Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 4  |  Page : 381-383  

Ruptured noncommunicating rudimentary horn of unicornuate uterus at 12 weeks


1 Department of Obstetrics and Gynecology, PGIMS, Rohtak, Haryana, India
2 Department of Orthopedics, PGIMS, Rohtak, Haryana, India

Date of Submission31-Jan-2017
Date of Acceptance29-Mar-2017
Date of Web Publication4-Sep-2017

Correspondence Address:
Kriti Agarwal
Sanghi Hospital, Chotu Ram Chow, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_22_17

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  Abstract 

Pregnancy in a rudimentary horn of a unicornuate uterus is rare but ruptured horn has a mortality rate of 5%. We report a case of 26-year-old G4P3 L3 with previous full-term vaginal deliveries, who presented at 12-week gestation with severe abdominal pain. Transvaginal ultrasound imaging was suggestive of ruptured right ectopic pregnancy and patient was taken up for emergency laparotomy. Intraoperatively, 2500 cc hemoperitoneum was present and ruptured right rudimentary horn in the posterolateral part was found, with fetus in the pouch of Douglas, the uterus was of unicornuate type. Excision of ruptured right rudimentary horn along with the right salpingectomy was done. Despite advances in imaging, in developing countries where the prerupture diagnosis is unlikely, a high index of suspicion is crucial in saving mother's life.

Keywords: First, horn, ruptured, rudimentary, trimester


How to cite this article:
Dahiya K, Agarwal K, Sanghi S. Ruptured noncommunicating rudimentary horn of unicornuate uterus at 12 weeks. Med J DY Patil Univ 2017;10:381-3

How to cite this URL:
Dahiya K, Agarwal K, Sanghi S. Ruptured noncommunicating rudimentary horn of unicornuate uterus at 12 weeks. Med J DY Patil Univ [serial online] 2017 [cited 2021 Dec 6];10:381-3. Available from: https://www.mjdrdypu.org/text.asp?2017/10/4/381/213929


  Introduction Top


Ruptured rudimentary horn is a life-threatening obstetrical emergency. Despite the advances in imaging, diagnosis is rarely made preoperatively. An incidence of 1 in 76,000–150,000 pregnancies is reported in the literature.[1] There is no communication between the two cavities in 75%–90% of the cases and the incidence of pregnancy in noncommunicating horn is high as 83% with an incidence of uterine rupture observed mostly in the second trimester.[2],[3] We report a case of 26-year-old multigravida with first-trimester rupture of the right-sided noncommunicating rudimentary horn of unicornuate uterus.


  Case Report Top


A 26-year unbooked patient with parity as G4P3 L3, with previous full-term vaginal deliveries 9, 6, and 4 years back, respectively, presented at 12-week gestation with severe abdominal pain since 6 h before admission. On examination, the patient was conscious, pulse - 110/min, blood pressure - 90/60 mm of Hg, pallor - 2+. Abdomen was tender and distended; uterine contour was not appreciable. On per speculum examination, a normal healthy cervix and vagina were observed without any bleeding. Per vaginal examination demonstrated cervical motion tenderness, uterine size, and contour could not be appreciated, fullness was present in the right fornix. Hb - 7.5 g/dl on admission.

Transvaginal ultrasound imaging showed normal sized uterus, mild fluid in endometrial cavity without evidence of intrauterine pregnancy, right adnexa revealed heterogeneous mass of 8 cm × 6 cm, with an irregular gestational sac, containing fetus of crown-rump length - 34.6 mm without any fetal cardiac activity, right ovary not visualized and left adnexa was normal. The final impression was of ruptured right ectopic pregnancy.

With a provisional diagnosis of ruptured ectopic pregnancy, probably an interstitial one due to prolonged period of amenorrhea of 12 weeks, the patient was taken up for emergency laparotomy with simultaneous resuscitation with blood and blood products. Abdomen was opened by transverse incision, abdominal cavity was full of blood and clots (2500 cc of blood was aspirated), ruptured right rudimentary horn in the posterolateral part was found, with fetus in the pouch of Douglas [Figure 1], the uterus was unicornuate with normal left tube and ovary, right tube and ovary were apparently normal [Figure 2]. Excision of ruptured right rudimentary horn along with right salpingectomy was done. The horn was noncommunicating with uterine cavity. The patient received 3 pints packed cell volume and 3 units fresh frozen plasma. Postoperative period was uneventful, and she was discharged home on the 7th postoperative day with an Hb of 9 g/dl. Ultrasound of the whole abdomen to look for associated renal anomalies was normal. The patient had no antenatal visits earlier. Moreover, no ultrasound was done in previous pregnancies. Timely emergency laparotomy with resuscitation saved the patient's life.
Figure 1: Ruptured rudimentary horn along with dead fetus of seven centimeters in length

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Figure 2: Intra operative photograph showing unicornuate uterus with normal appearing left fallopian tube and ovary, right-sided rudimentary horn with rupture in the posterolateral aspect and right fallopian tube attached lateral to it

