Long term, it is possible for 40% of these women to develop endometriosis.
      • Tian W
      • Chen N
      • Liang Z
      • et al.
      Clinical features and management of endometriosis among patients with MRKH and functional uterine remnants.
      • Pitot MA
      • Bookwalter CA
      • Dudiak KM:
      Müllerian duct anomalies coincident with endometriosis: a review.
      • Brosens I
      • Puttemans P
      • Benagiano G
      Endometriosis: a life cycle approach?.
      Additionally, these anomalies result in risks to future pregnancies, ranging from recurrent pregnancy loss to preterm birth.
      • Akhtar MA
      • Saravelos SH
      • Li TC
      • et al.
      Reproductive implications and management of congenital uterine anomalies: scientific impact paper no. 62 November 2019.
      It is important to have a basic understanding of these conditions, given that they can affect women at any stage of life and have potential impacts on reproductive health, including fertility and pregnancy.
      • Akhtar MA
      • Saravelos SH
      • Li TC
      • et al.
      Reproductive implications and management of congenital uterine anomalies: scientific impact paper no. 62 November 2019.
      The approach to diagnosis and management might differ based on available health care resources worldwide. This article seeks to review these anomalies as well as specific diagnostic pitfalls and strategies to approach these conditions in both high-income countries (HICs) and low- and middle-income countries (LMICs).

      Methods

      This review was undertaken with a PubMed focused search, using terms related to the diagnosis and management of Mullerian anomalies in many worldwide settings. Consideration was made to assess the medical resources available in LMICs, which could impact diagnostic and management decisions, compared with HICs. Concurrent medical conditions and both gynecologic and obstetric outcomes were also searched. Practice recommendations from international societies were reviewed and compared. Finally, 4 conditions were evaluated more closely to assess management differences based on geographic locations; specifically, those evaluated included lower vaginal atresia, uterovaginal agenesis, bicornuate uterus, and septate uterus.

      Discussion

      Mullerian anomalies encompass a wide variety of conditions, ranging from subtle anatomic changes without concurrent anomalies to complex conditions associated with anomalies of the kidney or spine. Internationally, among developed nations, these conditions are managed very similarly, and societal clinical guidance has demonstrated consistent messaging.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Obstructive reproductive tract anomalies.
      ,
      • Atkinson E
      • Bennett MJ
      • Dudley J
      • et al.
      Consensus statement: the management of congenital genital tract anomalies in women.
      • Grimbizis GF
      • Gordts S
      • Di Spiezio Sardo A
      • et al.
      The ESHRE–ESGE consensus on the classification of female genital tract congenital anomalies.
      ACOG Committee Opinion No. 728
      Müllerian agenesis: diagnosis, management, and treatment.
      Certain anomalies might be managed differently based on the resources available geographically. A few conditions are highlighted in this review, based on publications in the literature, and include examples of lower vaginal atresia, uterovaginal agenesis, bicornuate uterus, and septate uterus.

