Vaginal delivery in case of isolated longitudinal vaginal septum: an uncommon situation: a case report

¹Sidi Mohamed Ben Abdellah University, Department of Gynecology-Obstetrics II, Hassan II Teaching Hospital, Fez, Morocco

^&Corresponding author
Alpha Boubacar conte, Sidi Mohamed Ben Abdellah University, Department of Gynecology-Obstetrics II, Hassan II Teaching Hospital, Fez, Morocco

Introduction    

The longitudinal vaginal septum corresponds embryologically to a lack of resorption of the lower part of the Müllerian canals. It is often associated in varying proportions with other genital anomalies. Isolated vaginal partitions are non-frequent. They are associated for the majority of them with a uterine septum, achieving then a complete utero-vaginal septum as part of the uterus septate, with a single cervical mass or in that of the hemi matrices uterine with 2 distinct cervical massifs [1]. Longitudinal vaginal septum is a rare Mullerian malformation that may be associated with dyspareunia, dysmenorrhea, primary amenorrhea, and infertility [2]. There are three types of longitudinal vaginal septum: isolated longitudinal vaginal septum, vaginal septum associated with a septate uterus and vaginal septum associated with two hemi-uterus [1]. It may present clinically as a difficulty in inserting tampons, persistent bleeding despite the presence of a tampon, or dyspareunia. On the other hand, it may be asymptomatic [2].

Patient and observation     

This is a 19-year-old patient married for less than a year who consulted for the management of abdominal and pelvic pain like uterine contractions in a pregnancy said to be at term. She is primigravida with no particular history apart from a notion of dyspareunia during sexual intercourse. The clinical examination found a stable patient with a uterine height of 30cm, regular uterine contractions of normal intensity, positive and regular fetal heart sound rate, and the vaginal examination found the presence of two cavities separated by a tissue of soft and elastic consistency, one of the cavities was leading to the cervix and the other one was leading to a side wall of the vagina with a centralizing cervix that is 80% shorted and dilated at 2cm with a mobile cephalic presentation, an intact membranes and a clinically normal pelvis. This tissue separating the vagina into two cavities was painless. A more deep examination of the vaginal cavity was made by placing a speculum, which allow to highlight a complete vaginal septum drawing a straight convex arc extending to the bottom of the vagina (Figure 1). There were no other visible deformities.

The diagnosis of vaginal septum was made. An obstetric ultrasound performed showed an evolving pregnancy in cephalic presentation with a fundic placenta, an amniotic fluid of normal quantity with an estimated fetal weight of 2900g. A decision to accept the vaginal delivery under epidural was taken and the patient was transferred to a delivery room. During labor, the patient progressed harmoniously to full dilation with a presentation in process of reaching the vagina. At this step, we proceeded to the ligature followed by the section of the septum with the delivery by vaginal route without episiotomy and without incident of a male newborn (Apgar 10/10 in the first and fifth minutes). After delivery, we performed a complete resection of the two upper and lower edges of the septum. The evolution in the postpartum period was remarkable with a complete restoration of the vaginal anatomy. The patient was checked after the post-partum period by pelvic ultrasound, which did not find any uterine abnormalities, and an evaluation of the quality of her sexuality was made based on a questionnaire, looking for the notion of dyspareunia and satisfaction during sexual relations. She was no longer feeling any pain during intercourse and the quality of her sexual life was better than the time before giving birth.

Discussion     

Maldevelopment of the mullerian ducts occurs in a variety of forms. The incidence varies from 2-3% in fertile women [3]. The overall incidence is 0.16-10%. It is seen in 1% of the general population and 3% of those with recurrent pregnancy loss [4]. Since 1988, the Mullerian anomalies where classified by the American Fertility Society. There may be agenesis, unicornuate uterus (20%), uterus didelphys (5-7%), bicornuate unicollis or bicollis uterus (10%), septate uterus (55%) or arcuate uterus [4,5]. Although a rare condition, longitudinal vaginal septum should always be taken into consideration in differential diagnoses when a varying combination of dyspareunia, cyclic pelvic pain, hematocolpos, hematometra, and mucocolpos is present, either associated or not with primary amenorrhea, which may be present when there is complete obstruction of the vaginal canal. Diagnosis and treatment should be timely in order to avoid possible complications such as pelvic adhesions and damage to the fallopian tubes, principally in cases of complete obstruction, as well as the discomfort and psychological repercussions of painful symptoms such as dyspareunia [5,6]. The diagnosis of vaginal septum is difficult when there are no symptoms or when it is not associated with uterine abnormalities, which may lead to infertility or pregnancies loss. In our present case, the vaginal septum was diagnosed during the delivery labor of the patient who has been complaining of dyspareunia since the onset of her sexual life.

The discovery of such abnormality requires an investigation of the uterine cavity. The most common investigation is ultrasound. Newer 3 D ultrasound offers better visualization of uterine body than 2 D. It approaches the sensitivity and specificity of MRI. MRI is still the gold standard [7]. The resection of a longitudinal vaginal septum may be performed during vaginal delivery, thus avoiding a cesarean section. Ideally, resection should be performed prior to the patient becoming pregnant or early in pregnancy [2]. According to this experience, the management of vaginal septum is easy when it is isolated. It is mandatory to assess the septum whether it is smooth or tough. During delivery, the management requires two steps, the first step is the ligature and section of the septum when the presentation is about to be in contact with it and start pushing the tissue and the second step is the resection of the septum after the delivery. The post-delivery care will be based on local antibiotherapy and examination 2 or 3 weeks after the delivery so that to assess the anatomical structure of the vagina.

Conclusion     

Longitudinal vaginal septum is a rare condition. Its discovery during delivery labor is not a formal indication of caesarean. Vaginal delivery is possible with a good management of the situation by the ligature and the section of the septum when the presentation came on its contact. We observed in our case that the resection of the septum improved the sexual life quality of the patient.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and agreed to the final manuscript.

Figure     

Figure 1: vaginal septum

References