Prerupture Diagnosis Research Articles

Rudimentary horn pregnancy - ten years of experience.

This study aimed to evaluate data on early diagnosis and therapeutic management of rudimentary horn pregnancy (RHP). Patients diagnosed with RHP at a tertiary center between for two periods of 2008-2012 and 2013-2018 were analysed retrospectively. We obtained information of patients from hospital electronic archive registration system. Data on demographic characteristics, clinical presentation, gestational age at presentation, presenting symptoms, diagnostic methods, and therapeutic management were noted and analysed by descriptive statistical method. Demographic datas, the complaint of patient's admission to hospital, history of cesarean section, preliminary diagnosis and intraoperative diagnosis were compared between periods of 2008-2012 and 2013-2018. A total of 14 RHP patients were included. Eight (57.1%) of these patients were diagnosed between 2008-2012 (Group 1), whereas six patients (42.9%) were diagnosed between 2013-2018 (Group 2). Rudimentary horn was non-communicating in 13 patients (92.8%). Communicated form was observed in 1 patient in group 1. RHP was diagnosed on the left side in nine patients (64.2%). Six of these patients were observed in group 1 and 3 were in group 2. The pre-rupture diagnosis was made in 10 (71.4%) patients. Six (100%) of 10 patients were in group 2. In addition, in group 1, four patients (50%) experienced intraoperative RHP rupture. RHP was diagnosed before rupture in 2 (33.3%) patients in group 2. It is an indication of advanced ultrasonographic technology as well as increased carefulness on the physician side and raised alertness on the patient side that today both RHP and preoperative rupture of RHP are less frequent. Still, further awareness is required among physicians of the necessity of excision of a rudimentary horn that is detected at the time of C-section.

Conservative surgical management of a ruptured non–communicating rudimentary horn of pregnancy at 13 weeks period of gestation in previous caesarean delivery – A Rare Case Report

Introduction: Unicornuate uterus with Non– communicating rudimentary horn occurs due to failure of complete development of one of the Mullerian ducts and incomplete fusion with the contralateral side. Pre rupture diagnosis of pregnancy in rudimentary horn with ultrasonography is technically difficult and missed frequently (sensitivity 30%). Many times it is diagnosed during laparotomy. The standard treatment is excision of the ruptured horn. However, this is technically difficult due to distorted anatomy, time-consuming and can lead to more blood loss. In this case, the ruptured horn was repaired and the surgery was coupled with bilateral tubectomy. This is a new conservative approach to rupture the non-communicating horn of pregnancy. Case Report: A 27-year-old woman presented to us with a history of amenorrhea of 13 weeks and abdominal pain. Her obstetric score was Gravida 3 Para 2 Living 2. She had undergone 2 cesarean sections which were uneventful. On ultrasonography, the gestational sac was seen outside the uterus, hence a diagnosis of ruptured ectopic was made. As she was hemodynamically unstable and she had completed her family and consented for tubectomy, a decision to repair the horn was made. Conclusion: Diagnosis and management of rudimentary horn pregnancy remain a challenge. A high index of suspicion during a prenatal ultrasound can result in early diagnosis, and thereby resulting in decreased maternal morbidity and mortality. A Conservative surgical approach coupled with tubectomy in women who have completed their families can decrease operative time, blood loss and potential complications due to distorted anatomy.

Ruptured noncommunicating rudimentary horn of unicornuate uterus at 12 weeks

Pregnancy in a rudimentary horn of a unicornuate uterus is rare but ruptured horn has a mortality rate of 5%. We report a case of 26-year-old G4P3 L3 with previous full-term vaginal deliveries, who presented at 12-week gestation with severe abdominal pain. Transvaginal ultrasound imaging was suggestive of ruptured right ectopic pregnancy and patient was taken up for emergency laparotomy. Intraoperatively, 2500 cc hemoperitoneum was present and ruptured right rudimentary horn in the posterolateral part was found, with fetus in the pouch of Douglas, the uterus was of unicornuate type. Excision of ruptured right rudimentary horn along with the right salpingectomy was done. Despite advances in imaging, in developing countries where the prerupture diagnosis is unlikely, a high index of suspicion is crucial in saving mother's life.

Pregnancy in a noncommunicating rudimentary horn of a unicornuate uterus: Prerupture diagnosis and management

ObjectiveThe estimated incidence of rudimentary horn pregnancy is one in 76,000. It is a life-threatening entity with a 50% risk of uterine rupture. With advances in prenatal ultrasound in recent decades, there may be an opportunity to detect rudimentary horn pregnancy earlier, resulting in a lower incidence of maternal morbidity and mortality. Management is typically resection of the rudimentary horn and the ipsilateral fallopian tube by either laparotomy or laparoscopy. Case ReportHere, we present the case of a 22-year-old woman with a suspected ectopic pregnancy of 12 weeks' gestation. Ultrasound and magnetic resonance imaging were performed as preoperative evaluations. A definitive diagnosis was made during laparotomy, and resection of the rudimentary horn pregnancy was performed. ConclusionDiagnosis and management of rudimentary horn pregnancy remain a challenge. We should be alert to prenatal ultrasound with the intention of making an earlier diagnosis, thereby resulting in decreased maternal morbidity and mortality.

