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The motility of the nonpregnant congenitally malformed uterus
EUROP. J. OBSTET. GYNEC. REPROD.
BIOL., 1974,4/2, 51-60.
EXCERPTA
MEDICA
The motility of the nonpregnant congdtally malformed uterus P. R. Hein”, L. A. M. Stolte, T. K. A. B. Eskes, J. Janssens, J. T. Braaksma, E. B. Kars-Villanueva, J. J. van der Harten and P. A. de Jong of Obstetricsand Gynecology, Vrije Universiteit,
Department Department
of Pathology,
_____~~__..
Vrije Universiteit,
Amsterdam,
Department of Obstetrics The Netherlands
und Gynecology,
.-_____
Sint Lucas Ziekenhuis,
and
~~~~~
HEIN, P. R., STOLTE, L. A. M., ESKES, T. K. A. B., JANSSENS, J., BRAAKSMA, J. T., KARS-VILLANUEVA, E. B., VAN DER HARTEN, J. and DE JONG, P. A. (1974): The motility of the nonpregnant congenitally malformed uterus. Europ. J. Obstet.
Gynec. reprod.
Biol., 4/Z, 51-60.
Uterine motility in 5 patients with a complete double uterus and in 1 patient with a bicornuate uterus is described. In all cases the right and left side seldom contracted synchronously and sometimes not even with the same force. In 5 patients the motility patterns were the same for right and left uterus. In 1 patient with a complete double uterus, however, the motility patterns of the left uterus followed the menstrual cycle and could be influenced by estrogens or Vasopressin@ (Sandoz), whereas the right uterus did not react to these stimuli and continued to contract in its own ‘ahormonal’ way. The endometrium of both uteri reacted in a normal way to hormonal stimuli. This suggests lacking of receptors for estrogens and progesterone in the myometrium of the right uterus, whereas the endometrium of both uteri seems to have these receptors. The patient became pregnant in the left uterus. According to these findings it might be indicated to add intrauterine pressure recording to the preoperative diagnostic procedures before undertaking operative correctional procedures in cases of uterine anomalies.
congenital
uterine malformations;
double uterus; uterine motility; bicornuate
Introduction
Bengtsson (1970) described myometrial activity in vivo in a double uterus in a 20-year-old patient, the two uteri showing a normal ovulatory motility pattern throughout the cycle; progesterone treatment or combined treatment with estrogen and gestagen influenced both uteri in the same way. So did vasopressin (Postacton@, Ferring). In all recordings both uteri reacted in the same way but not synchronously (oxytocin did not show any effect). In this paper the uterine motility of 5 patients *
Present address: Department
Diaconessenhuis,
of Obstetrics and Gynecology, Arnhem, The Netherlands.
uterus
with a double uterus and I patient with a bicornuate uterus are described. Motility patterns were studied during normal cycles, amenorrhea and treatment with estrogens and gestagens. In some instances the influence of lysine-vasopressin (Vasopressin @- Sandoz) was studied.
Materials and methods
The sponge-tipped open-tip catheter method (a modification by Bengtsson (1968) of Hendricks’s open-tip catheter method (1964)) was used. The recording system consisted of pressure transducers type Bell and Howell and Statham
P. R. Hein et al., Motility of malformed uterus
52 TABLE 1
Group 1: similar motility Age
Diagnosis
1
28
2
19
secundary amenorrhea coincidental finding
3
27
4
21
Patient nr.
primary sterility + dyspareunea coincidental finding
Probe lengths (mm) R L
BBT*
Cycle length
HSG**
1vp***
65
65
65
R=L
normal
R=L
normal
biphasic
70
70
28
biphasic
65
70
Vasopressin@ 4 1U
normal
65
28
Medication
D-norgestrel (0.25 mg) + ethinylestradiol (0.05 mg)
-
normal ~~~.~
Patient nr.
Age
1 2 3
28 19 21
4
21
Motility pattern
Recording on day
Cycle nr
11 recordings in 44 weeks 1: 1: 2: 1: 2:
10 6
13
R=L R=L R=L
20 4
R=L
10 15
28
* BBT = basal body temperature ** HSG = hysterosalpingogram *** IVP = intravenous pyelogram
TABLE II
Group 2: dissimilar motility
Patient nr.
Age
Diagnosis
23
primary sterility
Cycle length
-____ 5
Patient nr.
