Journal of Obstetrics and Gynaecology

ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20

Frequency and types of uterine anomalies during

caesarean section

Magdy A. Mohamed & Mohamed Y. AbdelRahman

To cite this article: Magdy A. Mohamed & Mohamed Y. AbdelRahman (2018): Frequency and
types of uterine anomalies during caesarean section, Journal of Obstetrics and Gynaecology, DOI:
10.1080/01443615.2018.1499712

To link to this article: https://doi.org/10.1080/01443615.2018.1499712

Published online: 29 Oct 2018.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
https://doi.org/10.1080/01443615.2018.1499712

ORIGINAL ARTICLE

Frequency and types of uterine anomalies during caesarean section

Magdy A. Mohamed and Mohamed Y. AbdelRahman
Department of Obstetrics and Gynaecology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt

ABSTRACT KEYWORDS
In this study all women undergoing caesarean section were included regardless of the indication. After Caesarean section; uterine
the foetus and placenta were delivered, the uterus was examined for the presence or absence of con- anomalies; septate uterus
genital malformation through digital palpation of uterine cavity and direct inspection of the fundus. Of
the 653 caesarean sections included, uterine anomalies were diagnosed in 31 women (4.75%). Most of
the anomalies were septate and sub-septate uterus (71%) followed by bicornuate uterus (19.4%), while
the frequency of unicornuate uterus was 6.4% and uterine didelphys represented only 3.2%. In conclu-
sion, an examination of the uterus internally and externally should be performed as a routine step dur-
ing caesarean section.

IMPACT STATEMENT
 What is already known on this subject? Most of the data of uterine anomalies has been derived
from studies of patients with reproductive problems and not from those with a normal reproduct-
ive outcome.
 What do the results of this study add? Approximately 5% of women were found to have uterine
anomalies when examined during caesarean section. If any were detected, we feel that the patient
should be informed, as they may affect future reproductive performance and the choice of
contraception.
 What are the implications of these findings for clinical practice and/or further research? An
examination of the uterus internally and externally should be considered as a routine step during a
caesarean section.

Introduction At the time of caesarean section, there is a significant

Caesarean section is one of the most frequently performed
operations worldwide (Lumbiganon et al. 2010; Zwecker
et al. 2011; Gregory et al. 2012). In the USA, it has been esti-
mated that 36% of deliveries were performed via caesarean
section (Barber et al. 2011). Moreover, the incidence may be
on the rise in developing countries. Some reports from Egypt
indicate an incidence of more than 50% (Ministry of Health
and Population, Egypt et al. 2015).
Uterine anomalies affect 6.7% of women in their reproductive
years (Troiano and McCarthy 2004), with the septate uterus being
the most commonly encountered anomaly (Grimbizis et al. 2001).
Most of the data of uterine anomalies are derived from
studies of patients presenting with reproductive problems.
Analysis of the reproductive performance of the malformed
uteri needs to take into account not only those presenting
with reproductive failures, but also asymptomatic individuals
with a normal reproductive outcome (Raga et al. 1997).
Although there have been great advances in the imaging
techniques to diagnose uterine anomalies, combined laparos-
copy and hysteroscopy is still the gold standard in the diagno-
sis of congenital uterine anomalies, which is an invasive
procedure with potential morbidity (Turkgeldi et al. 2015).
opportunity to diagnose congenital anomalies of the uterus
in a few seconds, with no increase in operative time or
increase in the risk to patients. This opportunity should not
be missed, as it will be greatly helpful to inform undiagnosed
women, which will affect future gynaecological and obstetrics
management with regard to the future use of intrauterine
contraceptive devices (Tepper et al. 2010), the insertion of
cerclage during subsequent pregnancy (Yassaee and
Mostafaee 2011), add caution during the evacuation oper-
ation of future abortions, and more. Also, searching for asso-
ciated urinary and skeletal anomalies should be considered.
We conducted this observational study to determine the
frequency and types of congenital uterine anomalies discov-
ered during a caesarean section.
Materials and methods
This was a descriptive observational study conducted at the
emergency unit of OB/GYN Department of Sohag Faculty of
Medicine, Sohag University from March 2016 until February 2017.
After the approval of the local ethical committee (No. 522), all
women who were subjected to caesarean section were included
in the study after giving a written informed consent.

