Dear Dr Mitchell,

I had a miscarriage in my 14th week in 2000 at University Hospital of the West Indies. Since then I have been pregnant twice ending also in miscarriages in 12 and 16 weeks. Since then I have found that I have a septum pressing on my uterus and my uterus was ok (2.5cm) which is causing the miscarriages. I have come to terms that pregnancy is not for me, as even if I remove the septum it would mean bed rest for nine months with no guarantee that the septum would not return. Tests also showed spillages from one uterus.

My current problem is that I would like to tie off or remove my uterus to prevent further pregnancies, but my gynaecologist has refused to do so. He says I'm too young (30). I had been using Yasmin contraceptive and I continued to see bleeding with the use of the tablet. I was told the dosage was too low for me, so I switched to Nordette, but after two weeks the bleeding started again. The IUD was considered at one point, but because of the spill from the uterus this was not used.

I am frustrated. Help, please!!!!

Dear Frustrated,

I am truly sorry to learn of the unfortunate outcome of your pregnancies. The losses mostly seem to occur at the end of the first trimester and into the second trimester and this is definitely suggestive of a uterine abnormality and possible cervical incompetence. The presence of a septum in the uterus can actually cause these pregnancy losses. In the presence of a uterine abnormality, the tendency is for the woman to take the pregnancies to a more advanced stage before the loss occurs and then eventually even to full term (9 months).

Cervical incompetence (weakness in the muscles of the cervix) sometimes co-exists with a uterine abnormality and results in pregnancy losses in the second trimester (after 14 weeks) and these losses tend to occur at a successively decreasing gestational age, so the woman loses the pregnancy earlier with each pregnancy. The good news is that these problems can be treated. The uterine septum may be removed by doing a minor surgery. This may be done using hysteroscopy, which is a special technique that allows for removal of the septum via the vaginal route. The recovery is quite quick, the outcome is excellent and this may be done as an outpatient at the University Hospital. Cervical incompetences is usually treated by inserting a suture to close off the cervix at the end of the first trimester (after 13 weeks). This allows for spontaneous abortions due to chromosomal or gross congenital malformations to occur in the first trimester, so that one does not secure an abnormal foetus. This suture is removed usually at 38 weeks or whenever the patient goes into labour. The presence of cervical incompetence may be confirmed by doing an x-ray of the uterus called a hysterosalpingogram. This is done in the non-pregnant state. During pregnancy an ultrasound done in the second trimester may also confirm cervical incompetence.

It is also important for you to do other tests to rule out other causes of recurrent pregnancy losses. This includes a TORCH's screen and a lupus anticoagulant antibody screen. The TORCH's screen checks for toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus and syphyllis.

I know that you are frustrated with all these losses, but you are still young and doing a hysterectomy or tubal ligation is far too drastic and permanent. You will definitely regret this later on in life. I would strongly recommend that you consider resection of the uterine septum and then the placement of a cervical suture after conception at the end of the first trimester. I'm confident that the outcome will be good. It is clear that you truly desire to become a mother and that is why you tried three times.

The abnormal bleeding that you experience on the oral contraceptive pills should be investigated. You need a detailed gynaecological evaluation including a pap smear.
The Intra-Uterine contraceptive device is not an appropriate option for women with a septate uterus and should not be entertained as it cannot effectively prevent pregnancy in both sides of the uterus.

Consult your gynaecologist who will advise you in more detail about hysteroscopic resection of the uterine septum.

Best wishes.

Dr Sharmaine Mitchell is an Obstetrician and Gynaecologist. Send questions or comments by e-mail to allwoman@jamaicaobserver.com, fax to 968-2025 or call 511-2461 to leave a 30-second voicemail message.

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