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  Discussion Top


Rudimentary horn with a unicornuate uterus results from failure of complete development of one of the Mullerian ducts and incomplete fusion with the contralateral side. The incidence of Mullerian duct malformations in the general population is estimated to be 4.3% while that of unicornuate uterus is about 0.4%.[4] The unicornuate uterus may have an attached horn with a cavity that communicates with the unicornuate uterus, or there may be no uterine horn or a uterine horn with no cavity. Some debate has focused on whether the unicornuate uterus with a communicating horn can represent a hypoplastic side of a bicornuate uterus.[5] The attachment of the rudimentary horn to the main uterus varies from a fibromuscular band to an extensive fusion between the two horns where there is no external separation between them. Most likely mechanism of pregnancy in a noncommunicating rudimentary horn is transperitoneal migration of the spermatozoa. Usual time of diagnosis is in the second trimester during rupture. In our case, it was in the first trimester, maybe due to the small size of horn which was 4 cm × 4 cm approximately. Depending on the ability of the horn to undergo hypertrophy and its musculature the rupture occurs between 5 weeks and 35 weeks. Ruptured rudimentary horn pregnancy results in massive hemorrhage with a mortality rate of 5%.[6] Despite this only few cases of early ( first trimester) prerupture sonographic diagnosis of this condition have been reported.[7],[8] Buntugu used placement of a Foley's catheter into the uterine cavity before performing a transabdominal ultrasound for diagnosing an extrauterine pregnancy although not accepted as a preferred method.[8] Sonographic diagnostic criteria suggested by Tsafri are the presence of pseudo-pattern of an asymmetrical bicornuate uterus, absent visual continuity between the cervical canal and the lumen of the pregnant horn and the presence of myometrial tissue surrounding the gestational sac.[9] The early diagnosis of a rudimentary horn pregnancy is difficult, particularly because women often have a history of previous normal pregnancies.[10] This happened in our patient, and a pregastational diagnosis could not be made. Chances of placental adherence are increased due to poorly developed musculature, scant decidualization, and small size of the horn. Magnetic resonance imaging is useful for prerupture diagnosis of pregnancy in rudimentary horn as well as any abnormal placentation. Surgical removal of the rudimentary horn is mandatory to avoid risk of recurrence of rupture with increased maternal morbidity. However, conservative management until viability is achieved has been advocated in selected cases with larger myometrial mass, if emergency surgery can be performed anytime and the patient is well-informed.[3] Laparoscopic excision of unruptured rudimentary horn pregnancy has been increasingly carried out with safe and favorable outcome, but this was not done in this case because of acute presentation of the patient with significant hemoperitoneum. Rudimentary horn pregnancy puts mother's life at risk as it can cause massive hemorrhage and even death in case of rupture. Moreover, in developing countries where the prerupture diagnosis is unlikely, a high index of suspicion is crucial in saving mother's life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ural SH, Artal R. Third-trimester rudimentary horn pregnancy. A case report. J Reprod Med 1998;43:919-21.  Back to cited text no. 1
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2.
Chopra S, Keepanasseril A, Rohilla M, Bagga R, Kalra J, Jain V. Obstetric morbidity and the diagnostic dilemma in pregnancy in rudimentary horn: Retrospective analysis. Arch Gynecol Obstet 2009;280:907-10.  Back to cited text no. 2
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3.
Nahum GG. Rudimentary uterine horn pregnancy. The 20th century worldwide experience of 588 cases. J Reprod Med 2002;47:151-63.  Back to cited text no. 3
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4.
Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN, Devroey P. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod Update 2001;7:161-74.  Back to cited text no. 4
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5.
Rock JA, Jones HW. Te Linde's Textbook of Operative Gynecology. 10th ed. Philadelphia: Lippincott Williams and Wilkins; 2011. p. 540.  Back to cited text no. 5
    
6.
Johansen K. Pregnancy in a rudimentary horn. Two case reports. Obstet Gynecol 1969;34:805-8.  Back to cited text no. 6
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7.
Kriplani A, Relan S, Mittal S, Buckshee K. Pre-rupture diagnosis and management of rudimentary horn pregnancy in the first trimester. Eur J Obstet Gynecol Reprod Biol 1995;58:203-5.  Back to cited text no. 7
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8.
Buntugu K, Ntumy M, Ameh E, Obed S. Rudimentary horn pregnancy: Pre-rupture diagnosis and management. Ghana Med J 2008;42:92-4.  Back to cited text no. 8
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9.
Tsafrir A, Rojansky N, Sela HY, Gomori JM, Nadjari M. Rudimentary horn pregnancy:First-trimester prerupture sonographic diagnosis and confirmation by magnetic resonance imaging. J Ultrasound Med 2005;24:219-23.  Back to cited text no. 9
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10.
Oya SK, Hanifi Ş, İlay G. Rupture of pregnancy in the rudimentary uterine horn at 32 weeks. Austin J Obstet Gynecol 2015;2:1043.  Back to cited text no. 10
    


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