17 Week non-communicating rudimentar uterine horn pregnancy and uterine rupture: case report

Objective

The review of diagnostic and therapeutic requirements of a non communicating uterine horn pregnancy case as a rare situation according to the existing literature.

Case(s)

A 26 years old, G4 P3 L2 A0 D&C 0 pregnant woman introduced to emergency unit of our hospital with serious abdominal pain and fainting.Arterial blood pressure of the patient was 9040 mmHg and her heart beat count was 110 beats per minute at admission Intraoperatively,a dead fetus at 17 weeks of gestation has been seen in the abdominal cavity as a result of non communicating uterine horn rupture.

Conclusion

Rudimentary horn pregnancy is a rare pregnancy presentation that can not always be diagnosed sonographically and excision of the rudimentary horn is the advised management.

Keywords

Rudimentary, rupture, uterine anomaly, diagnostic difficulty, management.

Introduction

Overall incidence of congenital Mullerian duct anomalies is 0.1-3.8% in women. Unicorniate uterus is the least frequent Mullerian anomaly and seen 4.4%.1 It is assumed that there is a migration defect to proper location of one of Mullerian ducts.(2) American Society for Reproductive Medicine (ASRM) divided unicorniate uterus into 4 groups; communicating rudimentary horn unicorniate uterus, noncommunicating rudimentary horn unicorniate uterus, isolated unicorniate uterus and noncommunicating rudimentary horn unicorniate uterus with no cavity.(3)Unicorniate uterus may cause spontaneous abortus, ectopic pregnancy, abnormal presentation, intrauterine growth restriction and preterm labour. Implantation in rudimentary horn is related with high rate of pregnancy loss and tubal pregnancy. Most of them are noncommunicating and do not contain functional endometrium therefore asemptomatic. 40% of patients have urinary system anomalies. Myometrium in rudimentary horn is thin. Therefore, the risk of uterine rupture is high in pregnancies in that location.(4) Due to potential problems prophylactic excision is recommended when it is met.(5 )
 
 

Case(s)

26-year-old G4, P3, L2, A0, D&C0 pregnant woman introduced to emergency unit of our hospital with severe abdominal pain and fainting. In respect of her history, she had irregular menstrual cycle and was 13 week pregnant according to her last menstrual period. Left lower quadrant pain and tenderness in servical movements determined in pelvic examination. Uterine enormity was not evaluated due to voluntary defence. Arterial blood pressure was 90/40 mmHg and heart rate was 110 beats per minute. Free fluid and an extrauterine dead fetus at 17 week 5 day of gestation has been seen in right upper quadrant by abdominal sonography. Transvaginal sonography revealed bicornuate uterus (Figure 1). Preoperatively ruptured horn with echogenic plasenta and echolugent myometrium around plasenta revelaed by sonography but did not differentiated from abdominal pregnancy (Figure 2). Hemoglobin level was 8.1 g/dl before operation and she was admitted to laparatomy. Intraoperatively a dead fetus at 17 weeks of gestation has been seen in the abdominal cavity as a result of noncommunicating uterine horn rupture (Figure 3). Fetus has taken and 1500 cc hemorrhagic fluid drained from abdominal space. Rudimentary horn has excisied with its point connected to uterus. Then uterus sutured with baseball technique (Figure 4). 2 units of blood transfused to patient and there was no any complication in postoperative follow up. 

 

Discussion

 Rudimentary horn pregnancy is a rare pregnancy presentation with high maternal and perinatal mortality risk and cannot always be diagnosed sonographically. There are a few term pregnancies in rudimentary horn in the literature and they have high maternal and perinatal mortality rates. In communicating rudimentary horn cases mechanism of pregnancy is clear but in noncommunicating type, transperitoneal migration of sperms is assumed. In both conditions there is a thin myometrial layer and noncomplete uterine cavity development.(6) The risk of uterine rupture increases with advanced gestational age. It is a rare condition but due to clinical outcome and effect on fertility of patient it causes important gynecological and obstetric problems.(7) Acute abdomen, dysmenorrhea, dyspareunia or chronic pelvic pain may be clinical outcome, when there is hemometria, pyometria, torsion, endometriomas with retrograde menstruation in rudimentary horn. 

Conclusion

Rupture in noncommunicating rudimentary uterine horn pregnancy is a frequent outcome. A concomitant heterotopic pregnancy should be considered with rudimentary horn intrauterine pregnancy.(8) Therefore excision assumed a proper approach when pregnancy diagnosed. 
 

References

1. Speroff L, Glass RH, Kase NG. Clinical Gynecologic Endocrinology and Infertility. Sixth Edition, 1999. ISBN 0-683-30379-1.
2. Panayotidis C, Abdel-Fattah M, Leggott M. Rupture of rudimentary uterine horn of a unicornuate uterus at 15 weeks' gestation. J Obstet Gynaecol 2004; 24(3): 323-4.
3. The American Fertility Society. The American Fertility Society classifications of adnexal adhesion, distal tubal occlusion, secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesion. Fertil Steril 1988; 49: 944-55.
4. Daskalaskis G, Pilalis A. Rupture of noncommunication Rudimentary Uterine Horn Pregnancy. Obstet Gynecol 2002; 100: 1108-10.
5. Sefrioui O, Azyez M, Babahabib A, Kaanane F, Matar N. Pregnancy in rudimentary uterine horn: diagnostic and therapeutic difficulties. Gynecol Obstet Fertil 2004; 32(4): 308-10.
6. Kuşçu NK, Laçin S, Kartal Ö. Rupture of rudimentary horn pregnancy at the 15 th week of gestation: a case report. Eur J Obstet Gynecol Reprod Biol 2002; 102: 209-10.
7. Atmaca R, Germen AT, Burak F, Kafkaslı A. Rudimenter Hornlu Unikornuat Bir Olguda Akut Batın. Artemis 2003; Vol 4(4): 74-6.
8. Ozan H, Kimya Y, Esmer A, Karahasan M. A Case of Heterotopic Pregnancy. Gynecology Obstetrics and Reproductive Medicine 2001; Vol 7 (2): 172-3.

	File/Dsecription
	Figure 1. Sonographic appearance of fetus and plasenta located in abdominal cavity just near to uterus.
	Figure 2. Ruptured rudimentary uterine horn with echolucent myometrium layer around echogenic placenta just near to fetal head in abdomen
	Figure 3. Intraoperative digital photograph of fetus and placenta that rupture rudimentary horn and go to abdomen.
	Figure 4. Apperance of uterus after intraoperative excision of rudimentary uterine horn