5
Age
Cycle nr.
23
1: 2: 3:
* BBT = basal body temperature ** HSG = hysterosalpingogram *** IVP = intravenous pyelogram
28-35
BBT*
Probe lengths (mm) R L
HSG**
80
R+L
__~
._ biphasic
13
26
10
21 20
75
left side: double kidney + ureter Motility pattern
Recording on day
15
Medication
1vp***
R+L
Vasopressin@ 4 1U ethinylestradiol
(0.075 mg)
P. R. Hein et al., Motility of malformed uterus
TABLE III Patient nr.
6
Patient nr.
6
53
Bicornuate uterus Age
Diagnosis
Cycle length
27
habitual ahortion
28
Age
Cycle nr.
27
1: 2:
BBT*
Day of the cycle
21
28
Probe lengths (mm) R L
HSG**
1vp***
65
R-L
normal
50
Recording on day
31
Medication
Motility pattern R=L
3
* BBT = basal body temperature ** HSG = hysterosalpingogram *** IVP = inlravenous pyelogram
(P-23Db) and an eight-channel Hellige recording unit. In contrast to recordings made in normal uteri, insertion of the vinyl catheter (Beckton, Dickinson Co., Rutherford, N. J., No. VX 020) was performed by means of a special insertion probe (De Haan, Janssens, Braaksma, Van der Weide, 1971; De Haan, 1971), consisting of a smooth plastic tube with a central channel having the shape of a normal uterine probe, with an outer diameter of 3 mm and an inner diameter of 1 mm. The catheter (filled with a heparin-saline solution) was inserted through this probe, which was removed thereafter. The paper speed was 30 mm/min and the sensitivity of the recordings could be chosen from 10-300 mm Hg full scale. In 5 patients with double vagina, cervix and uterus, 25 recordings of simultaneously registered motility in right and left uterus were made (Tables I and II). In 1 patient with a bicornuate uterus 4 recordings of simultaneously registered motility in the right and left horn were made (Table III). Whereas in patients 1, 2, 3, and 4 bimanual investigation revealed a right and left uterus of equal size, in patient 5, the left side gave the impression of being smaller in size. This was confirmed by the probe length showing the left uterus to be slightly shorter than the right one (Table II). Also, on hysterosalpingography, the left uterus seemed to be smaller than the right one (Fig. 1). In contrast to normal findings in patients 1, 2, 3,
4, and 6, examination in patient 5 revealed a duplication of both left ureter and kidney (Fig. 2). Arteriography showed a symmetrical vascularization of right and left uterus (Fig. 3), and endometrial biopsies simultaneously performed in both uteri on the first day of menstruation on two occasions showed normal secretory endometria. The spontaneous uterine motility in all patients was studied: - during the course of ovulatory cycles, - during amenorrhea, - during treatment with ethinylestradiol alone (orally 0.075 mg per day), and - during treatment with a combination of 0.25 mg o-norgestrel and 0.05 mg ethinylestradiol (Neogynon 21@, Schering). The influence of Vasopressin@ was studied in some instances (Table I). Since quantitative judgement of uterine motility varies widely for different investigators but qualitative judgement is fairly consistent, we have limited ourselves to the method of ‘pattern recognition’ (Hein, 1972) to describe uterine motility.
Results
According to motility patterns the recordings of the patients with a complete double uterus could be didided into 2 groups:
P. R. Hein et al., Motility of malformed uterus
54
Fig. 1 Simultaneously performed hysterosalpingography in patient 5 was impossible because of the small left vagrina. Instead of this the contrast fluid was injected through the catheter after pressure recording. Bc)th catheters with the sponge at the tip are visible, filled with contrast fluid. Note that the left side seems to be smaller than t he right side.
1. similar motility of both uteri (patients 1, 2, 3, 4). 2. dissimilar motility of both uteri (patient 5).
Fig. 2 Intravenous pyelogram left ureter and kidney.
of patient 5 with double
1. Similar motility (Table I) Recordings were performed during: - the preovulatory phase of a normal ovulatory cycle: n = 4 - the postovulatory phase of a normal ovulatory cycle: n = 3 - moderate estrogenic amenorrhea: n = 11 - combined treatment with D-norgestrel and ethinylestradiol: n = 1 In general the motility was not synchronous and the absolute values of basal pressure, amplitude, intensity, frequency, etc. of the contractions were not the same in both uteri. In all cases, however, the intrauterine pressure records always showed the same patterns for both uteri. The motility during
54
P. R. Hein et al., Motility of malformed uterus
Fig.
