The lower two-thirds of the vagina develops embryologically from the urogenital sinus, while the upper vagina, cervix and Fallopian tubes develop from the Müllerian duct system(1-3). Failure of vertical fusion or canalization of the two systems may result in cervical stenosis or atresia, vaginal atresia or transverse vaginal septa. There are two kinds of vaginal septa: transverse and longitudinal. A transverse vaginal septum is thought to be the result of abnormal canalization of the embryonic vagina, while a longitudinal septum is a faulty fusion of the distal ends of the Müllerian ducts(4-6). This anomaly has been linked to autosomal recessive transmission(7,8). The incidence of congenital Müllerian anomalies is estimated between 0.001% and 10% of the general population(9); however, not all cases are reported and diagnosed but, generally, only those that are symptomatic or lead to pregnancy loss(10,11).
For the paraclinical diagnosis of the vaginal septum, especially longitudinal and incomplete, imaging investigations such as ultrasonography or magnetic resonance imaging (MRI), and hysterosalpingography can be used. These investigations can measure the thickness and location of the septum, as well as the coexistence of associated congenital defects(12-14). The sensitivity of these techniques has increased so much, that today this diagnosis can be made in utero, in the third trimester of pregnancy; sometimes, this can be confused with a cystic tumor of the pelvis in a female fetus(12).
In terms of treatment, the resection of the vaginal septum can be performed at the same time with the vaginal birth, thus avoiding caesarean section, which increases the morbidity of the patients. Ideally, septum resection should be performed before the woman becomes pregnant, or at the beginning of pregnancy. Taking into account the risks of surgical intervention, both for the mother and the fetus, waiting for labor is justified, considering that the septum can be resected during labor or expulsion, depending on the characteristics of each case(15,16).
In this article, we report a case of an incomplete high longitudinal vaginal septum diagnosed for the first time during labor.
A 28-year-old primigravida presented to the Labor and Delivery Department at 38 weeks of gestation, with labor pains and spontaneous membrane rupture about one hour and a half before. She was married for two years and had a history of dyspareunia and septate uterus, but she conceived without difficulty. No history of vaginal septum. Upon arrival, on local examination, she had a 3-4 cm dilation, with a mobilized fetal cranium, ruptured membranes, and a horizontal vaginal thick wall under the cervix reaching the vagina posteriorly that was not diagnosed before. She was having uterine contractions, for about 5 minutes, lasting for 20-30 seconds. Fetal heart sounds were 140 beats/min and regular, her blood pressure was normal, and the ultrasound estimated a fetus in cephalic presentation, with a fetal weight of 2500 g.
She was admitted to the labor room, and two hours and a half later, after precipitous labor, she gave birth in cephalic presentation to a 2530 g healthy baby boy, with a thick cervical nuchal cord, and with an Apgar score of 8/1 minute, 9/5 minutes, 9/10 minutes. Episiotomy was also required for fetal bradycardia. After delivering the baby and the placenta, the vaginal exploration revealed a small cervical tear, the two ends of the septum that were not bleeding, and the episiotomy, with no other vaginal laceration. The cervix was sutured, the cut ends were clamped, cut and ligated once again at the base, and the episiotomy was also sutured with a continuous surjet suture.
The patient was discharged after 48 hours of birth, with well healed vaginal cavity and normal blood count.
Usually, a longitudinal vaginal septum is associated with uterine malformations(17). Because it is asymptomatic, this condition is usually discovered accidentally during a routine examination or during labor. It can lead to dystocia in delivery, dyspareunia, or to frequent vaginal infections. Even endometriosis is more frequently found in these patients (38%)(18).
During labor, a transverse vaginal septum may result in significant vaginal lacerations during vaginal delivery or obstructed labor resulting in a ruptured uterus. In literature, there are various opinions regarding the recommended modality of birth for these cases. Fenton and Singh have advocated for caesarean section(5).
If a vaginal delivery is chosen, there are two suggested options: (1) expectant management with a plan of either allowing spontaneous dissection of the septum as a result of dilatation of cervix and descent of the fetal head, or (2) incision late in labor, if needed, after the septum has been thinned and pressure from the head can provide hemostasis; or (3) incision of the septum before labor(19). In 2003, Blanton and Rouse have reported two patients with transverse vaginal septa for whom vaginal delivery was decided. Their septa were incised in active labor, resulting in vaginal delivery with no related complications(20).
Distinct types of longitudinal vaginal septa were identified. Considering their clinical appearance, a classification based on four criteria was made: (i) completeness of vaginal division, in partial and complete type; (ii) symmetry – symmetric and asymmetric position (with dominant left and right side); (iii) association with the cervix – merged and isolated forms; and (iv) concomitant vaginal openings – normal, and narrow openings – vaginal stenosis and hymen persistent(21). In our case, there was a partial division of the vagina, an asymmetric position on the right side, without vaginal stenosis.
The final decision regarding the way of delivery (caesarean section versus vaginal delivery) should be individualized.
In some cases, vaginal delivery is indicated, although it requires intensive maternal and fetal surveillance. This is also a better choice, considering that we can remove the septum in the same procedure.
The classical surgical approach is the excision of the longitudinal septum with scissors after the application of two Kelly or Kocher forceps to prevent blood loss, after which the edges are sutured for hemostasis with 3-0 absorbable sutures.
It is also important to mention that the resection of the septum can also be done in the second trimester, protecting the bladder, urethra and the rectum(22). The longitudinal vaginal septum can be resected using bipolar laparoscopic cutting forceps(23), LigaSure®(24), or a surgical stapler(25). It is indicated to remove the septum and restore the vaginal anatomy.
In our opinion, the fact that the diagnosis was not made during prenatal care ultimately avoided a possible (and unnecessary) caesarean section.
In addition to the fact that the diagnosis was only made intrapartum, labor was allowed to progress normally in the present case, with the septum being resected just before delivery.
Conflict of interests: The authors declare no conflict of interests.