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Pregnancy in the non communicating rudimentary horn.

INTRODUCTION: Mullerian anomalies were initially classified in 1979 by Buttram and Gibbons, then further revised by the American Society of Reproductive Medicine (ASRM) in 1988. Unicornuate uterus with communicating rudimentary horn belongs to class II A (ASRM/AFS). ESHRE/ESGE 2013 has classified it into type U4a, which includes a hemiuterus with a rudimentary (Functional) cavity characterized by the presence of a communicating or non-communicating functional contralateral horn. (1)

Incidence of Unicornuate uterus in the general population is 1 in 4000. Unicornuate uterus with rudimentary horn may be associated with many complications like infertility, endometriosis, hematometra, urinary tract anomalies, abortions, and preterm deliveries; 40% of women with unicornuate uterus have associated renal anomalies.

Incidence of pregnancy in the Rudimentary horn is rare and approximately 1 in 76,000-1,50,000. (2)

Pregnancy in the Non-Communicating Rudimentary horn has been described and is possible with transperitoneal migration of sperm or fertilized ovum. (3)

CASE REPORT: A 29 year old G3P2L2 who had previous 2 Caesarean sections outside, both for breech presentation, documented to have Unicornuate uterus with noncommunicating rudimentary horn on the left side in the first Caesarean delivery, came to our antenatal clinic at 8 weeks of amenorrhoea for routine antenatal checkup. She had regular (3-4/28) menstrual cycles with no history of dysmenorrhea. Urine pregnancy test positive 1 week after missing her period. She had no history of abdominal pain.

On examination, she had a pulse rate of 84/min, blood pressure 130/80mmHg, no pallor, abdomen soft and nontender, no mass felt per abdomen. Bimanual examination revealed a soft cervix, uterus anteverted, normal size with a non-tender, non-pulsatile cystic mass approximately 4cm in the left adnexa, cervical excitation test negative.

A routine transvaginal ultrasonogram was performed which showed a bicornuate uterus with a gestational sac in the left rudimentary horn with a fetal pole of approximately 6 weeks and 4 days with cardiac activity and no free fluid in the pelvis. (Fig. 1)

With history, clinical examination and USG, the diagnosis of rudimentary horn pregnancy was made and the patient was counselled for laparoscopic excision of the rudimentary horn.

Intraoperative findings-Normal sized unicornuate uterus with right tube and ovary seen. A left-sided rudimentary horn enlarged to 6 weeks' size and connected to the unicornuate uterus by a non-communicating fibrous band was noted. Left tube and ovary attached to the rudimentary horn. (Fig. 2)

Laparoscopic Resection of Rudimentary horn with left salpingectomy was done. (Fig. 3)

Specimen of Rudimentary horn with gestational sac was retrieved via colpotomy and sent for histopathology. HPR: Section from tissue shows myometrium and endometrium with extensive decidualisation. Few chorionic villi and trophoblastic cells are seen within the endometrial cavity. Section from smaller pieces show fallopian tube with congested vessels.

DISCUSSION: Rudimentary Horn in a unicornuate uterus results from failure of complete development of one of the Mullerian ducts and incomplete fusion with contralateral side. The attachment of the rudimentary horn to the main uterus can vary from a fibro-muscular band to extensive fusion between the two horns where there is no external separation between them; in this case it was the former.

In 83% of cases, the rudimentary horn is noncommunicating. (4)

Pregnancy in the rudimentary horn is associated with high rate of spontaneous abortion, preterm labor, IUGR, uterine rupture and intraperitoneal hemorrhage. The usual outcome of rudimentary horn pregnancies is rupture in the second trimester in 90% cases with fetal demise. The timing of rupture varies from 5 to 35 weeks and varies with the horn musculature and ability to hypertrophy and dilate. In 588 cases of rudimentary horn pregnancies, Nahum (2002) identified that half had uterine rupture and 80 percent did so before third trimester.

Imaging allows early diagnosis of rudimentary horn pregnancy (Edelman, 2003; Khati, 2012; Worley, 2008). Diagnosis can be made by USG or MRI.

Tubal ectopic pregnancy, cornual pregnancy, intrauterine pregnancy, and abdominal pregnancy are common sonographic misdiagnosis.

Tsafrir et al., proposed criteria for diagnosis of pregnancy in the rudimentary horn. (5)

1. Pseudo pattern of asymmetrical bicornuate uterus.

2. Absent visual continuity tissue surrounding gestational sac and uterine cervix.

3. Presence of myometrial tissue surrounding gestational sac.

It is recommended by most that immediate surgery be performed whenever a diagnosis of rudimentary horn pregnancy is made, even if unruptured. (6) as in this case wherein we performed a minimally invasive surgery at an early gestation. Prior documentation of the uterine anomaly as well as disparity in the clinical examination led to our diagnosis which was confirmed with the help of an early ultrasound.

