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Int J Pharm Biomed Res 2011, 2(3), 179-181

International Journal of
PHARMACEUTICAL AND BIOMEDICAL RESEARCH ISSN No: 0976-0350

Case Report

Pre-rupture diagnosis and management of rudimentary horn pregnancy in second trimester

G. Nagarathna*, H. Mahesha Navada, B. Poornima R. Bhat
Department of Obstetrics and Gynecology, Father Muller Medical College, Mangalore -575002, Karnataka, India.

Received: 04 Jul 2011 / Revised: 16 Jul 2011 / Accepted: 20 Jul 2011 / Online publication: 13 Aug 2011

ABSTRACT Pregnancy in the rudimentary horn is rare and carries grave consequences to the mother and fetus. Early diagnosis of rudimentary horn pregnancy (RHP) is challenging. The natural history of RHP is usually the rupture of pregnant horn during second and third trimester resulting in life threatening heavy bleeding. Therefore early pre-rupture diagnosis is of major importance. We are reporting a second trimester pre-rupture diagnosis and management of RHP. Key words: Pre-rupture Diagnosis, Rudimentary horn pregnancy, Management

1. INTRODUCTION Unicornuate uterus with rudimentary horn is a type of Mullerian duct malformation and is estimated to be found in 1 in every1000 women [1]. A rudimentary horn is found in 84% of unicornuate uteri [2]. The rudimentory horn may consist of a functional cavity, which is usually noncommunicating or it may be a small solid muscle with no functional endometrium. The pregnancy in a non communicating horn is possible only through trans peritoneal migration of the sperm or fertilized ovum with an estimated incidence of 1 in every 1,00,000 to 1,40,000 pregnancies [3]. It is associated with high rate of spontaneous abortion, preterm labor, intraperitoneal hemorrhage and uterine rupture [4]. The definitive diagnosis of RHP prior to rupture is unusual and is possible only at laparotomy. The clinical suspicion, Ultrasonography and magnetic resonance imaging (MRI) may help in preoperative diagnosis. We report one such case of second trimester pre-rupture diagnosis of RHP and its management. 2. CASE STUDY 27 year old Gravid 3 Para 2 living 2 at 23 weeks 2 days period of gestation was referred with the diagnosis of intra*Corresponding Author. Tel: +91 824 2238267, Fax: +91 824 2437402 Email: nagarathnaga@yahoo.in

Fig.1. T 2-Weighted sagittal MRI. Rudimentary horn pregnancy surrounded by hypointence rim of tissue suggestive of myometrium

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Fig.2. T-2 weighted sagittal MRI. Showing no communication between the rudimentary horn and uterine cavity

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peritoneal pregnancy. She was apparently asymptomatic and was suspected to have extra uterine pregnancy by routine second trimester ultrasonography. She had previous two vaginal deliveries at term and birth weights of first and second babies were 2.2 and 2.3 kg respectively. Her past medical and gynecologic histories were unremarkable with regular menses and without dysmenorrhoea. Her vital parameters were normal. Her abdominal examination revealed mass arising from the pelvis corresponding to 20 weeks of gravid uterine size. Fetal parts were felt superficial. On per vaginal examination, cervix was deviated to right side with narrow right fornix and free left fornix. Ultrasonographic evaluation revealed an empty enlarged uterus displaced to right side by the neighboring gestational sac with endometrial thickness of 20 mm. The gestational sac was extending from left adnexa up to the umbilicus with irregular wall thickness of 3 to 5 mm containing a live fetus corresponding to 18-20 weeks of gestation. The placenta was located in the anteroinferior part of the sac and there was no free fluid in the abdomen. Hence MRI was performed for further evaluation of the anatomy and location of the gestational sac. MRI showed a fetus outside the uterus within a clearly defined gestational sac. The placenta was seen with definitive borders located in the antero inferior part of the sac. No signs of placental invasion of the neighboring structures were observed. Thinned out myometrial tissue was seen surrounding the gestational sac (Fig.1). No cavitary connection between the gestational horn and the uterus (Fig.2). Diagnosis of RHP was established. The decision for pregnancy termination was made in view of high risk of rupture of the sac and the laparotomy was performed. At laparotomy, there was enlarged uterus of 6 week gravid uterine size with pregnancy in the left rudimentary horn attached to it by a thick fibrous band (Fig.3). The anterosuperior portion of the horn was thin and was about to rupture. The right tube and ovary were normal. The left ovary was normal and the tube was normally attached to the rudimentary horn. Excision of left rudimentary horn with intact gestational sac and ipsilateral salphingectomy was carried out. The cut section of the specimen showed the fetus and placenta inside the thin wall of the rudimentary horn (Fig.4). Histopathology confirmed the gestational sac lined by a thin myometrial tissue and the horn had no connection with the right uterine cavity. Postoperative period was uneventful and was discharged 7 days later. 3. DISCUSSION Pregnancy in rudimentary horn may not be as rare as previously calculated. In exhaustive review of the 20th century literature, Nahum summarized 588 such cases. In that series, uterine rupture occurred in 80% of RHPs. Among these neonatal survival was only 6%. The maternal mortality was 5.1 %, although none was reported after 1960 [5].