3
Arteriography
in patient
5: symmetrical
vascularization
the pre- and postovulatory phase showed the pattern normal for that phase for both uteri (Figs. 4 and 5). One of the ovulatory patients (patient 2) was given Neogynon 21@ during 21 days and was recorded on day 10 of the treatment. At that time the motility normally seen during oral contraceptive
Fig.
4
6th
are not equal
day
of
a normal
ovulatory
in force and not synchronous.
cycle (patient
of right and left uterus.
treatment (Eskes, Hein, Kars-Villanueva, Braaksma, Janssens and Kollerie, 1969; Bengtsson and Theobald, 1966; Moawad and Bengtsson, 1968) was observed in both uteri. The contractions of the left uterus were much stronger than those of the right one (Fig. 6). In patient 1 (suffering from moderate hypo-
3): contractions
of right
and left uterus
have the same pattern
but
56
P. R. Hein et al., Motility
Fig. 5 28th day of a normal ovulatory cycle (patient 4): contractions are not equal in force and not synchronous.
of malformed
uterus
of right and left uterus have the same pattern but
Fig. 6 10th day of a combined daily oral treatment with o-norgestrel (0.25 mg) and ethinylestradiol (0.05 mg) (patient 2): contractions of right and left uterus have the same pattern but are not equal in force and not synchronous; artery pulsations are stronger in the left uterus.
estrogenic amenorrhea), the 11 recordings performed over a period of 10 months were all identical and showed similar activity of both uteri. Vasopressin@ (4 or 5 IU) administered i.m. in this patient gave a quick rise in basal pressure, intensity and frequency, and a decrease of amplitude and duration in both uteri (Fig. 7). 2. Dissimilar motility (Table II) The uterine motility of patient 5 was recorded on days 13, 15, 21, and 26 of normal ovulatory cycles. The left uterus showed the normal motility pattern pertaining to these days, but the right uterus showed a monotonous pattern. All recordings of this uterus were of the same ‘ahormonal’ motility type, corresponding with the patterns seen in early post
menopause, following ovariectomy or during the late postovulatory phase (Figs. 8 and 9) (Hein, 1972). In order to further investigate the dissimilarity observed, the patient was put on ethinylestradiol 0.075 mg daily (orally) from the first day of the cycle onward. On days 10 and 20 the left uterus revealed the expected normoestrogenic motility pattern (Hein, 1972), whereas the right uterus did not show any reaction to the estrogen treatment; it continued contracting in its own ‘ahormonal’ way (Figs. 10 and 11). Also Vasopressin@ only influenced the left uterus (Fig. 12). Following resection of the septum between right and left vagina the patient became pregnant and in the 16th week echoscopy revealed an intact pregnancy in the left uterus.
P. R. Hein et al., Motility of malformed uterus
57
VasopressinB administered intramuscularly in patient 1 (moderate hypo-estrogenic amenorrhea) influences both Fig. 7 uteri in the same way; higher pressure scales had to be chosen in order to be able to follow change in activity. Contractions of right and left uterus have the same pattern but are not equal in force and not synchronous. The heart rate (recorded as a so-called tachogram) decreases slightly after the injection of Vasopressin@. I.U.P. = intrauterine pressure.
TIME (min)
V-P
Fig. 8 Uterine activity just before ovulation in patient 5 (day 15): only the left uterus has an estrogenic activity, the right uterus shows ‘ahormonal’ activity.
Discussion
All 4 recordings in patient 6, suffering from a bicornuate uterus (Table III) showed the patterns normal for the day of the cycle for both horns, but the contractions were not synchronous and those of the left horn were stronger than those of the right horn.
The similarity of motility patterns in both parts of a double uterus as described by Bengtsson (1970), was confirmed and extended in 4 patients with a double uterus and in 1 patient with a bicornuate uterus. The dissimilarity of motility patterns in viva in
58
P. R. Hein et al., Motility
of malformed
utetlls
”
Fig. 9 Uterine activity just before menstruation in patient 5 (day 26). Now both uteri show ‘ahormonal’ activity (as seen for example early post menopause, after castration, during anestrogenic amenorrhea and immediately before, during and after menstruation).
