uterine malformations can cause amenorrhea , infertility , recurrent pregnancy loss and pain and can also be normally functioning , depending on the nature of the defect [ 13,5 ] .
the prevalence of uterine malformation is estimated to be 6.7% in the general population , slightly higher ( 7.3% ) in the infertile population , and significantly higher in a population of women with a history of recurrent miscarriages ( 16% ) . until the sixth week of life , the male and female genital systems are identical .
there are two pairs of symmetrical genital ducts , the mesonephric ( wolffian ) ducts and the paramesonephric ( mullerian ) ducts . in the female embryo ,
the mullerian ducts grow caudally and become enclosed in the peritoneal folds , which later give rise to the broad ligaments of the uterus to which the ovaries , fallopian tubes and uterus are attached .
the mullerian ducts approach each other and begin to fuse . at 9 weeks gestation ,
mullerian tract anomalies result from incomplete bilateral duct elongation , fusion , canalization , or septal resorption of the mullerian ducts .
an accessory cavitated uterine mass ( acum ) is associated with an otherwise normal uterus .
acum can be difficult to differentiate from true cavitated adenomyomas and cavitated rudimentary uterine horns .
an accessory uterine mass can be caused by duplication and persistence of the ductal mllerian tissue in a critical area at the attachment level of the round ligament , possibly related to gubernaculum dysfunction .
for the differential diagnosis of acum and cavitated non - communicating rudimentary uterine horns , hysterosalpingography showing a normal eutopic uterine cavity is helpful .
an old classification had been put by jone h.w jr . in 1953 for the congenital anomalies of the female urogenital system : 1.uterus : ( a ) single uterus .
a recent eshre / esge classification of female genital tract anomalies ( 1)uterine anomalies :- u0 .
( b ) without rudimentary cavity ( bi- or unilateral uterine remnants / aplasia ) .
a 20-year - old female married for 2 years had undergone a full - term pregnancy with normal vaginal delivery , one year prior to this case report .
the patient presented with 3 missed periods with lower abdominal pain , and a pelvic ultrasound examination revealed an intrauterine pregnancy of twins that had died at 13 weeks of gestation ( miscarriage ) ( fig .
1 ) . induction of abortion by oxytocin drip had been attempted twice but failed .
the gynecologist proceeded to perform cervical dilatation and curettage , but the uterus was found to be empty .
the patient was seen by another gynecologist who repeated the curettage and also did not find the dead twins , and an ultrasound after the procedure still showed the dead twin fetuses .
the patient was then seen at our clinic , and we submitted the patient to another curettage .
perforation of the uterus was expected ; thus , we opened the abdomen and found a slightly enlarged normally shaped and positioned uterus with 2 fallopian tubes and 2 ovaries .
there was a uterine perforation at the fundus ; thus , the omentum was pulled in through the perforation , drawn out of the uterus , transfixed , ligated by suture and trimmed .
the perforation of the fundus was repaired with 3 stitches using one zero vicryl sutures , no other visceral injury was found . on exploration , we found a large pear - shaped mass emerging from the right broad ligament with a thick pedicle that ended near the uterine cervix .
because we did not obtain a detailed gynecological history of the patient , we assumed the mass was a broad ligament cyst .
the mass was easily excised by clamping , transfixing , ligating and cutting the pedicle .
the mass is pear - shaped and 10    13  cm in size .
the wide upper portion of the mass has 2 small appendages at either corner that are each 1  cm long ( fig .
the narrow lower end of the mass was firm in consistency ( arrow in fig .
2 ) . we opened the mass and observed amniotic fluid and two dead fetuses , each 6  cm in length ( fig .
the mass wall was thin in the upper segment and thick in the lower segment .
the portion of the mass representing the cervix was solid and did not have an internal opening or cervical canal , as confirmed using a fistula probe .
tissue samples taken from the upper and lower portions of the specimen for histopathological analysis both exhibited the smooth muscle fiber arrangement of uterine tissue .
one year later , a hysterosalpingogram showed a normal uterine cavity and two patent fallopian tubes ( fig .
a few months later , she became pregnant , and she had a full term pregnancy with normal vaginal delivery .
she had four subsequent pregnancies over 9 years that all reached full term and all resulted in normal vaginal deliveries .
there was a lack of a full medical history and poor communication between the gynecologist and the ultrasonographist .
thus , despite the proficiency of the ultrasonographist , during two examinations , he did not thoroughly examine all pelvic organs once he detected a twin miscarriage in what appeared to be a uterine cavity .
if he had examined all pelvic organs , he should have detected the empty normal uterus just beside the gravid abnormal uterus as it is clear in the post - operative hystersalpingography ( fig .
hysteroscopy could have been useful in this case , but unfortunately , the only available hysteroscope in the hospital was broken - down .
most of the congenital anomalies of the uterus are due to a fault in one or more step in the fusion process of the mullerian ducts . in this case , however , the accessory uterus most probably developed as a growth from the right mullerian duct generating an incompletely developed separate accessory uterus ( non - communicating , cavitated accessory uterus ) acum . most probably , the ovum entered the accessory uterus through the small appendages on the sides of the dome , which represent rudimentary fallopian tubes .
the ovum likely became fertilized by sperms passing through the normal cervical canal of the normal uterus , uterine cavity , fallopian tube , and the peritoneal cavity , or the sperms may have travelled through the lymphatic vessels of the accessory uterus to fertilize the ovum inside it .
1.a deficient case history , lack of communication between the clinicians and the ultrasonographist and repeated shifting of the patient from one doctor to another , all led to the misdiagnosis and mismanagement of this patient.2.conception can occur in acum , however , it is very rare and may be difficult to diagnose .
a deficient case history , lack of communication between the clinicians and the ultrasonographist and repeated shifting of the patient from one doctor to another , all led to the misdiagnosis and mismanagement of this patient .
conception can occur in acum , however , it is very rare and may be difficult to diagnose .
harith m. alkhateeb : surgery for the patient , writing of original text , communication with the editorial team .
enas m. yaseen : the last gynecologist dealing with the patient , periodical clinical examinations and follow up of the patient .
a copy of the written consents are available for review by the editor - in - chief of this journal .
 highlightsobtaining a detailed medical history is important , and we should not depend on examination tools when dealing with patients.unexplained findings should raise suspicions regarding other possible diagnoses , and the same non - conclusive procedures should not be repeated.following this advice can prevent unnecessary operative procedures and the complication of perforation of the uterus . 
Introduction
The case
Surgical pathology
Discussion
Conclusions
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