Management of Arcuate Uterus in Women of Reproductive Age
Primary Recommendation
No surgical intervention is recommended for arcuate uterus, as the balance of evidence does not support an association with adverse reproductive outcomes, and routine hysteroscopic resection is not indicated. 1
Diagnostic Confirmation
- Three-dimensional ultrasound (3D US) is the primary imaging modality to confirm the diagnosis of arcuate uterus, with accuracy comparable to MRI for detecting Müllerian anomalies 2
- Saline infusion sonohysterography (SIS) combined with 3D imaging was shown to be 100% accurate in classification of arcuate uteri when compared with hysteroscopy 2
- Transvaginal ultrasound should be performed first, followed by 3D US or SIS if initial imaging suggests a uterine anomaly 2
Clinical Significance and Reproductive Outcomes
- Arcuate uteri are associated with increased rates of second-trimester miscarriage (RR 2.39,95% CI 1.33-4.27) and fetal malpresentation at delivery (RR 2.53,95% CI 1.54-4.18) 3
- However, arcuate uteri do not reduce fertility or increase first-trimester miscarriage rates, distinguishing them from septate uteri which significantly impair reproductive outcomes 3
- The height of fundal indentation does not correlate with clinical outcomes, as demonstrated in a prospective study showing no difference in miscarriage rates between subseptate (≥1.5 cm indentation) and arcuate (<1.5 cm indentation) uteri after metroplasty (14.0% vs 11.1%) 4
Management Algorithm
For Asymptomatic Women or Those Without Recurrent Pregnancy Loss:
- Expectant management with reassurance is the appropriate approach, as most women with arcuate uteri have good pregnancy outcomes 5
- No surgical intervention is warranted, as the risks outweigh potential benefits and evidence for benefit is lacking 5, 1
For Women With Recurrent Miscarriage:
- Complete evaluation for other causes of recurrent pregnancy loss must be performed before attributing losses to the arcuate uterus 1
- Surgical resection should only be considered at clinician discretion for highly symptomatic patients without otherwise identifiable etiology, recognizing that evidence for benefit is inconclusive and conflicting 5, 1
- If surgery is performed, counsel patients that there is no proven improvement in live birth rates, as the evidence remains equivocal 5
For Pregnant Women With Known Arcuate Uterus:
- Monitor for preterm birth risk using appropriate protocols, as women with congenital uterine anomalies may be at increased risk even without surgical intervention 5
- Assess fetal presentation in the third trimester, given the 2.53-fold increased risk of malpresentation 3
- Screen for fetal growth restriction and pre-eclampsia, as these complications may occur with increased frequency in women with uterine anomalies 5
Critical Pitfalls to Avoid
- Do not confuse arcuate uterus with septate uterus, as septate uteri have significantly worse reproductive outcomes (RR 2.89 for first-trimester miscarriage) and may benefit from surgical correction 3
- Avoid routine surgical intervention based solely on the diagnosis of arcuate uterus, as hysteroscopic resection does not appear to be universally indicated 1
- Be aware that the ESHRE/ESGE classification system discards the arcuate uterus category entirely, potentially reclassifying 26.5-58.2% of previously diagnosed arcuate uteri as partial septate uteri depending on measurement technique used, which could lead to unnecessary surgical procedures 6
- Recognize that acquired uterine pathology (fibroids, adenomyosis) may coexist in 28.5% of cases, which can complicate both diagnosis and management decisions 6
Additional Imaging Considerations
- MRI pelvis without IV contrast may be used when the uterus is incompletely visualized by ultrasound or findings are indeterminate, though 3D US remains the primary diagnostic tool 2
- Hysteroscopy is not routinely necessary for diagnosis but may be considered if intrauterine pathology is suspected or if surgical intervention is being contemplated 2