Rupture of rudimentary horn pregnancy

Bicornuate uterus with second trimester fetal demise in a rudimentary horn

Bicornuate uterus is a congenital uterine anomaly associated with reproductive complications such as recurrent pregnancy loss, preterm birth, cervical insufficiency and uterine rupture. A bicornuate uterus occurs owing to failure of septal resorption after fusion of the paramesonephric ducts during organogenesis, resulting in a uterus divided into two horns. Most cases are only identified once reproductive difficulty is experienced or as an incidental finding in patients with a normal obstetric history. Here we present a patient who had two previous normal vaginal deliveries at term who was incidentally found to have a bicornuate uterus with second trimester fetal demise in the rudimentary horn. A hysterotomy and bilateral tubal ligation was performed, and the patient was discharged in good health after 48 hours.

Midgestational pre-labor spontaneous uterine rupture: a systematic review

OBJECTIVE

Second and early third-trimester uterine rupture in a non-laboring woman is a very rare and life-threatening condition for both mothers and newborns. However, there are scant epidemiologic data on this event.

STUDY DESIGN

Literature searches using Medical Subject Headings (MeSH) and non-MeSH terms were conducted in the PubMed/MEDLINE, Google Scholar and Embase databases from 1988 to 2020. Abstracts were reviewed and selected if they reported on uterine rupture in the second and third trimester. Uterine rupture was characterized as a full-thickness uterine wall defect. A total of 80 singleton intrauterine pregnancies between gestational ages of 14 and 34 weeks' gestation were included.

RESULTS

The mean gestational age at diagnosis of uterine rupture was 22.4 ± 5.4 weeks. The associated events in obstetric history for uterine rupture were: ≥1 previous cesarean section (45%; 36/80 of the cases), previous uterine rupture (10%; 8/80), previous classical uterine incision (7.5%; 6/80), myomectomy (25%; 20/80) and congenital uterine malformations (16.3%; 13/80 of the cases). Uterine ruptures were associated with a short IP interval in 13.7% (11/80) and 43.7% (35/80) were associated with abnormal placentation: placenta accreta spectrum (PAS) disorders (n = 26), placenta previa (n = 2) and placenta previa and PAS (n = 7). The rate of related prenatal ultrasound findings was 67.5%. Cesarean hysterectomy was performed in 27% of the cases. Maternal death was reported in 2.5% (2/80). For the neonates delivered ≥24 weeks' gestation (n = 27) peripartum fetal death was reported in 33.3% (9/27).

CONCLUSIONS

Midgestational pre-labor spontaneous uterine rupture is not an anecdotal event and may follow the worldwide increasing rate of cesarean sections. Health care providers should be familiar with the associated factors, presenting symptoms and complications of this obstetric emergency.

The pregnancy outcomes of patients with rudimentary uterine horn: A 30-year experience

OBJECTIVES

To evaluate the presentation, assessment, treatment, and pregnancy outcomes of 22 women with a rudimentary uterine horn.

METHODS

We reviewed the data regarding the outcomes of patients with a rudimentary horn pregnancy (RHP) who were managed at Peking Union Medical College Hospital over the last 30 years. Twenty-two pregnant patients with a rudimentary horn have been treated at our institute over the last 30 years. All patients with RHP were divided into two groups: Type A (n = 4), a rudimentary horn with a cavity that communicated with the uterus; and Type B (n = 7), a rudimentary horn with a cavity that did not communicate with the uterus. We classified all 22 patients into communicating group or noncommunicating group according to the anatomical connection of the rudimentary horn to the contralateral hemiuterus.

RESULTS

The mean gestational age of Type A patients (23.5 weeks) was significantly higher (P = 0.046) than that of Type B patients (10 weeks). The rudimentary uterine horn carried 4 of 5 (80%) pregnancies in the communicating group. Three case of rudimentary horn pregnancies ruptured before a gestational age of 12 weeks, and one abortion occurred after a gestational age of 12 weeks. In the noncommunicating group, 7 of 17 (41.2%) cases were RHPs, and 3 ruptured after a gestational age of 12 weeks.

CONCLUSIONS

The diagnosis and management of the rudimentary uterine horn continues to be challenging. Medical and radiological personnel must maintain a high degree of alertness to prevent the morbidity associated with this condition. In particular, patients with RHP (Type A), who have a higher chance being misdiagnosed before 12 gestational weeks, have a higher risk of potential complications. If pregnancy in the rudimentary horn is diagnosed, excision of the pregnant horn is recommended, regardless of the type of unicornuate uterus.

