Case Report: A 33-year-old lady first presented in 2008 with lower abdominal pain and fever, one month after having a laparotomy appendicectomy done in Brunei. There were dense pelvic adhesions intra-operatively. 

She attained menarche at 12 and had regular menstrual cycles with minimal dysmenorrhea. She had undergone two laparotomies at age 2 for ovarian cyst and subsequently at the age of 17, for a tuboovarian abscess.

During her admission in 2008, she underwent a CT scan of her thorax, abdomen and pelvis. The uterus was bulky with haematometra, with multiple loculated pelvic collections, suggestive of a pelvic abscess. Her right kidney was absent. She was given intravenous antibiotics for the PID, to which she responded, therefore, not requiring surgery, which would have been difficult in view of her previous multiple laparotomies. She remained well until 2012, when she was admitted again for PID, which resolved with antibiotics. She was then followed up by a consultant at the gynaecology clinic.

In 2014, a bedside pelvic ultrasound revealed a uterine didelphy, with a hypoechogenic mass below the uterus. At this time, she was seen by a gynaecologist with a special interest in Mullerian Anomalies, who suspected that she had OHVIRA (obstructed hemivagina, ipsilateral renal anomaly with uterine didelphy). Subsequently a MRI was done which confirmed the findings, as well as, a transverse vaginal septum obscuring the cervical opening on the right side and a single left kidney.

An examination under anaesthesia performed, which revealed a bulge at the right lateral vaginal wall with a cervix on the left side which was obscured by the bulge at the right lateral wall. The left uterus had a normal endometrial cavity with a single tubal ostium. A small opening was made on the right vagina to relieve the obstructed side.

After being married for 2 years, she was keen for a pregnancy. IUI was attempted but failed. 

Despite this, she was determined for a pregnancy, hence, she underwent a vaginal septoplasty, hysteroscopy and a hysterosalphingography (HSG) with an imagine intensifier (II) under general anaesthesia to assess her uterine cavities and tubal patency. The decision for a HSG with II was made due to the risks involved with a laparoscopy. Post septoplasty, two cervix with normal endometrial cavities in both uteri was seen. A single ostia was visible in the right uterus but none was seen on the left uterus. Bilateral tubal patency was confirmed.

Conclusion: OHVIRA is a rare Mullerian Anomaly that is often missed as in this case. A high index of suspicion is required to be able to diagnose it correctly.