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CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 261-263  

Ruptured rudimentary horn pregnancy masquerading as cesarean scar rupture in third trimester


Department of Obstetrics and Gynecology, PGIMS, Rohtak, Haryana, India

Date of Web Publication29-Jun-2018

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


DOI: 10.4103/MJDRDYPU.MJDRDYPU_125_17

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  Abstract 


Pregnancy in the rudimentary horn of a unicornuate uterus is extremely rare and usual fate is rupture in the second trimester. We have reported this case due to rarity of rupture of rudimentary horn in the third trimester initially misdiagnosed as cesarean scar rupture. A 27-year-old G2P1 L1 with previous lower segment cesarean section presented at 33-week gestation with pain abdomen and syncopal attack with hemodynamic instability. The abdomen was distended and tender, uterine contour could not be made out, fetal parts were felt superficially, and fetal heart sound was absent. On vaginal examination, os was closed, bleeding was absent, and presenting part of the fetus was high up. A provisional diagnosis of cesarean scar rupture was made, and the patient was taken up for emergency laparotomy with simultaneous resuscitation. Intraoperatively, a left-sided ruptured rudimentary horn pregnancy and a unicornuate uterus with an intact lower segment transverse scar were found, a 1.5-kg macerated stillborn fetus was lying in the peritoneal cavity, and approximately two litres of hemoperitoneum was present. Excision of the rudimentary horn with ipsilateral salpingectomy was performed. High index of suspicion for uterine malformation is required for cases with a previous history of cesarean section for malpresentation. Moreover, catastrophic hemorrhage consequent to ruptured horn pregnancy can be avoided by excision of the rudimentary horn encountered incidentally.

Keywords: Cesarean, horn, pregnancy, rudimentary, ruptured, scar, third


How to cite this article:
Hooda R, Agarwal K, Sirohiwal D, Bishnoi P. Ruptured rudimentary horn pregnancy masquerading as cesarean scar rupture in third trimester. Med J DY Patil Vidyapeeth 2018;11:261-3

How to cite this URL:
Hooda R, Agarwal K, Sirohiwal D, Bishnoi P. Ruptured rudimentary horn pregnancy masquerading as cesarean scar rupture in third trimester. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2021 Jun 12];11:261-3. Available from: https://www.mjdrdypv.org/text.asp?2018/11/3/261/235550




  Introduction Top


Unicornuate uterus occurs in 1 in 4020 women in the general population, and a rudimentary horn is present in about 84% of the cases.[1],[2] Pregnancy in the rudimentary horn of a unicornuate uterus is extremely rare being present in 1:76,000 pregnancies.[3] A unicornuate uterus is often asymptomatic. The clinical course of this condition is usually characterized by a high rate of uterine rupture with 85% of pregnancies in a noncommunicating rudimentary horn typically rupture before the third trimester.[4] These pregnancies rarely reach term, and when they do, fetal outcome is often poor, with a reported 6% survival rate.[3] We describe a rare case of ruptured rudimentary horn pregnancy (RHP) in the third trimester, initially misdiagnosed as cesarean scar rupture.


  Case Report Top


A 27-year-old G2P1 L1 with previous lower segment cesarean section (LSCS) 2 years back for breech presentation presented at 33-week gestation with pain abdomen for four hours and syncopal attack. On examination, she was pale with a pulse rate of 130/min and blood pressure of 80/40 mmHg. The abdomen was distended and tenderness, uterine contour could not be made out, fetal parts were felt superficially, and fetal heart sound was absent. On vaginal examination, os was closed, bleeding was absent, and presenting part of the fetus was high up. A provisional diagnosis of cesarean scar rupture was made, and the patient was taken up for emergency laparotomy with simultaneous resuscitation. Intraoperatively, a left-sided, ruptured noncommunicating RHP and a unicornuate uterus with an intact lower segment transverse scar were found [Figure 1]. The right  Fallopian tube More Details and ovary were normal. The left tube and ovary were attached lateral to the rudimentary horn. The 1.5 kg macerated stillborn fetus along with the placenta was lying in the peritoneal cavity, and approximately 2 L of hemoperitoneum was present. Excision of the rudimentary horn with ipsilateral salpingectomy was performed. Four units of packed cells and four units of fresh frozen plasma were transfused in the intraoperative and immediate postoperative period. The postoperative period was uneventful, and the patient was discharged on the 7th postoperative day with counseling for elective LSCS in subsequent pregnancy. Surprisingly, she was a booked case and had two antenatal ultrasonography (USG) reports, which were normal. Moreover, discharge certificate of LSCS of previous pregnancy was unavailable, and on retrospective enquiry, the patient was also unable to give history regarding this important preoperative finding, which could have probably aided in a pregestational and antenatal diagnosis.
Figure 1: Intraoperative photograph showing enlarged left-side noncommunicating rudimentary horn with rupture in the lateral aspect containing placental bits and a normal sized uterus on the right with an intact previous lower segment scar

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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 most likely mechanism of a pregnancy in a noncommunicating rudimentary horn is transperitoneal migration of the spermatozoa.