      Lower vaginal atresia

      The diagnostic hallmarks of lower vaginal atresia include the presentation of abdominal pain approximately 2 years from pubertal onset. The exact timing of this pain will differ, depending on the amount of upper vagina present and the length of the vagina developed before failing to canalize to the perineum. The smaller the length, the more likely pain will occur earlier, as it will take a smaller volume of hematocolpos to fill the enclosed upper vagina. Examination reveals a blind-ending vaginal pouch with variable dimple length but an otherwise normal appearance to the external genitalia. Patients might have a palpable bulge abdominally or simply have palpable abdominal tenderness. In patients who are able to undergo a vaginal exam, a bulge might be palpable 1 cm or many centimeters above the perineum. Among patients unable to undergo a vaginal exam, a rectal exam can yield similar information to estimate the distance from the perineum to the bulging upper vagina.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Obstructive reproductive tract anomalies.
      A pelvic ultrasound is a good first imaging study to obtain, but an MRI would be the gold standard imaging modality to assess the anatomy further, before surgery, although 3D ultrasound is also very reliable.
      • Cekdemir YE
      • Mutlu U
      • Acar D
      • et al.
      The accuracy of three-dimensional ultrasonography in the diagnosis of Müllerian duct anomalies and its concordance with magnetic resonance imaging.
      The farther away the upper vaginal bulge is from the perineum (>3 cm), the more complex the surgical repair can be.
      • Mansouri R
      • Dietrich JE:
      Postoperative course and complications after pull-through vaginoplasty for distal vaginal atresia.
      The recommended operation to reconstruct this condition is a vaginal pull-through. When the bulge is 3 cm or less from the perineum, it is easy to simply pull the upper vagina through to the perineum. When the bulge is higher than 3 cm, a simple pull-through could be fraught with complications, including stenosis and stricture. Typically, in these cases, other measures must be employed, such as consideration for tissue grafting (ie, buccal mucosa or split-thickness skin grafts) or delaying surgical repair until the distal vaginal dimple can be lengthened with vaginal self-dilation to meet the upper vagina above. Delaying surgery until a time of adolescent maturity or until the anatomy is better elucidated can be accomplished with the use of hormones in adolescents for menstrual suppression.
      • Mansouri R
      • Dietrich JE:
      Postoperative course and complications after pull-through vaginoplasty for distal vaginal atresia.
      ,
      • Lahoti A
      • Yu C
      • Brar PC
      • et al.
      An endocrine perspective on menstrual suppression for adolescents: achieving good suppression while optimizing bone health.
      The diagnostic approach and surgical repair can be straightforward in an HIC, as outlined above. However, in an LMIC, both diagnostic and management challenges exist.
      • Farrow NE
      • Commander SJ
      • Reed CR
      • et al.
      Laparoscopic experience and attitudes toward a low-cost laparoscopic system among surgeons in East, Central, and Southern Africa: a survey study.
      ,
      • Shah S
      • Bellows BA
      • Adedipe AA
      • et al.
      Perceived barriers in the use of ultrasound in developing countries.
      The first challenge relates to provider familiarity and experience in recognizing these conditions. The second relates to access to imaging tools to accurately diagnose and plan a surgical approach. Third, the surgical management as outlined in the ideal setting might not be logistically possible in an LMIC. Finally, access to hormonal medications for menstrual suppression might be limited.
      • Townsend JW
      • Sitruk-Ware R
      • Williams K
      • et al.
      New strategies for providing hormonal contraception in developing countries.
      All of these factors must be considered before a provider attempts to manage such a condition. In some cases, if the aforementioned challenges cannot be overcome, a provider might be faced with offering a solution to address the pain, which could address the socioeconomic constraints of the patient, including whether the patient can follow up, but might only offer the ability to remove the uterus to eliminate the pain and to minimize the need for follow-up.
      • Mansouri R
      • Dietrich JE:
      Postoperative course and complications after pull-through vaginoplasty for distal vaginal atresia.
      ,
      • Hertweck SP
      • Rothstein DH
      Challenges and opportunities in adolescent gynecology patients with surgically-treated congenital and acquired anomalies: transition of care from pediatric to adult surgery.