Fig. 10 treatment,
10th day of oral treatment with ethinylestradiol (0.075 mg) in patient 5: only the left uterus reacts to estrogen the right uterus continues to contract in its own ‘ahormonal’ way.
20th day of oral treatment with ethinylestradiol Fig. 11 uterus does not react to estrogen treatment.
(0.075 mg daily) in patient
5: even after 20 days the right
P. R. Hein et al., Motility
Fig. 12
of malformed
59
uterus
Vasoptessin@ administered intramuscularly in patient 5: only the left uterus reacts.
both uteri in patient 5 has, as far as we know, never been reported before. In this patient the myometrium of the right uterus (posing as being the better developed one) did not react to estrogens, progesterone and Vasopressin@, while the lesser developed myometrium of the left uterus did. In contrast to this myometrial difference, the endometrium of both uteri behaved in a quite comparable way. From the findings in patient 5 it can be stated that a dissociation of myometrial and endometrial reactivity in the uteri of a double uterus is possible. Presumably in this case the receptors for estrogens and progesterone are present in the myometrium of the left side only, whereas the receptors for both hormones seem to be present in the endometrium of both sides. A dissimilarity in endometrial morphology in one double uterus out of 17 was described by Kreibich (1949) but no investigation was done concerning uterine motility. In our study the morphology of the endometrium was not systematically investigated. In our patients with both uteri behaving in a similar way, this similarity pertained only to the motility pattern and not to absolute values of basal pressure, amplitude, etc. Moreover, there seldom was a synchronous motility on both sides. It is, of course, unknown as yet how far our findings can be extended to all uterine anomalies. Notwithstanding this uncertainty, the results of our investigations must have some bearings on the desirability of operative correctional procedures. Perhaps
it would be indicated to add pressure recordings to the preoperative diagnostic procedures.
Acknowledgement
We wish to thank Ms. J. M. v. d. Hoek, R. B. A. for her assistance in recording uterine activity.
References
Bengtsson,L. P. (1968): The sponge-tipped catheter. A modification of the open end catheter for recording of myometrial activity in vivo. J. Reprod. Fe&., 16, 115-l 18. Bengtsson, L. P. (1970): Myometrial activity in a double, non-pregnant human uterus. Acta obstet. gynec. stand., 49, suppl. 6, 13-19. Bengtsson, L. P. and Theobald, G. W. (1966): The effects of oestrogen and gestagen on the non-pregnant human uterus. J. Obstet. Gynaec. &it. Cwlth, 73, 273. De Haan, J., Janssens, J., Braaksma, J. T. and Van der
Weide, H. (1971): Der Einfluss von Uteruskontraktionen auf den fetalen Herzrhythmus (The influence of uterine contractility upon the fetal heart rate). In: Fortschritte der perinatalen Medizin, p. 159. Editors: E. Saling and K. A. Hiiter. Georg Thieme Verlag, Stuttgart. De Haan, J. (1971): De Snelle Variaties in het Foetaie Hartfiequentiepatroon (The short term irregularity in the foetal heart rate pattern). Thesis, Vrije Universiteit, Amsterdam. Eskes, T. K. A. B., Hein, P. R., Kars-Villanueva, E. B., Braaksma, J. T., Janssens, J. and Kollerie. A. (1969): The influence of steroids on the motility of the nonpregnant human uterus in vivo. Arch. int. Pharmacodyn., 182, 409.
Hein, P. R. (1972): De Contractiliteit
van de Uterus #dens
60 de Menstruele Cyclus en na Toediening van Geslachtshormonen (The contractility of the uterus during the menstrual cycle and after administration of sex hormones). Thesis, Vrije Universiteit, Amslerdam. Hrndricks, C. H. (1964): A new technique for the study of motility in the non-pregnant human uterus. J. Obstet. Gynaec. Brit. Cwlth, 71, 712-715.
P. R. Hein et al., Motility of malformed uterus Kreibich, H. (1949): Uber Endometrium-Untersuchungen beim Uterus duplex und Beitrslge zu dessen Pathologie (Studies of endometrium in cases of a double uterus and contributions to its pathology). Zbl.f. Gytrtik., 73, 546-553. Moawad, A. H. and Bengtsson, L. P. (1968): In vivo studies of the motility pattern of the non-pregnant human uterus. Amer. J. Obstet. Gynec., 101, 473-478.