Unicornuate uterus with a rudimentary horn diagnosed at scheduled third Cesarean Section

A unicornuate uterus with a rudimentary horn is an anomaly caused by defective fusion of the Müllerian duct, estimated to occur in one in 76,000 pregnancies. Life threateningly heavy bleeding is a highly expected clinical consequence of such pregnancies. According to the known literature, only two living twins and few living singleton pregnancies have been reported up to now. Here we report on an incidentally diagnosed unicornuate uterus with a communicating rudimentary horn, found during a cesarean section of a gravida 3, parity 2 (G3 P2) patient. This case is rather unique since the patient has had three full term pregnancies and three cesarean sections without significant fetal compromise. This delivery and the existing literature showed us that extensive uterine correction surgeries need not be automatically proposed when a unicornuate uterus is diagnosed in the preconception period. Such deliveries indicate that women with this uterine anomaly may have the potential to carry pregnancies to full term.

Diagnosis and Management of Congenital Uterine Anomalies in Pregnancy

Importance

Congenital uterine anomalies (CUAs) are strongly associated with adverse fertility and pregnancy outcomes. Health care providers must be able to diagnose these anomalies, understand their impact, and counsel women on interventions that might improve rates of pregnancy and live birth.

Objectives

The aims of this study were to characterize CUAs and their effects on adverse fertility and pregnancy outcomes, to describe the best imaging modalities to diagnose specific uterine anomalies, and to learn about interventions that may improve the reproductive outcomes of infertile and pregnant women.

Evidence Acquisition

A search of the PubMed database revealed 56 relevant studies, 49 of which were referenced in this comprehensive summary of the literature.

Results

Congenital uterine anomalies are strongly associated with recurrent pregnancy loss, low birth weight, preterm birth, hypertensive disorders of pregnancy, malpresentation, and cesarean delivery. Transvaginal 3-dimensional ultrasonography appears to be the best initial test for uterine anomaly evaluation. Prior to conception, women who undergo hysteroscopic metroplasty may have better fertility and pregnancy outcomes.

Conclusions and Relevance

Congenital uterine anomalies, although rare in the general population, pose significant challenges to women and their clinicians with regard to fertility and pregnancy management. Accurate diagnosis, preconception counseling and metroplasty, and antenatal monitoring may improve reproductive outcomes for women with CUAs.

Target Audience

Obstetricians and gynecologists, family physicians.

Learning Objectives

After completing this activity, the learner should be better able to (1) characterize congenital uterine anomalies and their potential effects on adverse fertility and pregnancy outcomes, (2) determine the best imaging modalities to diagnose specific uterine anomalies, and (3) counsel both infertile and pregnant patients about interventions that may improve their reproductive outcomes.

Coring-type laparoscopic resection of a cavitated non-communicating rudimentary horn under hysteroscopic assistance

Non-communicating accessory uterine horns with an endometrial cavity are the most common and clinically significant unicornuate subtype of Müllerian duct abnormality. They are generally associated with symptoms of dysmenorrhea, dyspareunia, infertility, endometriosis, adhesions, and life-threatening cornual pregnancy. Treatment options include surgical resection of the rudimentary horn, hysteroscopic recanalization, and endometrial ablation. Currently, laparoscopic resection is the recommended treatment choice. Dissection of the rudimentary horn from the unicornuate uterus is the most challenging part of this procedure and may compromise the remaining unicornuate uterus wall. Here we describe a case of laparoscopic coring-type resection of a non-communicating functional rudimentary horn firmly attached to the unicornuate uterus, by using hysteroscopic assistance. The use of hysteroscopy, adjunct to laparoscopy, facilitates the coring-type resection and may strengthen the remaining myometrial scar.

Ruptured bicornuate uterus mimicking ectopic pregnancy: A case report

Ruptured uterus presenting in first trimester of pregnancy is extremely uncommon and should raise the suspicion of uterine malformations. We report a case of a 24-year-old primigravida with 10 weeks of gestation presenting with acute abdomen and hemoperitoneum. Laparotomy revealed bicornuate uterus with ruptured rudimentary horn. The incidence, diagnosis and management of such cases is discussed.

Obstetric morbidity and the diagnostic dilemma in pregnancy in rudimentary horn: retrospective analysis

BACKGROUND

Pregnancy in rudimentary horn of uterus, a form of ectopic gestation, is associated with significant rates of morbidity and mortality. Despite the recent advances in the ultrasonography, diagnosis of cornual pregnancy still remains elusive; with confirmatory diagnosis usually made during laparotomy. The aim of the present study is to analyze the obstetric implications and the diagnostic dilemma of rudimentary horn pregnancy.

MATERIALS AND METHODS

Records of women diagnosed with ectopic pregnancy in the rudimentary horn, during the years 2004 to 2008, managed in a referral hospital in northern India; were reviewed for their diagnostic difficulties and the associated morbidity.