Suspect Rudimentary Horn Pregnancy in Failed Induction

Background: Pregnancy in a rudimentary horn is an extremely rare and life-threatening condition, as it mostly terminates by rupture by the second trimester of pregnancy. This article reports on a case of unruptured rudimentary horn pregnancy for which the diagnosis was initially missed at an 18 weeks' sonogram. Case: A 27-year-old woman, gravida 2, para 1, living 1, was referred to an obstetric unit at 24 weeks of gestation in view of failed induction for intrauterine death. This patient presented with intrauterine death, and abortion induction was attempted with a number of medicines. Induction was not successful; thus, a rudimentary horn pregnancy was suspected. This timely prerupture diagnosis and excision of the rudimentary horn was performed, thus reducing the patient's morbidity and potential mortality. Results: This patient's postoperative period was uneventful. Conclusions: Only 8% of rudimentary horn pregnancies are diagnosed before the symptoms appear. A careful pelvic examination, USG and MRI points towards diagnosis. (J GYNECOL SURG 31:95)

Rudimentary Horn Pregnancy: A Rare First Trimester Acute Presentation

Introduction: Rudimentary horn pregnancy (RHP), an entity with a diagnostic dilemma is known to rupture most commonly in second trimester, sometimes in early third trimester. This case of ectopic rudimentary horn (RH) presented acutely in the first trimester. Case Presentation: A 30 years old G 3 P 2 L 2 with previous two vaginal deliveries presented with acute abdominal pain and features of hemorrhagic shock at 8 weeks 5 days gestational age. With clinical diagnosis of ruptured ectopic pregnancy, the patient immediately underwent laparotomy, which revealed hemoperitoneum with a unicornuate uterus along with ruptured RHP. RH excision with ipsilateral salpingectomy and right tubal ligation was done and the maternal life salvaged. Conclusion: High index of suspicion based on clinical history and examination complemented with diagnostic radiological modalities can help in prenatal and pre-rupture diagnosis of RHP, hence its prompt treatment to alleviate scope of any emergency

Successful Twin Pregnancy after Pre-Rupture Diagnosis and Resection of Non-Communicating Rudimentory Horn: Case report

Successful Twin Pregnancy after Pre-Rupture Diagnosis and Resection of Non-Communicating Rudimentory Horn: Case report Rudimentary horn pregnancy is a rare condition with difficult diagnosis. Pregnancy in rudimentary horn usually gets ruptured during second trimester, resulting in life threatening conditions. Therefore early pre-rupture diagnosis is of major concern. We report a case with second trimester rudimentary horn pregnancy with fetal demise, which was diagnosed later after the failed induction on revaluation sonography and was managed successfully by resection of rudimentary horn. Postoperative period remained uneventful and later she conceived having successful twin pregnancy at present.

Value of Serial Ultrasounds in Early Diagnosis and Management of Prerupture Ovarian Ectopic Pregnancy: A Case Report

Background: Primary ovarian pregnancy is a rare form of ectopic pregnancy. Even with the advance of ultrasound techniques and the sonographic establishment of fetal development, most ovarian pregnancies are found ruptured at the time of diagnosis or are a surprise finding at the time of surgery. In these cases, the associated hemorrhage is usually heavy and in approximately 23% of cases, the patients develop hypovolemic shock requiring blood transfusion. Case: A 30-year-old female patient at 7.4 weeks by a certain LMP presented for prenatal care. An ultrasound at the time of presentation revealed no intrauterine gestational sac. There was however, a simple cystic mass contiguous with the left ovary. Subsequently, the patient had a BhCG level drawn which was not consistent with the ultrasound image and therefore was felt to be abnormal. A primary ovarian pregnancy was suspected after serial ultrasounds revealed an enlarging cystic ovarian mass and serial quantitative human Chorionic Gonadotripin (hCG) levels were abnormal. In addition, the patient started feeling left lower quadrant abdominal discomfort and reported a scant amount of vaginal bleeding. Due to the suspicion of a possible ovarian ectopic pregnancy, a diagnostic laparoscopy was discussed with the patient. The suspicion was solidified, in order to avoid rupture, a diagnostic laparoscopy was made and the ovarian ectopic pregnancy was confirmed. A wedge resection of the ovarian cyst was performed and the final histopathology confirmed a primary ovarian pregnancy. Conclusion: Ultrasounds have been proven safe for management of obstetrical patients. The sonographic parameters for fetal development from conception to delivery have been well established and published.2 At this time, ultrasound is the best tool in detecting abnormal fetal development in pregnancy. In this case, serial ultrasound examinations in the early stage of the first trimester and inappropriately rising serial BhCG levels provide the clues for detecting the prerupture diagnosis of ovarian ectopic pregnancy. The combination of these two modalities and pelvic examination increase the suspicion of a diagnosis of an ovarian pregnancy and will lead to a prompt intervention to prevent morbidity, mortality and to the preservation of future fertility.