BIOL., 1974,4/2, 51-60.
EXCERPTA
MEDICA
The motility of the nonpregnant congdtally malformed uterus P. R. Hein”, L. A. M. Stolte, T. K. A. B. Eskes, J. Janssens, J. T. Braaksma, E. B. Kars-Villanueva, J. J. van der Harten and P. A. de Jong of Obstetricsand Gynecology, Vrije Universiteit,
Department Department
of Pathology,
_____~~__..
Vrije Universiteit,
Amsterdam,
Department of Obstetrics The Netherlands
und Gynecology,
.-_____
Sint Lucas Ziekenhuis,
and
~~~~~
HEIN, P. R., STOLTE, L. A. M., ESKES, T. K. A. B., JANSSENS, J., BRAAKSMA, J. T., KARS-VILLANUEVA, E. B., VAN DER HARTEN, J. and DE JONG, P. A. (1974): The motility of the nonpregnant congenitally malformed uterus. Europ. J. Obstet.
Gynec. reprod.
Biol., 4/Z, 51-60.
Uterine motility in 5 patients with a complete double uterus and in 1 patient with a bicornuate uterus is described. In all cases the right and left side seldom contracted synchronously and sometimes not even with the same force. In 5 patients the motility patterns were the same for right and left uterus. In 1 patient with a complete double uterus, however, the motility patterns of the left uterus followed the menstrual cycle and could be influenced by estrogens or Vasopressin@ (Sandoz), whereas the right uterus did not react to these stimuli and continued to contract in its own ‘ahormonal’ way. The endometrium of both uteri reacted in a normal way to hormonal stimuli. This suggests lacking of receptors for estrogens and progesterone in the myometrium of the right uterus, whereas the endometrium of both uteri seems to have these receptors. The patient became pregnant in the left uterus. According to these findings it might be indicated to add intrauterine pressure recording to the preoperative diagnostic procedures before undertaking operative correctional procedures in cases of uterine anomalies.
congenital
uterine malformations;
double uterus; uterine motility; bicornuate
Introduction
Bengtsson (1970) described myometrial activity in vivo in a double uterus in a 20-year-old patient, the two uteri showing a normal ovulatory motility pattern throughout the cycle; progesterone treatment or combined treatment with estrogen and gestagen influenced both uteri in the same way. So did vasopressin (Postacton@, Ferring). In all recordings both uteri reacted in the same way but not synchronously (oxytocin did not show any effect). In this paper the uterine motility of 5 patients *
Present address: Department
Diaconessenhuis,
of Obstetrics and Gynecology, Arnhem, The Netherlands.
uterus
with a double uterus and I patient with a bicornuate uterus are described. Motility patterns were studied during normal cycles, amenorrhea and treatment with estrogens and gestagens. In some instances the influence of lysine-vasopressin (Vasopressin @- Sandoz) was studied.
Materials and methods
The sponge-tipped open-tip catheter method (a modification by Bengtsson (1968) of Hendricks’s open-tip catheter method (1964)) was used. The recording system consisted of pressure transducers type Bell and Howell and Statham
P. R. Hein et al., Motility of malformed uterus
52 TABLE 1
Group 1: similar motility Age
Diagnosis
1
28
2
19
secundary amenorrhea coincidental finding
3
27
4
21
Patient nr.
primary sterility + dyspareunea coincidental finding
Probe lengths (mm) R L
BBT*
Cycle length
HSG**
1vp***
65
65
65
R=L
normal
R=L
normal
biphasic
70
70
28
biphasic
65
70
Vasopressin@ 4 1U
normal
65
28
Medication
D-norgestrel (0.25 mg) + ethinylestradiol (0.05 mg)
-
normal ~~~.~
Patient nr.
Age
1 2 3
28 19 21
4
21
Motility pattern
Recording on day
Cycle nr
11 recordings in 44 weeks 1: 1: 2: 1: 2:
10 6
13
R=L R=L R=L
20 4
R=L
10 15
28
* BBT = basal body temperature ** HSG = hysterosalpingogram *** IVP = intravenous pyelogram
TABLE II
Group 2: dissimilar motility
Patient nr.
Age
Diagnosis
23
primary sterility
Cycle length
-____ 5
Patient nr.
5
Age
Cycle nr.
