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What does DUH stand for?

DUH stands for double uterine horn model

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Sumathi Kotikela, Eric J. Bieber, Han Ying, Edie L. Derian Uterine anomalies are a relatively common congenital abnormality, with uterine septum being the most common.1 This is even truer in patients with recurrent pregnancy loss, in whom rates of uterine abnormalities may approach 15% to 27%. Historically, the uterine septum has been approached via laparotomy through either a Tompkins or Jones procedure. These successful, but highly morbid, procedures require laparotomy with significant hospital stays, subsequent cesarean delivery, and have carried a high risk of adhesion formation. More recently, this surgery has been supplanted by hysteroscopy or other minimally invasive methodologies. This section focuses on the embryologic development of the genital tract that may lead to müllerian abnormalities. It also discusses the workup of patients before treatment, reviews various modalities of treatment, including modern hysteroscopic approaches, and evaluates the appropriate candidates for surgical procedures, their outcomes, and postoperative recommendations. In addition, complications specific to these procedures are reviewed. EMBRYOLOGY It is unclear what the exact rate of müllerian abnormalities is in the general population, because no good cross-sectional studies of healthy patients have been performed. It is believed that the incidence is in the range of 1% to 6%, with the reported prevalence ranges from 0.16% to 10%.2 These disorders are associated with various gestational complications, including spontaneous abortion, intrauterine growth restriction, abnormal fetal lie, preterm labor, and preterm birth.3 Of note, women with recurrent pregnancy loss (RPL) appear to have a much higher incidence of anomalies relative to the general population. Three-dimensional ultrasonography and magnetic resonance imaging in the diagnosis of Müllerian duct anomalies is proving to be an effective modality for evaluating patients with and without RPL. Using this technique, Salim et al4 noted an anomaly rate of 1.7% in patients without RPL and a rate of 6.9% in those with 3 or more losses. Several hypotheses have been proposed to explain the wide range of abnormalities that may occur. Because such a wide range of abnormalities does exist, an accurate classification müllerian duct anomaly (MDAs) is all the more crucial to enabling the clinician to select the most appropriate treatment options, while avoiding unnecessary surgical intervention. To address this issue, in 1988 the American Fertility Society (AFS) (now the American Society for Reproductive Medicine) published a classification system to standardize the nomenclature among surgeons.5, 6 The developmental pathways involved in MDAs provide some useful etiological insight. The paired müllerian (paramesonephric) ducts are identifiable by week 6 of development, and they arise from coelomic epithelium along the lateral walls of the urogenital ridge. These solid tissue structures elongate caudally, cross the wolffian (mesonephric) ducts medially, and fuse in the midline to form the primitive uterovaginal canal. By week 10, the caudal end of the fused müllerian ducts connects with the urogenital sinus. Next, internal canalization of the müllerian ducts occurs, resulting in 2 channels divided by a septum. The septum is subsequently resorbed in the caudal to cephalad direction, with complete resorption by week 20. The fused caudal portion of the müllerian ducts becomes the uterus and upper vagina, and the unfused cephalad portion becomes the fallopian tubes.7 The most prominent theory suggests that the müllerian ducts initially fuse together as one structure and that this begins caudally at the müllerian tubercle and proceeds unidirectionally in a cephalad manner. The ultimate result is one cavity that is divided in the midline by a septum, which is then reabsorbed. Given the wide range of abnormalities, early in the century it was suggested that resorption of the septum may begin anywhere within the septum and proceed in either or both directions. Uterine anomalies were thus attributed to either failures of the müllerian elongation process, abnormal fusion, canalization, or resorption. More recently, several case reports of patients with a uterine septum and cervical duplication with a vaginal septum have been published–cases that would be inconsistent with the aforementioned hypothesis.8, 9 Muller et al10 proposed an alternate theory suggesting that, at the beginning of the 10th week, the lowermost portions of the müllerian ducts (between the isthmus cranially and the urogenital sinus caudally) fuse at the medial aspects. This creates a single cavity that comprises the upper vagina, cervix, and isthmus. Interestingly, they suggest that at the upper aspects there is not true fusion, but rather at the triangular junction between the 2 müllerian ducts, there is rapid division of cells that then connects the 2 ducts and converges with the lower septum. As with the original hypothesis, it is believed that resorption then follows. As prior case reports suggest, in this model, even if the initial fusion occurred incorrectly if the upper fusion did occur, a patient might have a vaginal septum and 2 cervices, but still have a unified cavity, separated by a septum. Septum can extend into the cervix or even into the entire length of the vagina. The thickness of the septum can also differ, presenting in either thin or thick variations. Patients with uterine anomalies may also have associated anomalies of the urogenital tract due to their close relationship during embryologic development. In the case of a unicornuate uterus, it has been estimated that up to 40% of patients may have renal anomalies as well. These are generally noted on the side of the remnant uterine horn.11 In an early report, Valle and Sciarra12 found 2 of 12 patients with uterine septum to have a urologic abnormality. More recently, Heinonen,13 in evaluating patients with a complete septum and vaginal septum, found that 11 of 55 patients (20%) had genitourinary abnormalities, 5 of whom had ipsilateral renal agenesis, while 6 had double ureters. MORPHOLOGY The actual morphology of the uterine septum has been suggested as the reason for poor reproductive function in patients with this abnormality. The most common hypothesis suggests a decrease in vascularity to the septum that may lower the likelihood of implantation and functional placenta ionization. Several groups have investigated these tenets to ascertain whether differences exist within the structure of the septum versus normal uterine...