Bicornuate Uterus with Recurrent Miscarriage Following a Successful Term Pregnancy: A Case Report

Bicornuate uterus is an uncommon congenital Müllerian duct anomaly resulting from incomplete fusion of the paramesonephric ducts and is associated with adverse reproductive outcomes, including recurrent pregnancy loss, preterm birth, and malpresentation. However, some affected women may achieve successful pregnancies before the anomaly becomes clinically apparent, creating diagnostic challenges that can delay recognition and treatment. We report the case of a 28-year-old multiparous woman from rural Southwestern Uganda who presented with recurrent pregnancy loss following a previously uncomplicated term vaginal delivery. Ultrasonographic evaluation revealed a bicornuate unicollis uterus after two consecutive first-trimester miscarriages. Diagnostic uncertainty persisted throughout, as definitive differentiation from a septate uterus was not possible given the imaging limitations in our setting. The diagnosis was complicated by limited access to advanced imaging modalities such as three-dimensional ultrasonography, hysteroscopy, and magnetic resonance imaging (MRI), highlighting challenges commonly encountered in low-resource environments. Given her adverse reproductive history, desire for future fertility, and the lack of access to laparoscopic surgical services within our setting, she underwent an open Strassman metroplasty, which was technically successful in restoring a unified uterine cavity. The postoperative course was uneventful, and extensive counseling was provided regarding fertility expectations, contraception, and timing of future conception. At the time of reporting this case, she remained clinically stable at 2 months of follow-up, although reproductive outcomes following surgery could not yet be assessed, and definitive conclusions regarding reproductive benefit cannot be drawn at this stage. This case highlights the paradoxical presentation of bicornuate uterus with an initial successful term pregnancy followed by recurrent miscarriage, underscores the diagnostic and management barriers faced in resource-constrained settings, and emphasizes the importance of considering congenital uterine anomalies in women presenting with secondary recurrent pregnancy loss despite a previously favorable obstetric history.