Two women arrived at the same Ethiopian hospital with problems that could hardly have been more different. One was 26, pregnant for the first time, and bleeding catastrophically into her abdomen at 17 weeks. The other was 50, postmenopausal, and had spent five years living with a mass protruding from her vagina and worsening urinary symptoms.
In both cases, surgeons discovered on the operating table that the patient had been born with two uteruses.
The case series by clinicians in Ethiopia, based at Aksum University College of Health Science, documents uterus didelphys presenting at two extremes of the same anomaly. The authors describe a spectrum running from life-threatening rupture to chronic prolapse, and their central argument is about suspicion rather than surgery.
The Anomaly Behind Both Cases
Uterus didelphys results from complete failure of the paired Mullerian ducts to fuse during fetal development. Instead of merging into a single uterine cavity, the two ducts remain separate, producing duplicated uterine horns, two cervices, and sometimes a divided upper vagina.
It is a class III Mullerian anomaly, and it is rare. Prevalence estimates vary widely by population and imaging method. A BMJ Case Reports analysis put the population figure somewhere between 0.3% and 5%, while noting that the true rate is hard to pin down because studies use different diagnostic tools and classification systems.
Most women with the anomaly have no symptoms and never learn about it. That is precisely why it surfaces in emergencies.
When it does cause trouble, the trouble is usually reproductive. Uterus didelphys has been linked to miscarriage, preterm birth, fetal malpresentation, and higher cesarean rates, largely because each cavity is smaller than a normally fused uterus. Some women have painful intercourse or unusually painful periods when a vaginal septum is present. Many have none of that, carry pregnancies successfully, and go a lifetime without a diagnosis.
A First Pregnancy That Ended in Massive Bleeding at 17 Weeks
The 26-year-old presented with unexplained massive bleeding into her abdominal cavity. At emergency laparotomy, surgeons found that one horn of her didelphic uterus had ruptured, expelling the fetus and the placenta into the peritoneal cavity. The published operative photograph shows the roughly 17-week fetus alongside the resected left horn, umbilical cord and placenta still attached.
Surgeons removed the ruptured horn above the cervix. The anomaly itself was established only at that point, meaning nobody knew it was there while the pregnancy was being carried.
Uterine rupture is overwhelmingly a third-trimester and labor event, usually associated with a previous cesarean scar. Second-trimester rupture in an unscarred uterus is uncommon, and it is particularly rare in the setting of a Mullerian anomaly. The authors describe obstetric rupture this early in a didelphic uterus as exceedingly rare in the published literature.
The presentation is what makes it dangerous. Massive bleeding into the abdomen at 17 weeks does not announce itself as a uterine rupture, because the classic triggers are absent. There is no scar, no labor, and no prior surgery to point at. In this patient, the source was only established once surgeons were inside and could see that one horn had given way.
Five Years of Symptoms and a Surprise on the Table
The 50-year-old's route to diagnosis was slower but no more informative. She reported a vaginal mass and urinary symptoms lasting five years, and was diagnosed before surgery with third-degree uterovaginal prolapse. That diagnosis was correct as far as it went.
She underwent transvaginal hysterectomy. During the procedure, the didelphic uterus was unexpectedly identified, and the specimen showed complete duplication of the uterine horns.
The relevant point is that a woman lived five decades, went through examinations for prolapse, and reached an operating table before anyone realized her reproductive anatomy was duplicated. Prolapse in a didelphic uterus is itself unusual, which the authors note explicitly.
Duplicated anatomy has surfaced this way before. A 2023 report from another Ethiopian hospital described a woman in whom one uterus carried a pregnancy while the other prolapsed, and a Cureus case published this July documented the anomaly being discovered during an emergency cesarean section.
Why Surgeons Care About Anatomy They Did Not Expect
Unexpected anatomy changes what an operation involves. A surgeon planning a hysterectomy encounters two cervices instead of one, potentially two sets of supporting ligaments, and a different arrangement of blood vessels. One published account of vaginal hysterectomy in a didelphic uterus was written up specifically to describe the surgical modifications for the vaginal approach, including staged division of the uterosacral ligaments and inversion of the uterus for delivery through the vaginal canal.
Two patients cannot tell anyone how often uterus didelphys presents this way. What the series does is document that it can, and that the anomaly is capable of staying hidden through decades of ordinary gynecological contact.
Both cases also share a diagnostic pattern worth naming. In the obstetric case, the anomaly was identified only after rupture. In the gynecological case, it was detected incidentally during prolapse surgery. Neither was caught by the imaging or examination that preceded the operation, which is a comment on how difficult uterine structure is to assess without studies aimed specifically at it.
The authors' conclusion is a clinical posture rather than a protocol. They urge maintaining a high index of suspicion in atypical presentations and being prepared for unexpected anatomy. For patients, nothing here calls for screening. Women with recurrent pregnancy loss, unusually painful periods, or symptoms that do not fit a straightforward explanation may benefit from discussing imaging with a clinician who can evaluate uterine structure.
Key Questions Answered
What is uterus didelphys?
It is a congenital condition in which the paired Mullerian ducts fail to fuse during fetal development, leaving two separate uterine cavities, usually with two cervices and sometimes a divided upper vagina.
How common is it?
Estimates range widely. One published analysis put the population prevalence between 0.3% and 5%, while noting that differing imaging methods and classification systems make the true figure difficult to determine.
Why did neither woman know she had it?
Most women with the anomaly have no symptoms. Without imaging that specifically evaluates uterine structure, a duplicated uterus can go unrecognized indefinitely.
What happened to the pregnant patient?
One horn of her didelphic uterus ruptured at 17 weeks, expelling the fetus and placenta into her abdomen and causing massive internal bleeding. Surgeons removed the ruptured horn above the cervix.
Is uterine rupture at 17 weeks normal?
No. Rupture usually occurs in the third trimester or during labor, most often at a previous cesarean scar. Second-trimester rupture is rare, and rarer still in a didelphic uterus.