23
1: 2: 3:
* BBT = basal body temperature ** HSG = hysterosalpingogram *** IVP = intravenous pyelogram
28-35
BBT*
Probe lengths (mm) R L
HSG**
80
R+L
__~
._ biphasic
13
26
10
21 20
75
left side: double kidney + ureter Motility pattern
Recording on day
15
Medication
1vp***
R+L
Vasopressin@ 4 1U ethinylestradiol
(0.075 mg)
P. R. Hein et al., Motility of malformed uterus
TABLE III Patient nr.
6
Patient nr.
6
53
Bicornuate uterus Age
Diagnosis
Cycle length
27
habitual ahortion
28
Age
Cycle nr.
27
1: 2:
BBT*
Day of the cycle
21
28
Probe lengths (mm) R L
HSG**
1vp***
65
R-L
normal
50
Recording on day
31
Medication
Motility pattern R=L
3
* BBT = basal body temperature ** HSG = hysterosalpingogram *** IVP = inlravenous pyelogram
(P-23Db) and an eight-channel Hellige recording unit. In contrast to recordings made in normal uteri, insertion of the vinyl catheter (Beckton, Dickinson Co., Rutherford, N. J., No. VX 020) was performed by means of a special insertion probe (De Haan, Janssens, Braaksma, Van der Weide, 1971; De Haan, 1971), consisting of a smooth plastic tube with a central channel having the shape of a normal uterine probe, with an outer diameter of 3 mm and an inner diameter of 1 mm. The catheter (filled with a heparin-saline solution) was inserted through this probe, which was removed thereafter. The paper speed was 30 mm/min and the sensitivity of the recordings could be chosen from 10-300 mm Hg full scale. In 5 patients with double vagina, cervix and uterus, 25 recordings of simultaneously registered motility in right and left uterus were made (Tables I and II). In 1 patient with a bicornuate uterus 4 recordings of simultaneously registered motility in the right and left horn were made (Table III). Whereas in patients 1, 2, 3, and 4 bimanual investigation revealed a right and left uterus of equal size, in patient 5, the left side gave the impression of being smaller in size. This was confirmed by the probe length showing the left uterus to be slightly shorter than the right one (Table II). Also, on hysterosalpingography, the left uterus seemed to be smaller than the right one (Fig. 1). In contrast to normal findings in patients 1, 2, 3,
4, and 6, examination in patient 5 revealed a duplication of both left ureter and kidney (Fig. 2). Arteriography showed a symmetrical vascularization of right and left uterus (Fig. 3), and endometrial biopsies simultaneously performed in both uteri on the first day of menstruation on two occasions showed normal secretory endometria. The spontaneous uterine motility in all patients was studied: - during the course of ovulatory cycles, - during amenorrhea, - during treatment with ethinylestradiol alone (orally 0.075 mg per day), and - during treatment with a combination of 0.25 mg o-norgestrel and 0.05 mg ethinylestradiol (Neogynon 21@, Schering). The influence of Vasopressin@ was studied in some instances (Table I). Since quantitative judgement of uterine motility varies widely for different investigators but qualitative judgement is fairly consistent, we have limited ourselves to the method of ‘pattern recognition’ (Hein, 1972) to describe uterine motility.
Results
According to motility patterns the recordings of the patients with a complete double uterus could be didided into 2 groups:
P. R. Hein et al., Motility of malformed uterus
54
Fig. 1 Simultaneously performed hysterosalpingography in patient 5 was impossible because of the small left vagrina. Instead of this the contrast fluid was injected through the catheter after pressure recording. Bc)th catheters with the sponge at the tip are visible, filled with contrast fluid. Note that the left side seems to be smaller than t he right side.
1. similar motility of both uteri (patients 1, 2, 3, 4). 2. dissimilar motility of both uteri (patient 5).
Fig. 2 Intravenous pyelogram left ureter and kidney.
of patient 5 with double
1. Similar motility (Table I) Recordings were performed during: - the preovulatory phase of a normal ovulatory cycle: n = 4 - the postovulatory phase of a normal ovulatory cycle: n = 3 - moderate estrogenic amenorrhea: n = 11 - combined treatment with D-norgestrel and ethinylestradiol: n = 1 In general the motility was not synchronous and the absolute values of basal pressure, amplitude, intensity, frequency, etc. of the contractions were not the same in both uteri. In all cases, however, the intrauterine pressure records always showed the same patterns for both uteri. The motility during
54
P. R. Hein et al., Motility of malformed uterus
Fig.