      Uterovaginal atresia

      Mayer-Rokitansky Kuster -Küster-Hauser (MRKH) syndrome affects 1 in 5000 46XX females and is be encountered not only in HIC societies but also in third world countries, as there is no single genetic mechanism by which this condition occurs, and it affects all ethnic groups. Hallmarks of diagnosis include amenorrhea, despite normal pubertal development, with the absence of abdominal pain. Exam findings will reveal normal secondary sexual characteristics but the absence of a vaginal opening. The urethra might be low set as well, but the external genitalia are normal appearing otherwise. These women have normal ovaries but no evidence of a uterus or the presence of uterine remnants noted on ultrasound and confirmed by pelvic MRI.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Obstructive reproductive tract anomalies.
      ,
      • Chen N
      • Pan H
      • Luo G
      • et al.
      Clinical characteristics of 1,055 Chinese patients with Mayer-Rokitansky-Küster-Hauser syndrome: a nationwide multicentric study.
      As outlined by experts and practice bulletins from many HICs, access to clinicians familiar with this condition is key.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Obstructive reproductive tract anomalies.
      ,
      • Atkinson E
      • Bennett MJ
      • Dudley J
      • et al.
      Consensus statement: the management of congenital genital tract anomalies in women.
      • Grimbizis GF
      • Gordts S
      • Di Spiezio Sardo A
      • et al.
      The ESHRE–ESGE consensus on the classification of female genital tract congenital anomalies.
      ACOG Committee Opinion No. 728
      Müllerian agenesis: diagnosis, management, and treatment.
      Clinicians familiar with this condition might not exist in certain third world countries. There are several immediate considerations for management and some long-term considerations. In the immediate period of diagnosis, it is important to provide psychological support to the individual who is just learning about the fact that their reproductive tract has not developed in the expected way. Counseling and access to support groups can be critical for these women and girls to cope. Such resources might not exist in third world countries, ranging from lack of mental health providers to limited technology access to connect women and girls with this condition.
      ACOG Committee Opinion No. 728
      Müllerian agenesis: diagnosis, management, and treatment.
      Timing for initiating vaginal lengthening might vary, but whenever the adolescent or young woman is ready to dilate, vaginal self-dilation can be taught. A variety of vaginal dilators exist in developed nations and can be easily ordered through medical supply companies online and are frequently affordable. This is a successful approach for most patients (>90%). Some adolescents and young women might even be able to dilate over time with regular sexual intercourse.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      ACOG Committee Opinion No. 728
      Müllerian agenesis: diagnosis, management, and treatment.
      ,
      • Townsend JW
      • Sitruk-Ware R
      • Williams K
      • et al.
      New strategies for providing hormonal contraception in developing countries.
      ,
      • Valappil S
      • Chetan U
      • Wood N
      • Garden A
      Mayer-Rokitansky-Kuster-Hauser syndrome: diagnosis and management.
      Although no current papers have assessed cultural differences with regard to dilator use, the ability to use dilators could be based on cultural beliefs, which plays a role in the options available to patients. Among those who fail dilation (<10%), surgical neovagina creation is possible, with techniques ranging from the no-graft vaginoplasty technique (Wharton-Sheares) to use of tissue grafts or laparoscopic vaginal lengthening procedures.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Brucker SY
      • Gegusch M
      • Zubke W
      • et al.
      Neovagina creation in vaginal agenesis: development of a new laparoscopic Vecchietti-based procedure and optimized instruments in a prospective comparative interventional study in 101 patients.