Ruptured Noncommunicating Rudimentary Horn Pregnancy at 19 Weeks with Previous Cesarean Delivery: A Case Report

Unicornuate uterus with noncommunicating rudimentary horn occurs due to incomplete fusion of mullerian ducts. Pregnancy in this horn is a rare phenomenon usually resulting in rupture during second trimester of pregnancy. Prerupture diagnosis of pregnancy in rudimentary horn with ultrasonography is technically difficult, with sensitivity of 30%. We report a case of ruptured non-communicating rudimentary horn at 19 weeks in a woman with previous Cesarean delivery. She had a routine malformation scan in which diagnosis was missed. Later she presented to emergency in shock, with massive hemoperitoneum and ruptured horn. So a high index of suspicion is required to save this catastrophic event and associated maternal morbidity and mortality. In our opinion, routine excision of rudimentary horn should be undertaken during nonpregnant state laparoscopically. However, those women who refuse should be adequately counseled regarding potential complications and if pregnancy occurs in rudimentary horn, first trimester laparoscopic excision should be done.

Rudimentary horn pregnancy: Pre-rupture diagnosis and management

Rudimentary horn pregnancy is a rare obstetric entity and the diagnosis and management may pose some problems especially in a low-resource center. We report our experience in diagnosing and managing a case of fetal death in a rudimentary horn.

Rudimentary horn pregnancy: Prerupture diagnosis and management

A unicornuate uterus with a rudimentary horn is a rare mullerian abnormality which may cause many gynecological and obstetrical complications. Rupture of pregnant rudimentary horn in the second trimester is the usual presentation, resulting in maternal morbidity and even mortality.

The Presentation and Early Diagnosis of the Rudimentary Uterine Horn

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. 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. 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. 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%). 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.

Magnetic resonance imaging and angiography for the prerupture diagnosis of rudimentary uterine horn pregnancy

Magnetic resonance (MR) imaging and MR angiography were used for the differential diagnosis and preoperative planning of a 17 weeks of age rudimentary horn pregnancy. A 26-year-old primigravida was referred to our hospital with a preliminary diagnosis of abdominal pregnancy. After an inconclusive ultrasound evaluation we were able to identify a rudimentary horn pregnancy, extent of the placental invasion, and the vascular supply via MR imaging and time of flight sequence MR angiography. The obtained data were also used for preoperative planning, which resulted in an uncomplicated, prerupture laparotomy for pregnancy termination and a healthy female.

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

A case of pregnancy in the rudimentary horn of a unicornuate uterus, suspected on routine pelvic examination and confirmed by sonography as early as at 8 weeks of gestation is presented. Ultrasonographic findings of the case and surgical management of ipsilateral adnexa at the time of excision of rudimentary horn are discussed.

Preoperative Endovaginal Sonographic Diagnosis of an Unruptured Interstitial Pregnancy

Interstitial pregnancies carry a higher maternal morbidity and mortality rate, due to the abundant ovarian and uterine arterial supply of this region, than do other tubal pregnancies. Prerupture diagnosis is crucial, inasmuch as rupture (which usually occurs at a later stage than in tubal gestations) may be followed by rapid exsanguination. Precise early diagnosis may permit conservative nonsurgical treatment with methotrexate. A case is presented in which preoperative diagnosis of an unruptured interstitial pregnancy was aided by endovaginal sonographic examination. Considerations of subsequent management are discussed.

Improved Fertility following Ectopic Pregnancy

The reproductive performance subsequent to operative removal of ectopic pregnancy was examined in 154 women. They represent 64% of 242 women admitted for ectopic pregnancy between 1969 and 1979. The follow-up period averaged 42 years. The patients at risk had a conception rate of 81%, with a repeat ectopic pregnancy incidence of 7.8%, and 65% had at least one live birth. Postoperative infertility was significantly associated with (1) previous sterility, (2) coexistent periadnexal adhesions and/or tubal disease, (3) rupture of the ectopic pregnancy, and (4) older age. A statistically significant advantage of conservative over radical treatment, as regards future fertility, was demonstrated only in 53 patients with either history or findings suggestive of previously impaired fertility. Early, prerupture diagnosis and treatment, coupled with conservative and restorative measures, might account for the improved reproductive performance.

Improved fertility following ectopic pregnancy

The reproductive performance subsequent to operative removal of ectopic pregnancy was examined in 154 women. They represent 64% of 242 women admitted for ectopic pregnancy between 1969 and 1979. The follow-up period averaged 4.2 years. The patients at risk had a conception rate of 81%, with a repeat ectopic pregnancy incidence of 7.8%, and 65% had at least one live birth. Postoperative infertility was significantly associated with (1) previous sterility, (2) coexistent periadnexal adhesions and/or tubual disease, (3) rupture of the ectopic pregnancy, and (4) older age. A statistically significant advantage of conservative over radical treatment, as regards future fertility, was demonstrated only in 53 patients with either history or findings suggestive of previously impaired fertility. Early, prerupture diagnosis and treatment, coupled with conservative and restorative measures, might account for the improved reproductive performance.