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IMAGING FOR RESIDENTS ANSWER Table of Contents  
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34-year-old female with recurrent abortions: A case of bicornuate uterus with cross-fused renal Ectopia


 Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

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Date of Submission30-Apr-2021
Date of Decision01-Dec-2021
Date of Acceptance28-Dec-2021
Date of Web Publication05-Jul-2022
 


How to cite this URL:
Goel S, Saran S. 34-year-old female with recurrent abortions: A case of bicornuate uterus with cross-fused renal Ectopia. J Med Ultrasound [Epub ahead of print] [cited 2023 Mar 22]. Available from: http://www.jmuonline.org/preprintarticle.asp?id=349877




[TAG:2]Section 2 – Answer [/TAG:2]


  Case Top


A 34-year-old married female presented to a gynecology outpatient clinic with the chief complaint of recurrent miscarriage in the first trimester. The patient had normal menstrual cycle. No other significant medical and surgical history was present. Pelvic examination of the patient revealed single uterine cervical orifice. Ultrasound examination of the patient was done and the images are shown in [Figure 1]. Magnetic resonance imaging (MRI) of the female was also performed [Figure 2] and [Figure 3]. What is your interpretation?
Figure 1: Transabdominal ultrasound images of the right lumbar region (a) and the pelvis (b) showing two uterine cavities (star) with single cervix (b). There is absence of kidney in left renal fossa. The left kidney was seen in the right renal fossa and fused with the right kidney (a)

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Figure 2: Magnetic resonance imaging of the abdomen and pelvis in coronal plane showing two uterine cavities (star) with single cervix (c). There is absence of kidney (k) in the left renal fossa. The left kidney was seen in the right renal fossa and fused with the right kidney forming S-shaped configuration. UB: urinary bladder, C- cervix

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Figure 3: Magnetic resonance imaging of the abdomen in coronal plane showing cross fused renal ectopia (star) in the form of fusion of upper pole of left kidney with the lower pole of right kidney. R: right kidney, L: left kidney

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  Interpretation Top


Ultrasound examination of the patient revealed two uterine cavities with single cervix. The depth of fundal depression was >1 cm. There was absence of kidney in the left renal fossa. The left kidney was seen in the right renal fossa and fused with the right kidney [Figure 1]. Pelvicalyceal system was not dilated in the fused kidneys. Corticomedullary differentiation was also maintained in the fused kidneys.

The patient further underwent MRI which revealed duplicated endometrial cavity with single cervical canal [Figure 2]. The two uterine cavities were widely separated, the fundal cleft measured ~1.9 cm, and the intercornual distance was ~ 4.4 cm. Bilateral ovaries were normal.

Further, bilateral kidneys were seen in the right renal fossa. There was fusion of upper pole of the left kidney with lower pole of the right kidney. The hilum of the left kidney faced laterally while that of the right kidney was seen facing medially resulting in type S/sigmoid type of crossed-fused renal ectopia [Figure 3].


  Discussion Top


Septate uterus is the most common Müllerian duct anomaly followed by bicornuate uterus. Bicornuate uterus is a type of Müllerian duct anomaly usually discovered incidentally. It most commonly presents with recurrent pregnancy loss. Infertility is not usually a problem with this type of malformation, but studies reveal that there is an association.[1]

Recurrent pregnancy loss on the other hand can be caused by congenital as well as acquired factors. Complete uterine evaluation should be performed by hysteroscopy, Hysterosalpingography, Ultrasound and MRI in the patient presenting with recurrent pregnancy loss.[2]

It is important to differentiate the septate uterus from the bicornuate uterus. It is not possible to differentiate the two on hysterosalpingography as hysterosalpingography only gives information about the triangular or divided uterine cavity contour. Ultrasound and MRI provide greater anatomic detail about the external uterine contour and thus help in differentiating between septate and bicornuate uterus [Figure 4] and [Figure 5]. Moreover, ultrasound and MRI provide information about the concomitant renal anomalies.
Figure 4: Schematic diagram showing difference between bicornuate and septate uterus

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Figure 5: Magnetic resonance imaging pelvis showing different measurements used in the case described to prove it as bicornuate uterus

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Renal ectopy and fusion are common congenital anomalies of the kidney and urinary tract. They result from disruption of the normal embryologic migration of the kidneys. Although most patients are asymptomatic, some can develop symptoms due to complications. There is a close association between renal tract defects and Müllerian duct malformations. Concomitant renal anomalies are reported in many Müllerian duct anomaly cases. Therefore, it is important to examine the kidneys in such cases. The spectrum of renal anomalies includes agenesis, horseshoe kidney, renal dysplasia, ectopic kidney, and duplicated collecting systems. Renal agenesis is the most common renal anomaly associated with Müllerian duct malformations.[3] However, association of crossed-fused ectopia with bicornuate uterus is very rare. Our extensive search of the literature revealed that till date there has only one such case been reported.[4]

The reason behind presenting this case is to highlight the importance of association between bicornuate uterus and cross fused renal ectopia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tulandi T, Arronet GH, McInnes RA. Arcuate and bicornuate uterine anomalies and infertility. Fertil Steril 1980;34:362-4.  Back to cited text no. 1
    
2.
Carbonnel M, Pirtea P, de Ziegler D, Ayoubi JM. Uterine factors in recurrent pregnancy losses. Fertil Steril 2021;115:538-45.  Back to cited text no. 2
    
3.
Heinonen PK. Renal tract malformations associated with müllerian duct anomalies. Clin Obstet Gynecol Reprod Med 2018;4:1-5.  Back to cited text no. 3
    
4.
Liu L, Yang J, Zhu L, Yi L, Zhu B, Song W, et al. Crossed-fused renal ectopia associated with inverted-Y ureteral duplication, ectopic ureter, and bicornuate uteruses. Urology 2010;75:1175-7.  Back to cited text no. 4
    

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Correspondence Address:
Sonal Saran,
Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None



    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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    -  Saran S


Section 2 –...
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Interpretation
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