Incidental Finding of a Müllerian Malformation on Two-dimensional Ultrasound

What Now?

SECTION 1 – QUIZ

CASE

A 25-year-old woman, nulligravida, with no relevant medical or surgical history, chronic medication, gynecologic symptoms, or history of infertility, underwent controlled ovarian stimulation for voluntary oocyte donation. Nine days after ovarian stimulation with 225 IU of follicle-stimulating hormone daily and 36 h after ovulation trigger with 0.2 mg of triptorelin, she was submitted to ultrasound (US)-guided vaginal ovarian puncture under sedation.

Before beginning the procedure, a longitudinal vaginal septum reaching the introitus was noticed, separating the vagina in 2 parts. Furthermore, there were 2 symmetrical uterine cervixes, both of slightly reduced size [Figure 1].

Figure 1: Complete longitudinal nonobstructing vaginal septum (black arrow) and 2 cervixes (white arrows)

On vaginal US, in addition to hyperstimulated ovaries, there were 2 uterine cavities. By performing an axial scan of the uterus toward the fundus, 2 cervical canals were noticed [Figure 2], each one giving access to an independent hemicavity, respectively [Figure 3]. Progressing toward the uterine horns, these cavities were progressively further away from each other [Figure 4].

Figure 2: Two-dimensional vaginal ultrasound, axial section at the level of the uterine cervix, showing 2 cervical canals (black arrows) with distinct outlines (open arrow pointing uterine serosa)

Figure 3: Two-dimensional vaginal ultrasound, axial section at the level of the uterine isthmus, showing 2 uterine cavities (black arrows) but a single uterine body (open arrow pointing uterine serosa)

Figure 4: Two-dimensional vaginal ultrasound, axial section at the level of the uterine body, showing 2 uterine cavities (black arrows) but a single uterine body (open arrow pointing uterine serosa)

Approximately at the level of the mid uterus, there was a median discontinuation of the uterine wall, separating the uterine body in 2 [Figure 5]. The presence of free fluid interposed between them, as a consequence of the ovarian puncture, provided a better visualization [Figures 6 and 7].

Figure 5: Two-dimensional vaginal ultrasound, axial section at the level of the uterine fundus, showing 2 uterine cavities (black arrows) and the beginning of the discontinuation of the midline wall (open arrows pointing the serosa, white arrow pointing the median part of the uterine fundus)

Figure 6: Two-dimensional vaginal ultrasound, axial section at the level of the uterine horns, showing 2 uterine cavities (black arrows) and 2 separated uterine horns (open arrows pointing the serosa, white arrow pointing free fluid lying on the uterine fundus, interposed between the 2 uterine horns)

Figure 7: Two-dimensional vaginal ultrasound, axial section at the level of the upper limit of the uterine horns, showing 2 uterine cavities (black arrows) and 2 uterine horns (open arrows pointing the serosa, white arrow pointing free fluid lying on the uterine fundus, interposed between the 2 uterine horns)

WHAT IS YOUR DIAGNOSIS?

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 her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.