Fig.3. Enlarged uterus deviated to right. Pregnancy in left rudimentary horn with normal left ovary and fallopian tube

Fig.4. Specimen showing fetus with placenta in the horn

Cases of late and false diagnosis leading to uterine rupture have been reported repeatedly in the recent literature [6]. In our case the diagnosis of RHP was challenging. Intra uterine pregnancy in a bicornuate uterus, ectopic pregnancy like tubal pregnancy, cornual pregnancy and abdominal pregnancies are common sonographic differential diagnosis. The continuity between the endometrium lining the gestational sac and the other uterine horn is typical of pregnancy in a bicornuate uterus [7]. Ectopic pregnancies beyond 12 weeks of gestation are rarely tubal. In cornual pregnancy, sonography will reveal an interstitial line that extends from the uterine cavity to the cornual gestational sac. So In our case the pregnancy was either an abdominal pregnancy or RHP. The previous two small for gestation babies in her obstetric history raised the possibility of uterine malformation. The sonographic criteria for the diagnosis of RHP described by Tsafir et al applies to early pregnancy and defining the myometrial tissue surrounding the gestational sac was difficult in the second trimester in this patient. Though the termination of pregnancy by laparotomy was the best option of management for both these condition, MRI was performed after inconclusive ultrasound observations for

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the preoperative planning as well as to evaluate the myometrium surrounding the gestational sac and the placental location. MRI confirmed the diagnosis of RHP. It is recommended by most that immediate surgery be performed whenever a diagnosis of pregnancy in rudimentary horn is made even if unruptured to prevent rupture [8]. In view of relatively advanced pregnancy, laporotomy was planned as treatment option. 4. CONCLUSIONS There is a need of detailed clinical evaluation, increased awareness of this rare condition and high index of suspicion for early prerupture diagnosis. If ultrasound diagnosis remains inconclusive, MRI has major contribution to the diagnostic evaluation and preoperative planning before an indicated surgical procedure.

ACKNOWLEDGEMENTS The authors are grateful to Dr. H.B.Suresh, Professor, Department of Radiology, Fr Muller medical college, Mangalore. REFERENCES
[1] [2] [3] [4] [5] [6] [7] [8] Heinonen, P.K., Fertil Steril 1997, 68, 224-30. Heinonen, P.K., Int J Gynaecol Obstet 1983, 21,145150. Johansen, K., Obstet Gynecol 1983, 61, 565-7. Jin Woo Shin, Hai Joong Kim, J Obstet Gynaecol Res 2005, 31, 329331. Nahum, G.G., J Reprod Med 1997, 42, 525532. Oral, B., Guney, M., Ozsoy, M., Sonal, S., Arch Gynecol Obstet 2001, 265, 100102. Tsafrir, A., Rojansky, N., Sela, H.Y., Gomori, J.M., Nadjari, M., J Ultrasound Med 2005, 24, 219-223. Yasmin Jayasinghe, Ajay Rane, Harry Stalewski, Sonia Grover, Obstet Gynecol 2005, 105, 1456-1467.