      • Callens N
      • De Cuypere G
      • De Sutter P
      • et al.
      An update on surgical and non-surgical treatments for vaginal hypoplasia.
      • Dietrich JE
      Review of surgical neovagina techniques and management of vaginal stricture.
      • Kölle A
      • Taran F
      • Rall K
      • et al.
      Neovagina creation methods and their potential impact on subsequent uterus transplantation: a review.
      Vaginal dilators might be too expensive to obtain or might not be easy to order in LMICs. By using a similar cylindrical object with pressure application on the vaginal dimple to stretch and lengthen the vaginal dimple, a similar goal could be achieved in this setting. In some LMICs, people have used medical tools such as test tubes or smooth wooden dowels to achieve this goal, although no studies exist evaluating these atypical tools. For those who might still fail dilation in an LMIC, creating a vagina with the use of grafts or in a minimally invasive way might not be possible, as certain factors must be weighed. These include basic factors such as the ability to sterilize equipment, access to the right equipment to perform the surgery, adequate operating room lighting, access to anesthesia, and a place for the patient to recover after surgery. Other factors such as patient candidacy are critical to evaluate as well. If surgery is performed, it is important to determine if the patient is in a current state of health to heal from the surgery. If these aspects are in place, it is important to then consider whether there is a surgeon with expertise to harvest and place a graft.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Kayondo M
      • Njagi J
      • Mukasa PK
      • Margolis T
      A modified neo-vagina procedure in a low resource urogynecological unit: a case report of a 21 year old with Mayer-Rokitansky-Küster-Hauser (mrkh) syndrome operated at Mbarara referral hospital, Southwestern Uganda.
      Later, when these individuals become interested in family building, several options are available in HICs. Using a gestational carrier is an option in some countries, whereas other countries prohibit this approach. Among countries that prohibit gestational carriers, another option has been growing in popularity for those with absolute uterine factor infertility (AUFI): uterine transplant. Babies have now been born to women with AUFI through this method. The first uterine transplant was performed in 2000,
      • Brännström M
      Uterus transplantation.
      ,
      • Brännström M
      • Belfort MA
      • Ayoubi JM
      Uterus transplantation worldwide: clinical activities and outcomes.
      although the first live birth following transplant occurred in 2014. Uterine transplant has been performed in 14 countries to date under strict experimental protocols, and outcomes are gradually improving, with live births increasing to date.
      • Brännström M
      • Belfort MA
      • Ayoubi JM
      Uterus transplantation worldwide: clinical activities and outcomes.
      Certainly, in high-resource nations with access to specialized transplant surgeons and medical doctors who manage immunosuppressive medications, this could be achievable. The type of neovagina method utilized can affect the success of uterine transplant as well. In an LMIC, achieving this might be insurmountable without transferring the care of the patient to another country or continent.
      Uterine remnants can be present in 10%-15% of women with an MRKH variant as well. This can be particularly challenging in the situation of a cervicovaginal atresia case and the need to diagnose this condition without the assistance of MRI. Poor outcomes are associated with any potential reconstruction of a cervix that is atretic. Regardless, a remnant might be easily removed laparoscopically or require a laparotomy depending on the patient history, surgeon experience, and access to advanced laparoscopic tools.
      • Mikos T
      • Lantzanaki M
      • Anthoulakis C
      • Grimbizis GF:
      Functional and reproductive outcomes following surgical management of congenital anomalies of the cervix: a systematic review.