3
Arteriography
in patient
5: symmetrical
vascularization
the pre- and postovulatory phase showed the pattern normal for that phase for both uteri (Figs. 4 and 5). One of the ovulatory patients (patient 2) was given Neogynon 21@ during 21 days and was recorded on day 10 of the treatment. At that time the motility normally seen during oral contraceptive
Fig.
4
6th
are not equal
day
of
a normal
ovulatory
in force and not synchronous.
cycle (patient
of right and left uterus.
treatment (Eskes, Hein, Kars-Villanueva, Braaksma, Janssens and Kollerie, 1969; Bengtsson and Theobald, 1966; Moawad and Bengtsson, 1968) was observed in both uteri. The contractions of the left uterus were much stronger than those of the right one (Fig. 6). In patient 1 (suffering from moderate hypo-
3): contractions
of right
and left uterus
have the same pattern
but
56
P. R. Hein et al., Motility
Fig. 5 28th day of a normal ovulatory cycle (patient 4): contractions are not equal in force and not synchronous.
of malformed
uterus
of right and left uterus have the same pattern but
Fig. 6 10th day of a combined daily oral treatment with o-norgestrel (0.25 mg) and ethinylestradiol (0.05 mg) (patient 2): contractions of right and left uterus have the same pattern but are not equal in force and not synchronous; artery pulsations are stronger in the left uterus.
estrogenic amenorrhea), the 11 recordings performed over a period of 10 months were all identical and showed similar activity of both uteri. Vasopressin@ (4 or 5 IU) administered i.m. in this patient gave a quick rise in basal pressure, intensity and frequency, and a decrease of amplitude and duration in both uteri (Fig. 7). 2. Dissimilar motility (Table II) The uterine motility of patient 5 was recorded on days 13, 15, 21, and 26 of normal ovulatory cycles. The left uterus showed the normal motility pattern pertaining to these days, but the right uterus showed a monotonous pattern. All recordings of this uterus were of the same ‘ahormonal’ motility type, corresponding with the patterns seen in early post
menopause, following ovariectomy or during the late postovulatory phase (Figs. 8 and 9) (Hein, 1972). In order to further investigate the dissimilarity observed, the patient was put on ethinylestradiol 0.075 mg daily (orally) from the first day of the cycle onward. On days 10 and 20 the left uterus revealed the expected normoestrogenic motility pattern (Hein, 1972), whereas the right uterus did not show any reaction to the estrogen treatment; it continued contracting in its own ‘ahormonal’ way (Figs. 10 and 11). Also Vasopressin@ only influenced the left uterus (Fig. 12). Following resection of the septum between right and left vagina the patient became pregnant and in the 16th week echoscopy revealed an intact pregnancy in the left uterus.
P. R. Hein et al., Motility of malformed uterus
57
VasopressinB administered intramuscularly in patient 1 (moderate hypo-estrogenic amenorrhea) influences both Fig. 7 uteri in the same way; higher pressure scales had to be chosen in order to be able to follow change in activity. Contractions of right and left uterus have the same pattern but are not equal in force and not synchronous. The heart rate (recorded as a so-called tachogram) decreases slightly after the injection of Vasopressin@. I.U.P. = intrauterine pressure.
TIME (min)
V-P
Fig. 8 Uterine activity just before ovulation in patient 5 (day 15): only the left uterus has an estrogenic activity, the right uterus shows ‘ahormonal’ activity.
Discussion
All 4 recordings in patient 6, suffering from a bicornuate uterus (Table III) showed the patterns normal for the day of the cycle for both horns, but the contractions were not synchronous and those of the left horn were stronger than those of the right horn.
The similarity of motility patterns in both parts of a double uterus as described by Bengtsson (1970), was confirmed and extended in 4 patients with a double uterus and in 1 patient with a bicornuate uterus. The dissimilarity of motility patterns in viva in
58
P. R. Hein et al., Motility
of malformed
utetlls
”
Fig. 9 Uterine activity just before menstruation in patient 5 (day 26). Now both uteri show ‘ahormonal’ activity (as seen for example early post menopause, after castration, during anestrogenic amenorrhea and immediately before, during and after menstruation).