CONTACT Magdy Abdelrahman Mohamed magdyelkardosy@gmail.com Department of Obstetrics and Gynaecology, Sohag Faculty of Medicine, Sohag
Governorate, Egypt
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2 M. A. MOHAMED AND M. Y. ABDELRAHMAN
Table 1. Findings of uterine examination during CS.
Normal uterus Uterine anomalies Total cases
No. 622 31 653
Percentage 95.25% 4.75%
After delivery of the foetus and placenta, the uterus was
examined for presence or absence of congenital malforma-
tion through the digital palpation of the uterine cavity and a
direct inspection of the fundus after the exteriorisation of the
uterus. There are no established guidelines to diagnose uter-
ine septum during caesarean section. We considered patients
to have a septate or sub-septate uterus if there is any degree
of midline projection that interferes with and prevents the
approximation of the index and middle finger during digital
palpation of the uterine cavity in addition to the normal con-
vex appearance of the uterine fundus by direct observation.
A bicornuate uterus was diagnosed if depression was
observed in the fundus with two separate cavities by digital
palpation. The types of congenital anomalies were recorded.
Indications for caesarean section were recorded, along
with the presence or absence of malpresentation, the
amount of blood loss during caesarean section, parity, and
gestational age at time of caesarean section. The patients’
previous history of abortion, preterm labour and subfertility
were also recorded.
The exclusion criteria:
 Patient refusal
 Dense adhesion around uterus which interferes with
exteriorisation of uterus and may prolong the time
of operation
 Pregnancy by assisted reproduction
 Previous history of recurrent miscarriages (three or more).
Demographic characteristics and obstetrics outcomes were
compared using Student's t test to compare the mean for
normally distributed variables, while the Chi-square test was
used to compare categorical variables. The analysis was car-
ried out using SPSS Inc., Chicago, IL, USA; and p < 0.05 was
considered to be statistically significant.
Results
During the period of study, 702 caesarean sections were per-
formed. Forty-nine were excluded (21 cases were excluded
due to patient refusal, 3 due to the presence of dense adhe-
sions during caesarean and 25 due to pregnancy by assisted
reproductive technique and/or recurrent miscarriage).
Therefore, 653 caesarean sections were included. Uterine
anomalies were diagnosed in only 31 women. The frequency
of uterine anomalies during caesarean section was 4.75%,
while 95.25% of women had a normal uterus, as shown in
Table 1. However, after exclusion of the women with previ-
ous one or two miscarriages, there was only 13 cases out of
420 with uterine anomalies (3.1%) which statistically lower
the frequency of uterine anomalies in those with who have
had one or two miscarriages (7.7%), as shown in Table 2.
There was no statistically significant difference with regard
to age, gestational age and amount of blood loss during cae-
sarean section between the women with a normal uterus
and those with uterine anomalies. However, a history of one
or two miscarriages and a history of preterm labour were
statistically significantly higher in women with uterine
anomalies with a statistically significant lower gravidity
(Table 3).
There was no statistically significant difference between
the two groups with regard to the indication for caesarean
section apart from an increased frequency of caesarean sec-
tion due to malpresentation in women with uterine anoma-
lies in comparison with women with normal uteri, as shown
in Table 4.
With regard to the types of uterine anomalies (Table 5),
the incidence of septate and sub-septate uterus was
(70.97%), followed by bicornuate uterus (19.35%) and then
unicornuate uterus (6.45%); the least common was the didel-
phys uterus (3.23%).
Discussion
Congenital anomalies of the uterus comprise one of the most
frequent problems that can be diagnosed during diagnostic
work-up in the cases of infertility and habitual abortion.
However, many cases of congenital anomalies are discovered
accidentally during caesarean section in women with more or
less normal reproductive outcomes (those with natural con-
ception and no history of recurrent miscarriages). To the best
of our knowledge, this is the first study trying to estimate
the frequency of congenital anomalies during caesar-
ean section.
The incidence in our study was 4.75% which is slightly
higher than reported by Raga et al. (1997) who found that
the incidence was 3.8% in fertile women; however, they were
mainly dependent on hysterosalpingography to diagnose
congenital anomalies in women subjected to tubal sterilisa-
tion. In contrast, in our study, we used more accurate meth-
ods which depend on direct visualisation of the fundus and
digital palpation of the open uterine cavity during caesarean
section. Also, our study may overestimate the incidence as
we only included women who delivered by caesarean sec-
tion; those who delivered vaginally were excluded as they
are expected to have a lower frequency of uterine anomalies.
The incidence of uterine anomalies in women with previ-
ous one or two miscarriage was 7.7% which is lower than
reported by Jaslow and Kutteh (2013). They found that the
incidence was 19.3% of uterine anomalies in women with
previous two or more miscarriages; this could be explained
by the different inclusion criteria as we excluded cases with
more than two miscarriages. Also, more than half of cases
reported by Jaslow and Kutteh (2013) did not have live birth.
The indication for caesarean section was variable, but the
most frequent cause was a scarred uterus in both women
with a normal uterus and those with a congenitally mal-
formed uteri; this reflects the national increase in the rate of
caesarean section. However, malpresentation was significantly
 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 3