      Bicornuate and septate uteri

      Typically, these individuals will be diagnosed incidentally, possibly during delivery, a tubal ligation, or infertility workup. This is primarily because these conditions do not present with an obstructive component, and therefore, these women might not be diagnosed early in life. Modern imaging can help distinguish these 2 conditions from one another through use of pelvic sonography, pelvic MRI, or hysterosalpingogram. Following diagnosis, especially among women with recurrent fertility concerns, initial surgical options in the 1950s focused on unification procedures to manage these anomalies, such as the Strassman unification metroplasty, Jones unification metroplasty, or Tompkins unification modification metroplasty.
      • Papp Z
      • Mezei G
      • Gávai M
      • et al.
      Reproductive performance after transabdominal metroplasty: a review of 157 consecutive cases.
      ,
      • Narita O
      • Asai M
      • Masahashi T
      • et al.
      Plastic unification of a double uterus and the outcome of pregnancy.
      The goal of these procedures was to unify the uterine halves and to remove the anatomic distortion present (bicornuate uterus) or remove the excess uterine wall (septate uterus). These procedures were performed as an open laparotomy in those days and historically carried a high risk of complications, including excessive blood loss.
      • Papp Z
      • Mezei G
      • Gávai M
      • et al.
      Reproductive performance after transabdominal metroplasty: a review of 157 consecutive cases.
      Obstetric outcomes were followed among these women, and over time, it became clear that women who underwent these unification procedures vs those who did not did not have reductions in rates of pregnancy loss, preterm labor, or intrauterine growth restriction. The risk of uterine rupture was also higher in the unification procedure group.
      Today, hysteroscopy lends itself to metroplasty for the patient with a uterine septum in a minimally invasive fashion, without the associated risks of the previously studied metroplasty methods.
      • Carrera M
      • Pérez Millan F
      • Alcázar JL
      • et al.
      Effect of hysteroscopic metroplasty on reproductive outcomes in women with septate uterus: systematic review and meta-analysis.
      ,
      • Casadio P
      • Magnarelli G
      • La Rosa M
      • et al.
      Uterine fundus remodeling after hysteroscopic metroplasty: a prospective pilot study.
      Among patients with a bicornuate uterus, a hysteroscopic metroplasty is not possible. In this population, a higher risk of incompetent cervix exists.
      • Mastrolia SA
      • Baumfeld Y
      • Hershkovitz R
      • et al.
      Bicornuate uterus is an independent risk factor for cervical os insufficiency: a retrospective population based cohort study.
      To manage higher risk for pregnancy loss and preterm labor among those with a history of painless cervical dilation, cerclage evolved. Access to cerclage is possible in many HICs to prevent early delivery. In a third world country, access to sophisticated equipment such as hysteroscopy for metroplasty or laparoscopy for abdominal cerclage placement might be extremely limited. It is therefore not unrealistic to imagine that old techniques, such as Strassman unification, might still be something to fall back on to improve obstetric outcomes. One case report in sub-Saharan Africa highlights this scenario in a woman with a bicornuate uterus and 6 prior pregnancy losses, whose only option for an improved pregnancy outcome was a Strassman metroplasty. She was able to undergo this procedure and had a successful pregnancy with delivery of a term infant.
      • Gulavi E
      • Kyende Mutiso S
      • Mariara Muriuki C
      • Mukaindo Mwaniki A
      Successful pregnancy outcome after open Strassman metroplasty for bicornuate uterus.
      Despite these geographic differences between HICs and LMICs, numerous medical societies in HICs have published guidance on the diagnosis and management of these conditions, but none has addressed the best recommended approach when resources are limited.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Atkinson E
      • Bennett MJ
      • Dudley J
      • et al.
      Consensus statement: the management of congenital genital tract anomalies in women.
      ,
      • Grimbizis GF
      • Gordts S
      • Di Spiezio Sardo A
      • et al.
      The ESHRE–ESGE consensus on the classification of female genital tract congenital anomalies.
      Nevertheless, it is important to stress individualization, especially as it relates to geographic location. A systematic approach and provider expertise are key for appropriate diagnosis and management. Counseling is critical for medical and surgical decision-making and might be limited or guided by the resources available in certain settings. The management of lower vaginal atresia, uterovaginal agenesis, bicornuate uterus, and septate uterus might be different based on geographic location and is directly impacted by medical resources available or accessible based on laws.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Obstructive reproductive tract anomalies.
      ,
      • Akhtar MA
      • Saravelos SH
      • Li TC
      • et al.
      Reproductive implications and management of congenital uterine anomalies: scientific impact paper no. 62 November 2019.
      ,
      • Atkinson E
      • Bennett MJ
      • Dudley J
      • et al.
      Consensus statement: the management of congenital genital tract anomalies in women.
      ,
      • Hertweck SP
      • Rothstein DH
      Challenges and opportunities in adolescent gynecology patients with surgically-treated congenital and acquired anomalies: transition of care from pediatric to adult surgery.