Fig. 10 treatment,
10th day of oral treatment with ethinylestradiol (0.075 mg) in patient 5: only the left uterus reacts to estrogen the right uterus continues to contract in its own ‘ahormonal’ way.
20th day of oral treatment with ethinylestradiol Fig. 11 uterus does not react to estrogen treatment.
(0.075 mg daily) in patient
5: even after 20 days the right
P. R. Hein et al., Motility
Fig. 12
of malformed
59
uterus
Vasoptessin@ administered intramuscularly in patient 5: only the left uterus reacts.
both uteri in patient 5 has, as far as we know, never been reported before. In this patient the myometrium of the right uterus (posing as being the better developed one) did not react to estrogens, progesterone and Vasopressin@, while the lesser developed myometrium of the left uterus did. In contrast to this myometrial difference, the endometrium of both uteri behaved in a quite comparable way. From the findings in patient 5 it can be stated that a dissociation of myometrial and endometrial reactivity in the uteri of a double uterus is possible. Presumably in this case the receptors for estrogens and progesterone are present in the myometrium of the left side only, whereas the receptors for both hormones seem to be present in the endometrium of both sides. A dissimilarity in endometrial morphology in one double uterus out of 17 was described by Kreibich (1949) but no investigation was done concerning uterine motility. In our study the morphology of the endometrium was not systematically investigated. In our patients with both uteri behaving in a similar way, this similarity pertained only to the motility pattern and not to absolute values of basal pressure, amplitude, etc. Moreover, there seldom was a synchronous motility on both sides. It is, of course, unknown as yet how far our findings can be extended to all uterine anomalies. Notwithstanding this uncertainty, the results of our investigations must have some bearings on the desirability of operative correctional procedures. Perhaps
it would be indicated to add pressure recordings to the preoperative diagnostic procedures.
Acknowledgement
We wish to thank Ms. J. M. v. d. Hoek, R. B. A. for her assistance in recording uterine activity.
References
Bengtsson,L. P. (1968): The sponge-tipped catheter. A modification of the open end catheter for recording of myometrial activity in vivo. J. Reprod. Fe&., 16, 115-l 18. Bengtsson, L. P. (1970): Myometrial activity in a double, non-pregnant human uterus. Acta obstet. gynec. stand., 49, suppl. 6, 13-19. Bengtsson, L. P. and Theobald, G. W. (1966): The effects of oestrogen and gestagen on the non-pregnant human uterus. J. Obstet. Gynaec. &it. Cwlth, 73, 273. De Haan, J., Janssens, J., Braaksma, J. T. and Van der
Weide, H. (1971): Der Einfluss von Uteruskontraktionen auf den fetalen Herzrhythmus (The influence of uterine contractility upon the fetal heart rate). In: Fortschritte der perinatalen Medizin, p. 159. Editors: E. Saling and K. A. Hiiter. Georg Thieme Verlag, Stuttgart. De Haan, J. (1971): De Snelle Variaties in het Foetaie Hartfiequentiepatroon (The short term irregularity in the foetal heart rate pattern). Thesis, Vrije Universiteit, Amsterdam. Eskes, T. K. A. B., Hein, P. R., Kars-Villanueva, E. B., Braaksma, J. T., Janssens, J. and Kollerie. A. (1969): The influence of steroids on the motility of the nonpregnant human uterus in vivo. Arch. int. Pharmacodyn., 182, 409.
Hein, P. R. (1972): De Contractiliteit
van de Uterus #dens
60 de Menstruele Cyclus en na Toediening van Geslachtshormonen (The contractility of the uterus during the menstrual cycle and after administration of sex hormones). Thesis, Vrije Universiteit, Amslerdam. Hrndricks, C. H. (1964): A new technique for the study of motility in the non-pregnant human uterus. J. Obstet. Gynaec. Brit. Cwlth, 71, 712-715.
P. R. Hein et al., Motility of malformed uterus Kreibich, H. (1949): Uber Endometrium-Untersuchungen beim Uterus duplex und Beitrslge zu dessen Pathologie (Studies of endometrium in cases of a double uterus and contributions to its pathology). Zbl.f. Gytrtik., 73, 546-553. Moawad, A. H. and Bengtsson, L. P. (1968): In vivo studies of the motility pattern of the non-pregnant human uterus. Amer. J. Obstet. Gynec., 101, 473-478.