What is the treatment approach for a patient with uterus didelphys?

Treatment of Uterus Didelphys

Most patients with uterus didelphys require no surgical treatment, as this congenital anomaly is compatible with successful pregnancy outcomes and the primary management is expectant with close obstetric monitoring.

When Treatment Is NOT Indicated

• Asymptomatic uterus didelphys discovered incidentally requires no intervention, regardless of the anatomic configuration 1, 2, 3, 4
• The majority of women with uterus didelphys maintain preserved reproductive and gestational performance, with live birth rates reaching 74-81% without any surgical correction 2
• Diagnosis is typically made incidentally (85.9% of cases) during evaluation for unrelated reasons, not due to the anomaly itself 2

When Treatment IS Indicated

Obstructed Hemivagina (The Primary Surgical Indication)

Surgical intervention is indicated specifically when uterus didelphys presents with obstructed hemivagina and ipsilateral renal agenesis, which causes hematocolpos after menarche 5, 3

• Treatment approach: Simple incision of the vaginal septum to drain the hematocolpos provides immediate symptom relief 5, 3
• This typically presents as progressive abdominal pain during menses, though atypical presentations with rectal pain and constipation can occur 5
• A hymenectomy may be required if the obstruction is at the hymenal level 3

Longitudinal Vaginal Septum (Optional)

• Longitudinal vaginal septum is present in approximately 85% of uterus didelphys cases 2
• Surgical excision of the vaginal septum is optional and should only be considered if it causes dyspareunia or obstructs vaginal delivery 2, 3
• The septum itself does not impair fertility and removal is not routinely necessary 2

Metroplasty (Uterine Unification Surgery): Rarely Indicated

Metroplasty should only be considered after recurrent pregnancy losses (≥3 spontaneous abortions) when all other causes have been excluded and corrected 2

• Before considering metroplasty, rule out and treat all other causes of recurrent pregnancy loss first 2
• The Bret-Palmer technique is the described surgical approach when metroplasty is performed 2
• Critical caveat: Most women with uterus didelphys achieve successful pregnancies without surgical correction, so metroplasty should be reserved as a last resort 2

Obstetric Management (Not Surgical Treatment)

While not surgical treatment of the anomaly itself, women with uterus didelphys require specific obstetric considerations:

• Increased surveillance for: preterm birth before 37 weeks, abnormal fetal presentation (breech), intrauterine growth restriction, and low birth weight 1, 4
• Cesarean delivery rates are elevated due to malpresentation, lack of labor progression, and poor response to oxytocin 1, 3, 4
• Consider elective cervical cerclage if cervical length is borderline (<2.5 cm), though progesterone supplementation is an alternative 4
• Plan delivery at facilities equipped for potential complications 1, 3, 4

Common Pitfalls to Avoid

• Do not perform prophylactic metroplasty in asymptomatic patients or those with primary infertility before excluding all other causes of infertility 2
• Do not assume the uterine anomaly is the cause of infertility - investigate and treat all other potential causes first 2
• Do not overlook associated renal anomalies - ipsilateral renal agenesis occurs with obstructed hemivagina and requires imaging evaluation 5, 3
• Do not delay surgical drainage of hematocolpos when obstructed hemivagina is diagnosed, as this causes progressive pain and potential complications 5, 3