      Imaging considerations

      In an HIC, access to a variety of imaging tools, such as sonography and MRI, is possible, both to augment the clinical picture established by history and physical exam and for surgical planning. MRI is the gold standard for evaluating Mullerian anomalies as well.
      • Santos XM
      • Krishnamurthy R
      • Bercaw-Pratt JL
      • Dietrich JE
      The utility of ultrasound and magnetic resonance imaging versus surgery for the characterization of Müllerian anomalies in the pediatric and adolescent population.
      In many cases, surgery can be planned with a minimally invasive approach. This proves beneficial for women with Mullerian anomalies thought to have endometriosis, adenomyosis, or an obstructed horn. There is typically an ability to make a diagnosis definitively, and manage surgically, utilizing a minimally invasive approach.
      In an LMIC, access to imaging can be extremely limited for several reasons. For instance, not all imaging tools might be available in these settings. In one study looking at the availability of MRI in Africa in 2015 and 2016, the continent was noted to have 84 MRI machines for a population of 350 million people, with 58 of these located in Nigeria.
      • Ogbole GI
      • Adeyomoye AO
      • Badu-Peprah A
      • et al.
      Survey of magnetic resonance imaging availability in West Africa.
      This is a dramatic shortage compared with HICs, such as Japan, the United States, Canada, and Spain, with 51.7, 40, 9.5, and 15.3 per million persons, respectively.
      • Ogbole GI
      • Adeyomoye AO
      • Badu-Peprah A
      • et al.
      Survey of magnetic resonance imaging availability in West Africa.
      Other barriers include access to tools to service equipment, even basic sonography equipment, power source concerns, paucity of radiologists, medical education for providers, cost, and limited patient access.
      • Shah S
      • Bellows BA
      • Adedipe AA
      • et al.
      Perceived barriers in the use of ultrasound in developing countries.
      To address education needs for providers, one survey study looked at opportunities for virtual training through mobile devices. This study addressed questions related to current access to training tools related to sonography and the acceptability of virtual learning resources if available. The response rate was 9%, and most respondents were physicians. Sonography was utilized for a variety of common emergent medical concerns, but most cited that they still faced many barriers related to equipment maintenance and desired access to ongoing education and distance learning.
      • Mazal JR
      • Ludwig R:
      Using mobile electronic devices to deliver educational resources in developing countries.

      Long-term reproductive considerations

      Similar barriers exist with regard to access to minimally invasive surgical tools. In a survey of 56 general surgeons who attended the college of surgeons of East, Central, and Southern Africa, only a minority used laparoscopy (38%), and 57% performed laparoscopy less than once a week. Cholecystectomy and appendectomy were more common, with few surgeons using laparoscopy for complex cases.
      • Farrow NE
      • Commander SJ
      • Reed CR
      • et al.
      Laparoscopic experience and attitudes toward a low-cost laparoscopic system among surgeons in East, Central, and Southern Africa: a survey study.
      Long-term outcomes are not as well understood among women with Mullerian anomalies who become pregnant. Among women with a unicornuate uterus, bicornuate uterus, or didelphys, the risk of preterm labor has been reported to be as high as 50%, 39%, and 33% respectively. Low birth weight has also been noted retrospectively, especially among those with a uterine didelphys.
      • Fox NS
      • Roman AS
      • Stern EM
      • et al.
      Type of congenital uterine anomaly and adverse pregnancy outcomes.
      Additionally, among women with a unicornuate uterus and a communicating uterine horn, pregnancy in a remnant horn is possible, and therefore, an ectopic rupture risk exists.
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Non-obstructive Müllerian anomalies.
      ,
      • Dietrich JE
      • Millar DM
      • Quint EH:
      Obstructive reproductive tract anomalies.
      ,
      • Atkinson E
      • Bennett MJ
      • Dudley J
      • et al.
      Consensus statement: the management of congenital genital tract anomalies in women.
      ,
      • Hertweck SP
      • Rothstein DH
      Challenges and opportunities in adolescent gynecology patients with surgically-treated congenital and acquired anomalies: transition of care from pediatric to adult surgery.
      ,
      In a low-resource environment, having these additional risks could compound the other risks that exist, such as malnutrition, anemia, and travel distance from a medical facility should life-threatening bleeding occur or should an infant need critical neonatal care with severe prematurity. Even mode of delivery can be impacted by the type of Mullerian anomaly present, and there is a paucity of data around outcomes in this area. Managing delivery on the basis of the type of anomaly is based on expert opinion primarily.
      • Belfort MA
      Operative techniques in obstetrics surgery. In.

      Conclusions

      Mullerian anomalies are common and present in isolated fashion or in conjunction with other syndromes and disorders. Limited outcomes are available in this particular population in LMICs; however, recalling archived tools might be important toward addressing the management at a basic level. Although outcomes are well understood regarding potential fertility impacts, outcomes in the obstetric population are less well understood. More research is needed in this population, which might help drive the importance of early diagnosis and management.

      Declaration of Competing Interest

      No conflicts of interest.

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