However, in exceptional cases with larger myometrial mass, conservative management until viability is achieved has been advocated, if emergency surgery can be performed any time and the patient is well informed. (7) Medical management with methotrexate and its resection by laparoscopy is also reported. Edelman et al., showed a case detected at an early gestational week and treated successfully with methotrexate administration. (8)

If diagnosed in a non-pregnant woman, most recommend prophylactic excision of a horn that has a cavity (Fedele, 2005; Rackow, 2007). (9, 10, 11, 12) In our institution, resection of the rudimentary horn is done if detected incidentally during caesarean section in order to avoid complications that may necessitate emergency intervention.

REFERENCES:

(1.) Grimbizis GF, Gordts S, Di Spiezio Sardo A, Brucker S, De Angelis C, Gergolet M, Li TC, Tanos V, Bro'lmann H, Gianaroli L et al. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod 2013;28:2032-2044.

(2.) Nahum G: Rudimentary uterine horn pregnancy: case report on surviving twins delivered 8 days apart. J Reprod Med 1997; 42: 525-532.

(3.) Panayotidis C, Abdel Fattah, Leggott M: Rupture of rudimentary horn of unicornuate uterus at 15 weeks gestation J Obstet Gynaecol 2004; 24:323-324.

(4.) Heinonen PK: Unicornuate uterus and rudimentary horn Fertil Steril 1997, 68: 224-230.

(5.) Avi Tsafrir, Nathan Rojansky, Hen Yitzhak Sela, John Moshe Gomori, and Michel Nadjar Rudimentary Horn Pregnancy: First-Trimester Prerupture Sonographic Diagnosis and Confirmation by Magnetic Resonance Imaging Journal of Ultrasound in Medicine February 2005 24:219-223.

(6.) Yasmin Jayasinghe, Ajay Rane, Harry Stalewski et al: The presentation and early diagnosis of the rudimentary horn Obstet Gynecol 2005; 105:1456-1467.

(7.) Nahum G: Rudimentary horn pregnancy: The 20th century world wide experience of 588 cases J reprod Med 2002; 47: 151-163.

(8.) A. B. Edelman, J. T. Jensen, D. M. Lee, and M. D. Nichols, "Successful medical abortion of a pregnancy within a noncommunicating rudimentary uterine horn," American Journal of Obstetrics and Gynecology 2003; vol. 189, no. 3, pp. 886-887.

(9.) Laparoscopic removal of the cavitated noncommunicating rudimentary uterine horn: Surgical aspects in 10 cases Fedele, Luigi et al. Fertility and Sterility, Volume 83, Issue 2, 432-436.

(10.) Patrick I Okonta, Harrison Abedi, Caroline Ajuyah, Lawrence Omo-Aghoja:Pregnancy in the rudimentary horn of a unicornuate uterus: a case report Cases J. 2009; 2: 6624.

(11.) Deepa V Kanagal and Lokeshchandra C Hanumanalu: Ruptured rudimentary horn pregnancy at 25 weeks with previous vaginal delivery: a case report. Case Reports in Obstetrics and Gynecology, vol. 2012, Article ID 985076, 4 pages, 2012. doi:10.1155/2012/985076.

(12.) Y. Kadan and S. Romano 'Rudimentary horn pregnancy diagnosed by ultrasound and treated by laparoscopy-case report and review of the literature.' Journal of minimally invasive gynae: vol 15 no5 pp527-30 2008.

Meenakshi Menon R [1], Mini lsac [2], Jayasree Thankachi [3]

[1] Resident, Department of Obstetrics and Gynaecology, Maiankara Orthodox Syrian Church Medical College, Kolenchery.

[2] Professor, Department of Obstetrics and Gynaecology, Malankara Orthodox Syrian Church Medical College, Kolenchery.

[3] Professor and HOD, Department of Obstetrics and Gynaecology, Malankara Orthodox Syrian Church Medical College, Kolenchery.

Financial or Other, Competing Interest: None.

Submission 29-10-2015, Peer Review 30-10-2015, Acceptance 10-11-2015, Published 19-11-2015.

Corresponding Author: Dr. Meenakshi Menon R, C/o. C. R. Menon, 'Yoganidra', Parthasarathy Temple Street, Olarikkara, Pullazhi P.O, Thrissur-680012.

E-mail: rmeenamenon@gmail.com

DOI:10.14260/jemds/2015/2314
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Title Annotation:Case Report
Author:Menon, Meenakshi R.; Isac, Mini; Thankachi, Jayasree
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Nov 19, 2015
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