Hindawi Publishing Corporation

Case Reports in Obstetrics and Gynecology

Volume 2014, Article ID 108973, 4 pages
http://dx.doi.org/10.1155/2014/108973

Case Report
Intrapartum Diagnosis and Treatment of
Longitudinal Vaginal Septum

Antonio Henriques de Frana Neto,1,2 Bianca Virgolino Nbrega,3 Jess Clementino Filho,3
Tiago Cavalcanti do ,4 and Melania Maria Ramos de Amorim3
1
The Medical Residency Program in Obstetrics and Gynecology at the Federal University of Campina Grande (UFCG),
Rua Antonio de Souza Lopes 120, Catole, Apartamento 1204, 58410-180 Campina Grande, PB, Brazil
2
Gynecology, School of Medical Sciences, Rua Antonio de Souza Lopes 120, Catole, Apartamento 1204,
58410-180 Campina Grande, PB, Brazil
3
Obstetrics and Gynecology, UFCG, 58410-180 Campina Grande, PB, Brazil
4
Programa de Valorizaca o do Profissional da Atenca o Basica (PROVAB), 58410-180 Campina Grande, PB, Brazil

Correspondence should be addressed to Antonio Henriques de Franca Neto; antoniomed1@gmail.com

Received 19 March 2014; Accepted 27 April 2014; Published 7 May 2014

Academic Editor: Svein Rasmussen

Copyright 2014 Antonio Henriques de Franca Neto et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Longitudinal vaginal septum is a rare Mullerian malformation that may be associated with dyspareunia, dysmenorrhea, primary
amenorrhea, and infertility. In this report, the authors present a case of longitudinal vaginal septum in a 15-year-old patient
with a full-term pregnancy whose diagnosis was only made during labor following bidigital vaginal and speculum examination.
Septoplasty was performed during the second stage of labor. Both mother and child progressed satisfactorily and were discharged
from hospital in good health. Six months later, ultrasonography, hysterosalpingography, and hysteroscopy were carried out and no
other associated abnormality was found.

1. Introduction solid vaginal plate. The lumen of the lower vagina is then
formed via apoptosis of the central cells in this vaginal plate,
The complex development of the genital tract during embryo- extending in a cephalic direction. Complete canalization
genesis involves a series of events that include cell differenti- occurs by 20 weeks of intrauterine life [1]. On the other hand,
ation, migration, fusion, and canalization [1]. Failure at any the Mullerian ducts fuse together between the 11th and 13th
stage in this process may result in a congenital abnormality. weeks of intrauterine life, with this fusion and subsequent
The American Society for Reproductive Medicine clas- absorption occurring in a caudal-cranial direction [36].
sifies abnormalities of the female genital tract into six In recent decades, advances in imaging techniques have
separate categories based on their clinical presentation and facilitated diagnosis of Mullerian duct anomalies, the inci-
on fetal prognosis after treatment [2]. This classification dence of which is estimated at 0.001 to 10% [3]. One of these
does not include nonuterine abnormalities but permits addi- abnormalities is transverse vaginal septum, a vertical fusion
tional descriptions for associated vaginal, tubal, and urinary disorder between the Mullerian ducts and the urogenital
anomalies. sinus, which has been linked to autosomal recessive trans-
The proximal two-thirds of the vagina are formed from mission [4]. It is unusual for pregnancy to occur when these
the fusion of the Mullerian ducts, while the distal third orig- malformations are present, since many of them may cause
inates from the urogenital sinus [1]. The sinovaginal bulbs, infertility.
two solid evaginations originating in the urogenital sinus Longitudinal vaginal septum is typically associated with
at the distal extremity of the Mullerian tubercle, proliferate uterine anomalies such as a septate uterus or uterus didelphys
at the caudal end of the uterovaginal canal to become a [7]. The septum that divides the vagina may be partial
2 Case Reports in Obstetrics and Gynecology

or complete. 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.
Treatment involves complete removal of the septum.
Excision is the traditional procedure, with care being taken
to avoid causing bladder or rectal lesions. The tissue should
be completely excised, since remaining fragments of the
septum may cause dyspareunia. The septal tissue is resected
and the normal vaginal mucosa on each vaginal wall is
sutured together along the length of the defect made by the Figure 1: Longitudinal vaginal septum detected during delivery.
resection. Surgery is not necessary in asymptomatic women
with a longitudinal vaginal septum; however, carrying out
the procedure will certainly facilitate a subsequent vaginal
delivery. To the best of our knowledge, no previous reports
have been published on the resection of longitudinal vaginal
septum during labor.

