9. Symptomatic Infected Fluid Collection Complicating a Gravid Uterus Didelphys

Congenital müllerian anomalies (CMA) are common, affecting approximately 5% of the population. Sonographic as well as MRI evaluation of CMA may help delineate anomaly classification, however a large gravid uterus may obfuscate ability to define these during pregnancy. This report illustrates an interesting case of a CMA diagnosis needed to evaluate and manage a non-obstetric complication during the second trimester of pregnancy.

A 19 year old G1 with no significant gynecologic history presented for a fetal dating and anatomy ultrasound at 16 weeks and was notable for suspected didelphys uterus. A singleton pregnancy was noted in right uterus whereas the left uterus was empty with a thickened endometrium and hematocolpos suggestive of a longitudinal vaginal septum. On follow up ultrasound, a growing, large complex fluid collection measuring 6.76 × 3.31 × 4.26 cm was noted. At 25 weeks she presented to an OB-ED with heavy vaginal bleeding and significant purulent discharge and was admitted for treatment of suspected PID in the non-gravid uterus in the setting of leukocytosis (16,200) and fundal tenderness. On vaginal and rectal exam, a second cervix was unable to be identified and no vaginal bulge noted on palpation. A pelvic MRI was obtained to rule out an obstructed hemi-vagina and unilateral renal anomaly (OHVIRA), but was instead suggestive of an occluded hemi-vagina. The patient was readmitted 72 hours later due to preterm contractions which resolved, however purulent discharge continued. At that time, patient underwent exam under anesthesia, and with ultrasound guidance, a uterine sound was advanced into a fistula tract and a word catheter was placed through the fistula tract into the left hemi-vagina. Once the purulent discharge was drained, the left cervix was palpated 3 cm anterior to the right cervix, but not visualized. At 27 weeks there was minimal residual drainage and the catheter was retracting into mucosa as uterus was growing. Worried that the catheter may get lost or be a site for ascending infection it was removed. She was subsequently diagnosed with gestational hypertension at 37 weeks and she underwent an induction of labor.

Ascertaining the proper anatomical CMA was integral to resolving the infection of the non-gravid müllerian structures and provide appropriate counseling on risks in this and future pregnancies. Uterine anomalies are difficult to detect during pregnancy, and this report illustrates a fascinating multi-subspecialty approach including MFM, Pediatric and Adolescent Gynecology, Infectious Disease, and Interventional Radiology as well as a multi-imaging modality approach to provide appropriate evaluation and management.

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