Successful management of a rudimentary uterine horn ectopic pregnancy by combining methotrexate and surgery: A case report

Laparoscopic Management of a 12-Week Pregnancy Loss in a Rudimentary Uterine Horn

Unicornuate uterus with rudimentary horn is a rare structural uterine anomaly resulting from incomplete Mullerian duct development and/or fusion. Pregnancy in rudimentary horn is an uncommon presentation of a Mullerian anomaly and may lead to substantial morbidity and mortality due to high risk of uterine rupture with intraabdominal hemorrhage. Medical and/or surgical management may be undertaken; however, currently, no treatment guidelines exist. We describe the management of a 12-week rudimentary horn pregnancy in a 25-year-old multiparous patient with a prior spontaneous preterm breech vaginal delivery and one spontaneous early term cephalic vaginal delivery in whom this congenital uterine condition was previously unknown. The rudimentary horn, nonviable pregnancy, and contiguous ipsilateral fallopian tube were excised laparoscopically without complication. Given the infrequency of rudimentary horn pregnancies and the high risk for obstetric complications, a high index of suspicion should be maintained. We emphasize that a history of preterm birth or malpresentation should raise suspicion for maternal Mullerian anomaly, and that a minimally invasive approach can be feasible for treatment of a rudimentary horn pregnancy.

Pregnancy in a rudimentary horn: multicenter's MRI features of a rare condition

PURPOSE

To describe the MRI features of rudimentary horn pregnancy (RHP) with surgical correlations.

METHODS

Nine women with a RHP underwent preoperative pelvic MRI. MRI protocol included T2- (n = 9), T1- (n = 7), and fat-suppressed contrast-enhanced T1-weighted sequences (n = 4). Two pelvic radiologists retrospectively analyzed MR images to assess the following MRI features: presence of a myometrium around the gestational sac (GS) and characteristics of its wall, GS surrounded by myometrium in contact with the round ligament, communication of the GS with the endometrial cavity of the main horn, continuity of the GS with the cervix, fibrous or muscular GS attachment to the main horn, lateral deviation, and endometrial thickness of the main horn. Ovaries and tubes were also assessed. MRI features were correlated with surgical findings.

RESULTS

Seven of the nine women [29 ± 6 SD years (range 16-37 years)] underwent surgical management. The first US diagnosed RHP in only 1/9 patients. All pregnancies were diagnosed using MRI. RHP was all located in the rudimentary horn of a unicornuate uterus. All the GS was surrounded by myometrium in contact with the round ligament. None of the RHP displayed communication with the endometrial cavity of the main horn nor with the cervix. An attachment between the RHP and the main horn was seen in 3/9 patients. All the main horns were lateralized and empty.

CONCLUSION

MRI diagnosed RHP in all patients by identifying the GS surrounded by myometrium in contact with the round ligament and the absence of continuity between the GS and the cervix.

LEVEL OF EVIDENCE

IV-retrospective study.

Successful Laparoscopic Management of Non-communicating Rudimentary Horn Pregnancy

Unicornuate uteri are a type of Mullerian duct anomaly and the majority present with rudimentary horns. Rudimentary horn pregnancies are extremely rare and have a high risk of rupture. A high index of suspicion is needed to diagnose them early and unfortunately, the majority of cases are undetected until the patient presents with a ruptured uterus. Early diagnosis and management will reduce morbidities and mortality for patients.

We present a case of a 29 year old who had a routine ultrasound scan in the first trimester that raised an index of suspicion for a rudimentary horn pregnancy. An MRI scan was performed and supplemented the ultrasound findings. The patient underwent laparoscopic management, and the non-communicating rudimentary horn, the foetus, and the attached tube were excised. The patient had a smooth recovery and had no complications. 

Due to the rarity of rudimentary horn pregnancies, a high index of suspicion is needed for a diagnosis. Timely detection and intervention are crucial to prevent complications. Ultrasound scans and MRIs can aid in the diagnosis. Traditional management involved laparotomy, but with surgical advancements, laparoscopic surgery can be utilized as a less invasive alternative.

Successful Management of a Noncommunicating Rudimentary Uterine Horn Pregnancy by Laparoscopic Surgery: A Case Report and Literature Review

Pregnancy in a noncommunicating rudimentary horn is extremely rare but can cause serious clinical complications, such as uterine rupture. The standard treatment is excision of the rudimentary horn, and recently, in some cases, laparoscopic resection has been performed in the first trimester of gestation. Herein, we present a case of noncommunicating rudimentary horn pregnancy (NCRHP), which was diagnosed by magnetic resonance imaging at 6 weeks of gestation and treated by laparoscopic surgery. However, we have also found some rare cases in which patients could obtain live newborn babies. Since management is affected by the different levels of obstetric medical care and diagnostic tools, we also performed a review and analysis of NCRHP. A PubMed search yielded 103 cases reported in the English literature. Correct diagnosis and laparoscopic treatment were achieved more frequently in developed countries, especially in the first trimester of gestation. On the other hand, symptoms, including abdominal pain and hypovolemic shock, tended to occur in the second trimester of gestation. This period was also found to be a risk factor for uterine rupture. Among 18 patients at the third trimester of gestation, 13 obtained live neonatal infants. Therefore, detailed information about this disease is crucial for proper treatments.

Successful pregnancy and term delivery after treatment of unicornuate uterus with non-communicating rudimentary horn pregnancy with local methotrexate injection followed by laparoscopic resection: a case report and literature review

Background

Pregnancy in a rudimentary horn is an extremely rare type of ectopic pregnancy. A rudimentary uterine horn pregnancy is associated with a risk of spontaneous rupture and bleeding during surgery due to the increased uterine blood flow. Recent advances in imaging modalities have enabled laparoscopic surgery to be performed in cases without rupture in the early stages of pregnancy. However, there are few reports of successful pregnancies and deliveries after treatment of rudimentary horn pregnancies. We report the successful management of a case of non-communicating rudimentary horn pregnancy by local injection of methotrexate followed by complete laparoscopic excision along with a review of the literature.

Case presentation

The patient was a 29-year-old Japanese woman, gravida 2, nullipara. She was diagnosed with a left unicornuate uterus with a right non-communicating rudimentary horn on hysterosalpingography and magnetic resonance imaging. A gestational sac with a heartbeat was observed in the right rudimentary uterine horn at 6 weeks of gestation. A diagnosis of ectopic pregnancy in a non-communicating rudimentary horn was made. Color Doppler detected multiple blood flow signals around the gestational sac, which were clearly increased compared to the left unicornuate uterus. Her serum human chorionic gonadotropin level was 104,619 mIU/ml. A 100 mg methotrexate injection into the gestational sac was administered, and laparoscopic surgery was performed on day 48 after the methotrexate treatment. The right rudimentary horn and fallopian tube were successfully excised with minimal bleeding. A spontaneous normal pregnancy was established 6 months after the surgery. The pregnancy was uneventful, and a baby girl was born by elective cesarean section at 38w0d.

Conclusion

Combined local methotrexate injection and laparoscopic surgery are safe treatment options for patients with a unicornuate uterus with a non-communicating rudimentary horn pregnancy.

Ectopic pregnancy in noncommunicating horn of unicornuate uterus: 3D-ultrasound and primary laparoscopic management

Unicornuate uterus with pregnancy in the noncommunicating rudimentary horn is extremely rare. Diagnosis requires awareness, high suspicion index, 3D ultrasound, and MRI. If missed, it can be catastrophic. Treatment varies across literature. We present a case where detection was done by 3D ultrasound and primary laparoscopic surgery done for treatment.