2. Case Presentation
NFB, a 15-year-old girl, gravida 1, para 0, was admitted
to the teaching hospital of the Fundaca o Assistencial da
Paraba (FAP) on September 13, 2011, at 37 weeks of gestation
according to the date of her last menstruation, which was
corroborated by a first-trimester ultrasonography scan. She Figure 2: Anesthetic injection into the septum.
reported having had intermittent lower abdominal pain for
the preceding two hours.
Physical examination revealed the patient to be in good
general health, with a normal complexion, well-hydrated,
afebrile, acyanotic, anicteric, with no edema, and alert and
oriented to place and time. Her blood pressure was 110
70 mmHg, heart rate 84 bpm, respiratory rate 18 breaths
per minute, and cardiopulmonary auscultation normal. The
patient had a gravid abdomen; fundal height 36 cm; fetus in
cephalic presentation. Fetal heart rate (FHR) was 140 bpm,
monitored in the lower left quadrant, with three contractions
of 30 seconds each in ten minutes. Digital vaginal examina-
Figure 3: Intrapartum resection of the septum performed using
tion revealed a cervix dilated to 4 cm, cephalic presentation,
scissors.
Hodge 1 (i.e., at the level of the pelvic inlet), left occiput
anterior (LOA) position, and membranes still intact. An
elastic structure around 3 cm behind the vaginal introitus
was palpable. It was painless to the touch and extended oxytocin was given to prevent postpartum hemorrhage. After
from the anterior wall to the posterior wall of the vagina. A delivery of the placenta, the other extremity of the septum
more detailed examination was made by inserting a Collins was clamped and subsequently resected, completely restoring
speculum, revealing a longitudinal vaginal septum in the the anatomy of the genital tract. No lacerations were detected
distal third of the vagina (Figure 1). (Figures 2, 3, and 4). Next, both resected bases were sutured
Expectant management was preferred in view of the with simple continuous sutures using plain catgut 2-0, and
patients good obstetric conditions. Labor progressed satisfac- the patient was released to return to the ward.
torily and the second stage occurred around eight hours after The postpartum was uncomplicated and the patient was
admission. discharged on September 15, 2011. She was followed up at
During the second stage of labor, with the pregnant the gynecology clinic of the Federal University of Campina
woman in a semiseated position on the delivery bed and Grande and six months after delivery she was submitted
the fetal head already in the vaginal canal, the septum was to three-dimensional ultrasound, hysterosalpingography, and
clamped and resected, permitting the birth of a male infant hysteroscopy for reevaluation. No associated abnormalities
weighing 3600 grams and measuring 51 cm. Apgar scores were found. She was initially prescribed progestin-only oral
were 9 at the first minute and 10 at the fifth minute. No defor- contraceptives; however, after she had stopped breastfeed-
mities or malformations were apparent. Childbirth occurred ing her prescription was changed to a combined estro-
without complication. Episiotomy was not required. Prophy- gen/progesterone pill. She has not expressed any desire to
lactic treatment with an intramuscular injection of 10 IU of become pregnant again up to the present date. A further
Case Reports in Obstetrics and Gynecology 3