RESULTS

During the four year study period, rudimentary horn pregnancies accounted for 12 pregnancies. Non communicating horn accounted for 75% of the cases. The mean age of women at presentation was 26 +/- 5.11 years and the period of gestation at diagnosis varied between 10 and 34 weeks. Preruputure diagnosis was possible only in two cases and sensitivity of ultrasonographic diagnosis was 33.3%. Laprotomy with excision of rudimentary horn and salpingectomy was done in all cases. Multiple blood transfusions were required in 83.3% of women.

CONCLUSION

Management of pregnancy in a rudimentary uterine horn continues to be a challenge to this day. Maintaining a higher degree of alertness, especially in high risk groups by emergency staff is required to prevent the morbidity, as they may present with acute uterine rupture in pregnancy.

The Presentation and Early Diagnosis of the Rudimentary Uterine Horn

OBJECTIVE

The key to successful management of the rudimentary uterine horn is early detection. This review of the literature seeks to illustrate important aspects of diagnosis and management of this anomaly.

DATA SOURCES

An English language MEDLINE search from 1966 to 2003 was performed, using the search terms "rudimentary uterine horn," "accessory horn," "uterus bicornis unicollis," "hematometra," "unicornuate or bicornuate uterus," and "mullerian anomaly." References from previously published sources were also obtained.

METHODS OF STUDY SELECTION

One hundred thirty letters, case reports, case series, and review articles featuring rudimentary uterine horn were found. Reports before 1966 were excluded because outcomes before the advent of modern diagnostic techniques were not relevant to this study.

TABULATION, INTEGRATION, AND RESULTS

Three hundred sixty-six rudimentary horn presentations (210 gynecologic and 156 obstetric) were found. Noncommunicating horns accounted for 92% of cases (95% confidence interval [CI] 88-95%, P < .001), and renal anomaly was found in 36% (95% CI 29-44%). Contrary to the American Fertility Society classification of uterine anomalies, rudimentary horns may occur without a corresponding unicornuate uterus. The mean age of presentation was similar for gynecologic and obstetric presentations (23 and 26 years, 95% CIs 21.2-24.6 and 124.9-27.3 years, respectively). Presentation in the third decade of life or later occurred in 78% of patients (95% CI 70-84%, P < .001). Sensitivity of ultrasound examination for diagnosis was 26% (95% CI 18-36%). Diagnosis before clinical symptoms occurred in 14% (95% CI 7-23%).

CONCLUSION

Many functional noncommunicating horns present during or after the third decade of life with acute obstetric uterine rupture. Surgical removal before pregnancy is recommended. Rates of prerupture diagnosis remain disappointingly low.

Fertility following laparoscopic removal of rudimentary horn with an ectopic pregnancy

BACKGROUND

Rudimentary horn pregnancies are rare. Although there have been previous reports of laparoscopic management, reports of successful pregnancies following previous excision of rudimentary horn were not found. Laparotomy remains the more common approach.

CASE PRESENTATION

We report the story of a woman found to have a rudimentary horn pregnancy who chose to be managed laparoscopically, and subsequently became pregnant and delivered a viable term infant 15 months following laparoscopic surgery.

DISCUSSION

The laparoscopic approach proffers decreased hospital stay, operating time, and potential for adhesions and is thus an important option for treatment of rudimentary horn pregnancies.

A case report and review of pregnancies in rudimentary noncommunicating uterine horns

A liveborn and subsequently thriving child was delivered abdominally from a pregnancy in a rudimentary noncommunicating uterine horn. This is the 13th English language report of neonatal survival from such an unusual and life-threatening situation. The case presents some 'clues' in the history and a review of the literature suggests that the previously reported bleak outlook for these pregnancies can now be tempered with cautious optimism. Ultrasound diagnosis of Müllerian abnormalities during pregnancy remains difficult but has been reported in several other cases in the literature and may become more common in the future.

Laparoscopic management of a rudimentary horn pregnancy

Rudimentary horn pregnancies are rare, and are associated with a high rate of maternal morbidity and mortality. The standard treatment is laparotomy, as patients usually experience massive abdominal hemorrhage or pregnancies too large to attempt laparoscopic removal. In our patient, early sonographic discovery facilitated laparoscopic management.

Unicornuate uterus with rudimentary horn

OBJECTIVES

To identify the effects of unicornuate uterus with rudimentary horn on reproductive function and analyze the diagnosis and treatment of the condition.

METHODS

The study was based in the gynecological unit of a city based Medical Center in Mainland China. Twenty-two cases of this anomaly were selected from a group of 130 cases of uterine abnormalities and were retrospectively analyzed.

RESULTS

This kind of anomaly can cause hematometra and endometriosis leading to acute abdominal pain, infertility, rupture of pregnant rudimentary horn and obstetrical complications with pregnant semi-uterus.

CONCLUSIONS

Rudimentary horn should be removed if detected.