Hidden Duplication: How Uterus Didelphys Surprised Surgeons in Two Ethiopian Cases at Opposite Ends of Life

Two women arrived at the same Ethiopian hospital facing vastly different health crises, yet both would leave a lasting impression for an unexpected reason — each was born with two separate uteruses, a rare congenital condition known as uterus didelphys.

The first was a 26-year-old woman in her first pregnancy, experiencing catastrophic abdominal bleeding at just 17 weeks. The second was a 50-year-old postmenopausal woman who had endured five years of a visible vaginal mass and escalating urinary issues.

In both instances, surgeons only confirmed the diagnosis when they opened the patients up. Their cases were documented in a series by clinicians at Aksum University College of Health Science, highlighting how uterus didelphys can remain undetected until it manifests in extreme ways.

The Rare Condition Behind the Cases

Uterus didelphys develops when the paired Mullerian ducts fail to fuse during fetal growth, resulting instead of one unified uterus, two distinct horns, two cervices, and sometimes even a partially divided vagina.

Classified as a Class III Mullerian anomaly, it’s considered rare. Estimates of prevalence vary widely depending on the population studied and the diagnostic tools used. A review published in BMJ Case Reports placed overall rates somewhere between 0.3% and 5%, though the actual number remains uncertain due to inconsistent reporting standards.

Most women with this anomaly never experience symptoms and live unaware of their condition. However, this very lack of awareness is what makes uterus didelphys so dangerous — it often reveals itself suddenly, during emergencies.

When complications do arise, they’re typically tied to fertility and pregnancy. Studies link uterus didelphys to increased risks of miscarriage, preterm birth, fetal malpresentation, and cesarean delivery — largely because each uterine cavity is smaller than average. Other symptoms like painful intercourse or heavy menstrual bleeding may occur if a vaginal septum is present.

Still, many women carry pregnancies successfully and remain undiagnosed throughout their lives.

A Pregnancy Complicated by Catastrophic Bleeding

The young patient initially sought help for severe internal bleeding. Upon emergency laparotomy, surgeons discovered that one horn of her duplicated uterus had ruptured, releasing the fetus and placenta into her abdominal cavity.

Photographs from the surgery show the tiny 17-week-old fetus next to the resected portion of the uterus, still attached to the umbilical cord and placental tissue.

Surgeons performed a resection of the affected horn above the cervix. Only then was the full extent of her anatomical difference revealed — confirming that neither she nor her medical team had any prior knowledge of the anomaly during her pregnancy.

Uterine rupture is usually seen late in pregnancy or during labor, frequently associated with previous cesarean scars. Second-trimester ruptures in otherwise healthy uteruses are uncommon — and exceptionally rare in cases involving Mullerian anomalies.

This case underscores the danger of assuming familiar patterns. Abdominal pain and bleeding without a clear cause shouldn’t be dismissed, especially in early pregnancy where atypical anatomies are seldom considered.

Five Years of Symptoms, One Surprising Diagnosis

The older patient took a quieter path toward discovery. Over five years, she noticed a growing lump protruding from her vagina along with worsening urinary difficulties. Before surgery, clinicians diagnosed her with advanced-stage uterovaginal prolapse.

She underwent a transvaginal hysterectomy, during which the duplicated uterus was unexpectedly identified.

Her case illustrates how deeply embedded these anomalies can become within routine diagnoses. Even experienced providers can mistake structural duplication for common conditions like prolapse, particularly when imaging isn’t focused directly on uterine anatomy.

Prolapse in a didelphic uterus is itself unusual, as noted by the authors of the Ethiopian report.

Similar discoveries have occurred elsewhere. In 2023, another Ethiopian hospital reported a woman whose two uteri hosted contrasting pregnancies — one normal gestation alongside a prolapsed uterus. Earlier this year, a case published in Cureus detailed how the anomaly was uncovered during an emergency C-section.

Surgical Implications of Unexpected Anatomy

Finding unanticipated anatomy dramatically shifts surgical planning. For example, a planned hysterectomy might encounter two cervices, altered ligament support, and unique vascular arrangements.

One case study of vaginal hysterectomy in a didelphic uterus emphasized special modifications required for safe access, including staged dissection of the uterosacral ligaments and inversion techniques for vaginal extraction.

These two patients highlight limitations in preoperative evaluation. Neither case involved prior imaging suggesting duplication. The diagnosis emerged solely through direct visualization during surgery.

While the sample size is small, the message resonates: uterus didelphys doesn’t always announce itself clearly. Awareness matters more than routine screening.

Clinicians should maintain heightened vigilance when evaluating atypical presentations. Recurrent miscarriages, persistent pelvic pain, irregular bleeding patterns, or recurrent infections could signal underlying anatomical complexity requiring targeted imaging.

For most women, however, no proactive testing is recommended. Instead, education and awareness should guide conversations around unexplained reproductive symptoms.

Key Questions Answered

What is uterus didelphys?

A congenital disorder where the Mullerian ducts don’t join properly during development, resulting in two separate uterine cavities, often accompanied by double cervices and occasionally a partially divided vagina.

How prevalent is it?

Studies estimate rates between 0.3% and 5%, though exact figures depend heavily on diagnostic methodology and classification criteria.

Why didn’t either woman know earlier?

Because most individuals with uterus didelphys show no signs. Without specific imaging targeting uterine structure, such anatomical differences can easily go unnoticed over decades.

What happened to the pregnant patient?

One horn of her duplicated uterus ruptured at 17 weeks, leading to massive internal hemorrhage. Surgeons removed the damaged portion of the uterus above the cervix.

Is second-trimester uterine rupture typical?

No — it is rare overall and especially unusual before 20 weeks, particularly in the absence of prior surgeries or scarring.

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