What is the recommended management for a primiparous (first-time mother) woman at 6 weeks gestation with a bicornuate uterus, and should she be referred to a Maternal-Fetal Medicine (MFM) specialist?

Management of Pregnancy with Bicornuate Uterus: Referral to Maternal-Fetal Medicine

A primiparous woman at 6 weeks gestation with a reported bicornuate uterus should be referred to a Maternal-Fetal Medicine (MFM) specialist for consultation and co-management due to the increased risk of pregnancy complications associated with this uterine anomaly.

Risks Associated with Bicornuate Uterus

• Bicornuate uterus is associated with adverse pregnancy outcomes including recurrent miscarriages, preterm labor and delivery, malpresentation, and increased risk of cesarean delivery 1
• Only 53% of pregnancies in women with uterine malformations end with a surviving child (>7 days), compared to 89% in women with normal uterine anatomy 2
• Specifically, bicornuate uterus has one of the poorest pregnancy outcomes among uterine anomalies, with only 40% viability rate and 47% ending in early abortions 2

Role of Maternal-Fetal Medicine in Management

• MFM subspecialists have advanced knowledge of obstetrical, fetal, and genetic complications of pregnancy and their effects on both mother and fetus 3
• MFM specialists provide consultation, co-management, or transfer of care for complicated pregnancies, promoting risk-appropriate care 3
• Referral to MFM is appropriate for women at increased risk of pregnancy complications, including those with anatomic abnormalities like bicornuate uterus 4

Recommended Management Protocol

First Trimester (Current Stage - 6 weeks)

• Confirm diagnosis of bicornuate uterus with detailed ultrasound and possibly MRI to assess the exact anatomy 1
• Evaluate for associated renal anomalies, as Müllerian duct anomalies can be associated with renal system abnormalities 5
• Discuss risks of pregnancy complications and develop a surveillance plan 4

Second Trimester

• Implement increased surveillance with ultrasound evaluations every 1-2 weeks to assess:
  • Cervical length (to monitor for cervical insufficiency) 1
  • Fetal growth 4
  • Amniotic fluid volume 4
• Consider cervical cerclage if there is evidence of cervical shortening, as cerclage has been shown to increase live birth rates from 21% to 62% in women with uterine anomalies 2

Third Trimester

• Continue close monitoring for:
  • Fetal growth restriction 4
  • Malpresentation 2
  • Preterm labor 1
• Develop a delivery plan, likely involving cesarean section, especially if there is evidence of obstruction of the lower uterine segment 5

Level of Care Considerations

• Women with bicornuate uterus should be managed at facilities with at least Level II maternal care capabilities 4
• For cases with additional complications or extremely high risk, consider Level III or IV facilities with full MFM team availability 4
• Planned delivery at a center experienced with high-risk pregnancies is recommended whenever possible 4

Prognosis and Expectations

• Despite the increased risks, successful pregnancy outcomes can be achieved with appropriate monitoring and management 6
• The patient should be counseled about the potential need for cesarean delivery due to malpresentation or obstruction of the lower uterine segment 5
• For future pregnancies, preconception counseling should be offered to optimize outcomes 7

Conclusion

Early referral to MFM is crucial for this primiparous patient with bicornuate uterus to establish appropriate surveillance and management plans that can significantly improve pregnancy outcomes through early detection and management of potential complications.