have been scheduled prior to delivery. On the other hand,

in our opinion, the fact that diagnosis was not made during
prenatal care ultimately avoided a possible (and unnecessary)
Cesarean section.
The principal tools for diagnosing longitudinal vaginal
septum are ultrasonography, magnetic resonance imaging
(MRI), and hysterosalpingography. These tests are recom-
mended because they enable the thickness and site of the
septum to be established in addition to alerting to the
coexistence of other associated congenital defects [2, 3, 6]. In
rare cases, ultrasonography can allow diagnosis to be made
Figure 4: Delivery following resection of the septum. Note the in utero during the third trimester of pregnancy, with the
anterior extremity of the septum is still clamped (sutures performed discovery of a cystic tumor of the pelvis in a female fetus [3].
following delivery). In the present case, another relevant aspect is the fact that
diagnosis was made exclusively on the basis of the physical
examination, without the use of any of the above-mentioned
supplementary tests, which were only requested following
gynecological examination was normal except for the scars delivery. In thesis, this may be justified by the fact that the
on the anterior and posterior vaginal walls resulting from the septum in question was situated low down in the vagina,
septum resection. allowing visualization in great detail and enabling the precise
thickness to be determined without further investigation. In
3. Discussion addition, it was possible to visualize the rest of the vaginal
canal and cervix, thus eliminating the possibility of one of
Although a rare condition, longitudinal vaginal septum the principal differential diagnoses of this condition, which
should always be taken into consideration in differential is congenital absence of the cervix.
diagnoses when a varying combination of dyspareunia, cyclic Longitudinal vaginal septum may lead to fertility prob-
pelvic pain, hematocolpos, hematometra, and mucocolpos is lems [6]. In the case described here, this dysfunction was
present, either associated or not with primary amenorrhea, notably absent, since the patient, still in adolescence, was
which may be present when there is complete obstruction already pregnant and had conceived without the benefit of
of the vaginal canal. Diagnosis and treatment should be any assisted reproductive techniques.
timely in order to avoid possible complications such as pelvic Publications in both national and international literature
adhesions and damage to the fallopian tubes, principally in recommend surgery in all cases of LVS and also suggest
cases of complete obstruction, as well as the discomfort and that resection must be performed early in cases of complete
psychological repercussions of painful symptoms such as septum. Excision is the procedure of choice for the treatment
dyspareunia [2, 3]. The principal differential diagnoses are of longitudinal vaginal septum; however, care should be
vaginal agenesia and imperforate hymen [3, 4]; possibilities taken not to provoke any accidental lesion to the rectum
that were eliminated in the present case due to the obvious or bladder. Although it is not obligatory in asymptomatic
fact that they would have prevented fertilization and preg- women with LVS, surgery should be performed whenever
nancy. the woman wishes to become pregnant in order to facilitate
An important aspect of the present case lies in the fact a subsequent normal delivery. In addition to the traditional
that the vaginal septum was located posteriorly, around technique described above, there are reports in the literature
three centimeters from the vaginal introitus, which makes of alternative procedures. Good results have been reported
it unusual, with only 1520% of all cases occurring at this with hysteroscopic resection, a technique that is used princi-
site compared to approximately 46% located anteriorly in the pally in young patients to permit preservation of the hymen
vagina [2, 3]. It should also be emphasized that there were [8].
no symptoms prior to diagnosis, with the septum only being In addition to the fact that diagnosis was only made
identified during labor, an even more unusual situation. intrapartum, labor was allowed to progress normally in the
The relative delay in diagnosing this anatomical abnor- present case, with the septum being resected during the
mality may be justified by the fact that in this case the vaginal second stage of labor. In fact, resection of a longitudinal
septum was partial. This fact helped attenuate symptoms of vaginal septum may be performed during vaginal delivery,
dyspareunia and dysmenorrhea in addition to permitting thus avoiding a Cesarean section, which would certainly
menstrual flow, whereas the presence of primary amenorrhea increase the likelihood of morbidity in the patient. Ideally,
could have caused severe problems in puberty [3, 6]. resection should be performed prior to the patient becoming
The lack of symptoms may have contributed to the fact pregnant or early in pregnancy; however, since the septum
that the condition was not diagnosed during the patients was relatively thin in the present case, resection was simple
prenatal care. This raises the question, however, of why she and more complex techniques were not required. Consid-
had never been submitted to a vaginal examination during ering the greater maternal and perinatal morbidity and
her prenatal care. If a speculum had ever been inserted, the mortality associated with Cesarean sections [9, 10], waiting
septum would certainly have been seen and its excision would for labor to begin is justified, since the septum can be resected
4 Case Reports in Obstetrics and Gynecology

during the course of labor or during delivery, depending on on maternal and perinatal health in Latin America, The Lancet,
the characteristics of each individual case. vol. 367, no. 9525, pp. 18191829, 2006.
To the best of our knowledge, the case described here [10] J. Villar, G. Carroli, N. Zavaleta et al., Maternal and neonatal
is the only report of a partial longitudinal vaginal septum individual risks and benefits associated with caesarean delivery:
managed during delivery, making it unique and justifying its multicentre prospective study, British Medical Journal, vol. 335,
publication. Furthermore, the efficacy of the form of man- article 1025, 2007.
agement adopted here is endorsed by the patients excellent
postoperative conditions and the normal delivery of a healthy
infant.

Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.

Acknowledgment
This study was conducted at the Department of Obstet-
rics and Gynecology, Medical Residency Program, Federal
University of Campina Grande (UFCG), Campina Grande,
Paraiba, Brazil.

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