Table 2. Frequency of uterine anomalies according to prior miscarriages.

History of miscarriages (one or two) (N. 233) No miscarriages (N. 420) p Value
Normal uterus 215 (92.3%) 407 (96.9%) 0.001a
Uterine anomalies 18 (7.7%) 13 (3.1%)
a
Using Chi Square test.

Table 3. Clinical characteristics of patients (mean ± SD).

Normal uterus (N. 622) Uterine anomalies (N. 31) p Value
Age 28.1 ± 5.4 27.7 ± 5.9 0.34a
Gravidity 3.4 ± 1.54 2.6 ± 1.26 0.04a
Gestational age 37.4 ± 1.67 36.1 ± 1.73 0.42a
Blood loss during CS (mL) 874 ± 69 952 ± 76 0.37a
History of miscarriages (one or two) 215 (34.6%) 18 (58.1%) 0.001b
History of preterm labour 76 (12.2%) 11 (35.5%) 0.001b
a
Using independent sample test.
b
Using Chi Square test.

Table 4. Indication of CS in both groups. The incidence of uterine anomalies was not high in the
Normal uterus (N. 622) Uterine anomalies (N. 31) p Value women with their reproductive outcome delivered by caesar-
Scarred uterusa 294 11 0.19b ean section (4.75%), however, this should not be neglected,
Malpresentation 112 10 0.046b as approximately one in every 20 women subjected to CS
Failure of progress 68 4 0.63b
Others 148 6 0.71b has a uterine malformation and will take some benefit from
a
Previous caesarean sections or previous myomectomy. just being informed of this finding in her future reproductive
b
Using Chi Square test. performance.
Our study suggests that the examination of the uterus
Table 5. Types of congenital anomalies. internally and externally should be a routine step during a
Type of anomalies Number Percentage caesarean section, with the documentation of any congenital
Septate and sub-septate uterus 22 70.97 malformation in the patient’s postoperative records in add-
Bicornuate uterus 6 19.35 ition to informing the women about this finding.
Unicornuate uterus 2 6.45
Uterus didelphys 1 3.23
Disclosure statement
higher in women with uterine anomalies in comparison with No potential conflict of interest was reported by the authors.
those with normal uteri.
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