Uterine didelphys is a very rare Mullerian duct anomaly resulting from complete failure of ductal fusion, leading to duplication of uterine horns, cervix, and sometimes the proximal vagina. Although many of them are asymptomatic, it can present as poor reproductive outcomes or, rarely, pelvic organ prolapse. Reports of obstetric rupture in early gestation or prolapse in a didelphic uterus are exceedingly rare. We present two contrasting cases that present differently in a didelphys uterus. First, a 26-year-old primigravida initially had an unexplained massive hemoperitoneum at 17 weeks of gestation. One uterine horn of a didelphys uterus ruptured during an emergency laparotomy, resulting in expulsion of the fetus and the placenta into the peritoneal cavity. This required a supracervical hysterectomy of the ruptured horn. The second case describes a 50-year-old postmenopausal woman with a 5-year history of vaginal mass and urinary symptoms. She was preoperatively diagnosed with third-degree uterovaginal prolapse and underwent transvaginal hysterectomy, during which a didelphic uterus was unexpectedly identified. Both patients recovered uneventfully after surgery. These cases illustrate the diagnostic and intraoperative challenges of uterine didelphys. In the obstetric case, the anomaly was identified solely post-rupture, whereas in the gynecologic case, it was detected incidentally during prolapse surgery. Uterine didelphys can present across a wide spectrum - from life-threatening rupture to chronic prolapse. Clinicians should maintain a high index of suspicion in atypical presentations and be prepared for unexpected anatomy to ensure safe, individualized management.

Congenital uterine anomalies are rare, with didelphys uterus being one of the least common. Although generally asymptomatic, it can be associated with infertility, dysmenorrhea, and various pregnancy complications including spontaneous abortion and preterm delivery. We present the case of a 29-year-old gravida one para zero female at 6 weeks and 4 days gestational age who presented with pelvic pain during pregnancy. She was incidentally found to have a didelphys uterus during evaluation. She was diagnosed with a hematopyometra in the right horn, likely the cause of her pelvic pain, while carrying a viable pregnancy in the left horn. She was successfully treated with antibiotics and hysteroscopy with dilation and curettage. The remainder of her pregnancy was relatively uncomplicated until delivery and her postpartum course was uneventful. This case demonstrates a rare but possible pregnancy complication in a patient with didelphys uterus as well as successful management of that complication in pregnancy.

To demonstrate the use of ultrasound-guided hysteroscopic technique for the successful surgical management of a missed abortion in a patient with uterus didelphys and complex cervical anatomy. Video case report demonstrating a stepwise, ultrasound-guided hysteroscopic approach. The case was managed in a tertiary referral center with a multidisciplinary team. A 36-year-old woman, gravida 4 para 3, with a known Müllerian anomaly and right renal agenesis, presented with a missed abortion at 9 weeks of gestation. Although the anomaly was previously suspected, the exact diagnosis - whether bicornuate uterus or didelphys uterus - remained unclear due to the presence of a single identifiable cervix. In this case, ultrasound identified the pregnancy within the right uterine horn. Under general anesthesia, a thorough speculum examination revealed a potential opening to the right uterine horn. Ultrasound-guided cervical dilation was attempted but proved unsuccessful due to the tortuous nature of the canal. Therefore, ultrasound-guided hysteroscopic approach was employed with a multidisciplinary team including gynecology, anesthesia, and sonography specialists. Surgical hysteroscopy facilitated precise navigation and evacuation of the gestational sac from the right uterine horn under ultrasound guidance. The procedure was completed without complications. Hysteroscopic and sonographic follow-up after two months, demonstrated a normal endometrial lining and no retained products of conception. This case underscores the importance of adapting surgical strategies to complex anatomical variations in patients with Müllerian anomalies. Ultrasound-guided hysteroscopy offers a safe and effective solution when standard methods such as D&C fail due to obstructive cervical anatomy. Its direct visualization capabilities allow for precise intervention, minimize procedural risks, and improve patient outcomes. Incorporating advanced hysteroscopic techniques into clinical practice is essential for managing challenging uterine malformations.

Uterine didelphys, also known as double uterus, is a congenital anomaly of the female reproductive system that can be associated with a significant number of threatening obstetric complications, such as uterine rupture. We report a rare and complex case of an 18-year-old primigravida who presented with uterine rupture due to uterine didelphys at 18 weeks of gestation. Patient had no prior medical or gynecological history. Physical examination revealed a diffusely distended and tender abdomen along with signs of hemodynamic instability. Ultrasound of the abdomen showed hemoperitoneum, with an intrauterine dead fetus. Second trimester intrauterine rupture was considered the initial diagnosis. After successfully resuscitating the patient, exploratory laparotomy was performed. Uterine didelphys with a right-sided uterus ruptured from the fundal region along with a wide-bore intestinal diverticulum was seen. After repairing the uterus in 2 layers and hemodynamically supporting the patient, retained products of conception were removed. Postoperative laboratory investigations were significant for disseminated intravascular coagulation and metabolic acidosis with respiratory compensation. These critical findings necessitated intensive care unit (ICU) admission where the patient received close monitoring, ultimately leading to stabilization of the patient. This case serves as a reminder that adolescents with Mullerian duct anomalies, even without a prior history of uterine scarring, can present with life-threatening obstetric complications such as uterine rupture. Prompt recognition and timely management are essential to prevent fatal outcomes.