Unicornate uterus
ICD-10 Q51.4 is a billable code used to indicate a diagnosis of unicornate uterus.
A unicornate uterus is a congenital malformation of the female reproductive system characterized by the presence of a single horn or uterine cavity, resulting from incomplete development of the Müllerian ducts during embryogenesis. This condition can lead to various reproductive complications, including infertility, ectopic pregnancy, and obstetric complications such as preterm labor and malpresentation. The unicornate uterus may be associated with renal anomalies, such as renal agenesis or ectopic kidney, due to the close embryological relationship between the development of the kidneys and the uterus. Diagnosis is typically made through imaging studies such as ultrasound or MRI, which can reveal the asymmetrical shape of the uterus. Management of patients with a unicornate uterus often involves careful monitoring during pregnancy and may require surgical intervention in cases of associated complications or severe symptoms.
Documentation should include detailed descriptions of the patient's history, physical examination findings, and any imaging studies performed. It is essential to note any associated congenital anomalies.
Common scenarios include evaluation of a newborn with ambiguous genitalia or a child presenting with recurrent urinary tract infections, which may prompt investigation for underlying congenital anomalies.
Pediatric coders should be aware of the implications of congenital conditions on growth and development, as well as the potential need for multidisciplinary care.
Genetic documentation should include family history, genetic testing results, and any syndromic associations with the unicornate uterus.
Genetic counseling may be required for families with a history of congenital malformations, particularly if there are multiple affected family members.
Genetic coders must ensure accurate coding of chromosomal abnormalities that may co-occur with congenital malformations.
May be performed in cases of severe complications related to unicornate uterus.
Indicate the reason for surgery and any associated conditions.
Obstetricians should document the specific indications for surgery.
Common complications include infertility, ectopic pregnancy, preterm labor, and malpresentation during delivery. Patients may also have associated renal anomalies, which require careful monitoring.
