What is the management approach for a female patient of reproductive age with uterine didelphys, considering her symptoms and desire for pregnancy?

Management of Uterine Didelphys in Reproductive-Age Women

Primary Management Recommendation

For reproductive-age women with uterine didelphys who desire pregnancy, expectant management with close monitoring is the appropriate approach, as surgical intervention (metroplasty) is not indicated and does not improve reproductive outcomes. 1

Initial Diagnostic Confirmation

• Confirm the diagnosis using transvaginal ultrasound combined with MRI, which provides definitive anatomical characterization of the duplicated uterine horns, cervices, and any vaginal septum 2, 3, 4
• Document whether a vaginal septum is present, as this influences delivery planning 3, 1
• Assess for associated renal anomalies, which occur in approximately 30% of Müllerian duct anomalies (though not specifically cited for didelphys in the provided evidence)

Fertility Counseling and Preconception Management

• Reassure patients that pregnancy is achievable with uterine didelphys, though conception may take longer (up to 18 months in documented cases) 1
• Counsel that each uterine cavity can independently support pregnancy 2, 3
• Explain increased risks: miscarriage, preterm labor (occurring as early as 29 weeks), breech presentation, and decreased live birth rates 1
• No surgical correction (metroplasty) should be performed, as uterine didelphys represents complete duplication and surgery does not improve outcomes 1

Management During Pregnancy

High-Risk Pregnancy Designation

• Classify all pregnancies in women with uterine didelphys as high-risk requiring specialized prenatal care 1
• Initiate prenatal care early, ideally by 13 weeks gestation 1

Monitoring Protocol

• Perform serial ultrasounds to monitor for:
  • Preterm labor signs (cervical changes can occur independently in each cervix) 2
  • Fetal growth restriction 4
  • Oligohydramnios 4
• Monitor for pregnancy complications including vaginal bleeding, which occurs commonly 5, 1

Preterm Labor Management

• If preterm labor occurs, administer tocolysis, which has demonstrated success in prolonging pregnancy even when one uterus shows contractions 2
• Recognize that each uterus and cervix functions independently—one may contract while the other remains quiescent 2

Delivery Planning

Mode of Delivery Decision Algorithm

For patients with vaginal septum present:

• Recommend cesarean section to avoid dystocia and maternal stress 1

For patients without vaginal septum:

• Vaginal delivery may be considered if fetal presentation is vertex 3
• However, cesarean section remains appropriate given increased risk of malpresentation 1

Cesarean Section Technique

• Perform lower uterine segment cesarean section on the gravid uterus 3, 4
• Be prepared to identify and avoid the non-gravid uterus intraoperatively 3, 4
• In rare dicavitary twin pregnancies, staged delivery may occur with interval delivery possible due to independent uterine function 2

Management of Asymptomatic Patients

For women not currently desiring pregnancy:

• No intervention is required for asymptomatic uterine didelphys 1
• Address symptoms if present:
  • Dysmenorrhea: treat with NSAIDs or hormonal contraceptives (standard abnormal uterine bleeding management applies) 6, 7
  • Dyspareunia: consider vaginal septum resection if present and symptomatic 1

Critical Pitfalls to Avoid

• Never perform metroplasty or uterine unification surgery—this is contraindicated in complete duplication anomalies and provides no benefit 1
• Do not assume both uterine cavities will labor simultaneously; each functions independently 2
• Do not miss the diagnosis during cesarean section—actively inspect for a second uterus intraoperatively 4
• Do not delay diagnosis; perform appropriate imaging (ultrasound + MRI) when Müllerian anomaly is suspected 3, 4

Long-Term Considerations

• Document the anomaly clearly in the medical record to prevent missed diagnosis in subsequent pregnancies 4
• Counsel regarding 1 in 1,000 risk of dicavitary twin pregnancy if ovulation induction is considered 3
• Emphasize that successful pregnancy outcomes are achievable with appropriate monitoring despite increased risks 2, 3, 1