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2025 ICD-10-CM code Q51.4

Unicornate uterus with or without a separate uterine horn.

Code Q51.4 should be used to describe a unicornuate uterus with or without a rudimentary horn. It is important to note that this code is not to be used on a maternal record.

Medical necessity for interventions related to a unicornuate uterus is established by the presence of symptoms like pelvic pain or complications such as recurrent miscarriage.Surgical intervention to remove a non-communicating rudimentary horn causing pain is considered medically necessary.Increased surveillance during pregnancy in patients with a unicornuate uterus is medically necessary due to the elevated risk of complications.

Diagnosis and management of this condition falls under the purview of gynecologists and obstetricians.They are responsible for confirming the diagnosis, counseling patients on potential reproductive implications, and managing any associated complications or pain.

In simple words: A unicornuate uterus is a birth defect where only half of the uterus forms, often with only one fallopian tube. It's shaped like a uterus with one horn.

Unicornate uterus with or without a separate uterine horn. This represents a congenital malformation where only one half of the uterus forms.

Example 1: A 25-year-old woman experiencing recurrent miscarriages undergoes imaging studies which reveal a unicornuate uterus. This diagnosis helps explain the pregnancy difficulties and guides future reproductive management., An adolescent female presents with cyclical abdominal pain. A pelvic exam and ultrasound reveal a non-communicating rudimentary horn associated with a unicornuate uterus.Surgical removal of the rudimentary horn is recommended to alleviate the pain., A 30-year-old pregnant woman with a known unicornuate uterus is closely monitored for potential complications like preterm labor, breech presentation, and miscarriage.

Documentation should include imaging reports (ultrasound, MRI, or hysterosalpingogram) confirming the presence of a unicornuate uterus.Operative reports detailing any surgical interventions (e.g., removal of a rudimentary horn) should also be included.Any history of pregnancy complications, such as miscarriage or preterm labor, associated with the condition should be documented.

** A unicornuate uterus is a rare congenital anomaly that can present challenges in pregnancy.Though not always impacting fertility, it increases the risk of complications.Appropriate management and monitoring are essential for optimizing reproductive outcomes.

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