A 30-year-old female with a recent spontaneous miscarriage presented to the ED with complaints of lower abdominal cramping and heavy vaginal bleeding. She reported that about 1 week prior to presentation to the ED, she had had a miscarriage at home and saw fetal parts pass. After the miscarriage, her bleeding had stopped, but then returned 3 days before her presentation to the ED. She was seen at another hospital when she initially had had miscarriage and reported her beta-HCG was about 8,000 at that time. She was trying to get pregnant, but she unfortunately had already had 2 previous miscarriages.
Initial VS: BP 110/55, HR 89, T 36.8 °C (98.2 °F), RR 16, SpO2 99% on RA
Physical exam revealed a soft but somewhat tender abdomen in the bilateral lower quadrants. Pelvic exam revealed a minimal amount of blood in the vaginal vault.
Labs including a quantitative beta-HCG and hemoglobin were obtained. While awaiting the results, a bedside transvaginal ultrasound was performed to look for evidence of retained products of conception.
Here are the longitudinal images of the uterus that were obtained:
Do you notice anything abnormal?
Here are the transverse images of the uterus, which make it easier to see what is going on:
What do you see?
When going through the uterus in transverse, you can see that there are 2 separate endometrial stripes near the fundus that then come together near the cervix. This is either a BICOURNUATE or SEPTATE uterus. You can also see that the endometrium on the right side of the uterus (screen left) is thicker and this is probably where the pregnancy was implanted.
Go back to the longitudinal views and you can see that as the sonographer sweeps from side-to-side there are two distinct endometrial stripes that come in and out of view.
Uterine Abnormalities and Miscarriage
- A septate uterus has a normal external surface, but has two endometrial cavities
- A bicornuate uterus has an indented fundus with two endometrial cavities
- Many with uterine abnormalities will have normal and uncomplicated pregnancies
- However, both of these abnormalities do carry a higher rate of spontaneous miscarriage and pre-term delivery than those without abnormalities
Her beta-HCG came back at 587. Her hemoglobin was stable. Her bleeding had slowed and her pain had subsided in the ED, and she was discharged with plans to follow-up in OB/gyn clinic in 2 days.
At follow-up the bleeding had stopped, and she was feeling improved.
References
- Heinonen PK. Complete septate uterus with longitudinal vaginal septum. Fertil Steril. 2006;85(3):700-705.
- Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simon C, Pellicer A. Reproductive impact of congenital Mullerian anomalies. Hum Reprod. 1997;12(10):2277-2281.