About 50% of the cases rupture usually in the second trimester while 30% go to term with a 0%–13% fetal salvage rate.[3] The poor obstetric outcome may be due to the abnormal shape, the insufficient muscular mass of the uterus, abnormal vasculature, and the reduced uterine volume and inability to expand.

Early clinical diagnosis of a RHP is challenging, particularly because women often have a history of previous normal pregnancies. However, careful clinical examination may help in clinching the diagnosis. The first-trimester sonography can aid in early diagnosis of mullerian anomalies. In our case, despite two antenatal scans, mullerian anomaly was missed. This might be due to scans being performed at 26 and 30 weeks, respectively. Moreover, despite previous history of cesarean section, a pregestational diagnosis before the second pregnancy could not be made due to lack of official records as the attendants had misplaced it. Herein, lies the importance of proper record keeping. There are no definitive clinical criteria to detect this life-threatening condition in case of emergency. However, a RHP can also be suspected on early clinical pelvic examination, wherein a mass extending outside the uterine angle can sometimes be felt on bimanual examination (Baart de la Faille's sign) or displacement of the fundus to the contralateral side with rotation of the uterus and elevation of the affected horn (Ruge Simon syndrome).[5] In our case, previous LSCS for breech presentation should have raised suspicion of uterine malformation. 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.[6] However, the sensitivity of ultrasound decreases as the pregnancy advances because the enlarging horn with a thinned myometrium can obscure the adjacent anatomic structures. Buntugu used the 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.[7] Tubal pregnancy, cornual pregnancy, intrauterine pregnancy, and abdominal pregnancy are common sonographic misdiagnosis, and preoperative diagnosis is made only in 26% of cases.[8] In our case too, USG was inconclusive and magnetic resonance imaging (MRI) could have clinched a preoperative diagnosis. MRI would also have been useful to exclude morbidly adherent placenta in our patient with a previous history of cesarean section. Moreover, chances of placental adherence are increased due to poorly developed musculature and scant decidualization in the rudimentary horn.

Over last few years, RHP has been managed laparoscopically.[9] Medical management with methotrexate is an option in unruptured cases although surgical excision of the horn is still recommended.[10] However, in few selected cases where the patient is well-informed and emergency surgery can be carried anytime, conservative management, until viability is achieved, has been advocated.[3]

Prophylactic excision during cesarean section of antecedent pregnancy could have saved the patient from life-threatening hemorrhage of the third-trimester ruptured RHP. At our center, we routinely perform prophylactic excision of rudimentary horn encountered during cesarean section.


  Conclusion Top


We have reported this case to highlight the importance of proper antenatal care with careful clinical examination as well as early sonography to prevent maternal mortality from late third-trimester rudimentary horn rupture. High index of suspicion for uterine malformation is required for cases with a previous history of cesarean section for malpresentations. Furthermore, proper maintenance of records is crucial for early diagnosis. Moreover, catastrophic hemorrhage consequent to ruptured horn pregnancy can be avoided by excision of the rudimentary horn encountered incidentally.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Reichman D, Laufer MR, Robinson BK. Pregnancy outcomes in unicornuate uteri: A review. Fertil Steril 2009;91:1886-94.  Back to cited text no. 1
    
2.
Heinonen PK. Unicornuate uterus and rudimentary horn. Fertil Steril 1997;68:224-30.  Back to cited text no. 2
    
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
    
4.
Fouelifack FY, Fouogue JT, Messi JO, Kamga DT, Fouedjio JH, Sando Z, et al. Spontaneous second-trimester ruptured pregnancy of rudimentary horn: A case report in Yaounde, Cameroon. Pan Afr Med J 2014;18:86.  Back to cited text no. 4
    
5.
Goel P, Aggarwal A, Devi K, Takkar N, Saha PK, Huria A. Unicornuate uterus with non-communicating rudimentary horn: Different clinical presentations. J Obstet Gynecol India 2005;55:155-8.  Back to cited text no. 5
    
6.
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. 6
    
7.
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. 7
    
8.
Jayasinghe Y, Rane A, Stalewski H, Grover S. The presentation and early diagnosis of the rudimentary uterine horn. Obstet Gynecol 2005;105:1456-67.  Back to cited text no. 8
    
9.
Sharma D, Usha MG, Gaikwad R, Sudha S. Laparoscopic resection of unruptured rudimentary horn pregnancy. Int J Reprod Contracept Obstet Gynecol 2013;2:95-8.  Back to cited text no. 9
    
10.
Edelman AB, Jensen JT, Lee DM, Nichols MD. Successful medical abortion of a pregnancy within a non-communicating rudimentary uterine horn. Am J Obstet Gynecol 2003;189:886-7.  Back to cited text no. 10
    


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