Arch Gynecol Obstet (2009) 280:907–910
DOI 10.1007/s00404-009-1013-4
O R I G I N A L A R T I CL E
Obstetric morbidity and the diagnostic dilemma in pregnancy
in rudimentary horn: retrospective analysis
Seema Chopra · Anish Keepanasseril ·
Meenakshi Rohilla · Rashmi Bagga ·
Jaswinder Kalra · Vanita Jain
Received: 14 December 2008 / Accepted: 12 February 2009 / Published online: 13 March 2009
© Springer-Verlag 2009
Abstract
Background Pregnancy in rudimentary horn of uterus, a
form of ectopic gestation, is associated with signiWcant
rates of morbidity and mortality. Despite the recent
advances in the ultrasonography, diagnosis of cornual preg-
nancy still remains elusive; with conWrmatory diagnosis
usually made during laparotomy. The aim of the present
study is to analyze the obstetric implications and the diag-
nostic 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 north-
ern India; were reviewed for their diagnostic diYculties and
the associated morbidity.
Results During the four year study period, rudimentary
horn pregnancies accounted for 12 pregnancies. Non com-
municating 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 trans-
fusions were required in 83.3% of women.
Conclusion Management of pregnancy in a rudimentary
uterine horn continues to be a challenge to this day. Main-
taining a higher degree of alertness, especially in high risk
groups by emergency staV is required to prevent the
S. Chopra (&) · A. Keepanasseril · M. Rohilla · R. Bagga ·
J. Kalra · V. Jain
Department of Obstetrics and Gynecology,
Postgraduate Institute of Medical Education and Research
(PGIMER), Sector-12, Chandigarh 160012, India
e-mail: drseemachopra@yahoo.com
morbidity, as they may present with acute uterine rupture in
pregnancy.
Keywords Rudimentary horn pregnancy ·
Mullerian anomaly · Ectopic pregnancy
Introduction
Anatomical aberrations of the female genital tract result
from abnormal fusion of the mullerian ducts and failure of
absorption of the female genital tract. The prevalence of
congenital uterine anomalies among fertile women is
reported as 1:200 to 1:600, whereas that of unicornuate
uterus with rudimentary horn is even rare (1 in 100,000)
[1]. Many women remain asymptomatic where as some of
them are diagnosed by the presence of infertility or obstetri-
cal complications such as recurrent pregnancy loss, malpre-
sentation, and premature labor [2–4].
Unicornuate uterus is caused by the non development of
the mullerian duct; usually associated with various degrees
of rudimentary horn which may be communicating or non-
communicating with the cavity of the uterus. Pregnancy in
the rudimentary horn is rare and represents a form of
ectopic gestation, with a reported incidence of one in
100,000 to one in 140,000 pregnancies [5]. Due to variable
muscular constitution of the rudimentary horn; pregnancy
can be accommodated up to varying gestation in diVerent
women. It often presents as rupture of the uterine wall in
the second trimester, manifesting as acute abdominal pain
with intraperitoneal hemorrhage, with high risk of maternal
morbidity and mortality. Despite the recent advances in the
ultrasound, diagnosis of cornual pregnancy remains elusive
with conWrmatory diagnosis usually made during laprot-
omy. The aim of the present study is to analyze the obstetric
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908 Arch Gynecol Obstet (2009) 280:907–910

implications and review the diagnostic dilemma of rudi-

Non communicating rudimentary horn, right (2,000 ml)

Non communicating rudimentary horn, right (1,000 ml)

Non communicating rudimentary horn, right (2,500 ml)

Non communicating rudimentary horn, left (1,500 ml)

Non communicating rudimentary horn, left (1,200 ml)

Non communicating rudimentary horn, left (1,700 ml)
mentary horn pregnancy.

Non communicating rudimentary horn, left (800 ml)

Non communicating rudimentary horn, left (600 ml)
Communicating rudimentary horn, right (1,000 ml)

Communicating rudimentary horn, right (200 ml)

Non communicating rudimentary horn, left (0)
Communicating rudimentary horn, left (0)
Materials and methods

Intraoperative diagnosis [blood loss (ml)]

Records of women diagnosed with ectopic pregnancy, who
were managed under the Department of Obstetrics and
Gynecology, Nehru Hospital attached to Postgraduate Insti-
tute of Medical Education and Research, Chandigarh were
reviewed from year 2004 to 2008. All women diagnosed to
have pregnancy in the rudimentary horn, either preopera-
tive using ultrasonography (transabdominal and transvagi-
nal) or during laprotomy were included in the study. Their
data was analyzed with regards to the gestational age at pre-
sentation, presenting feature, the diagnostic method and
management. Since this was a retrospective study analyzing

Unruptured ectopic pregnancy

Rudimentary horn pregnancy
Rudimentary horn pregnancy

Rudimentary horn pregnancy

Rudimentary horn pregnancy

the records, clearance from ethical committee was not

Rupture ectopic pregnancy

Rupture ectopic pregnancy

Rupture ectopic pregnancy

Rupture ectopic pregnancy

obtained; however this was approved by the departmental

Preoperative diagnosis
screening committee.

Placenta previa
Rupture uterus
Rupture uterus
Results

There were 224 ectopic pregnancies managed in our hos-

pital during the 4-year study period and rudimentary horn Pain abdomen, hypotension, bleeding per vaginum
pregnancies accounted for 12 pregnancies. The mean age Failed MTP, pain abdomen, bleeding per vaginum
of these women at presentation was 26 § 5.11 years.

Rupture uterus with intrauterine fetal death

Period of gestation at diagnosis varied between 10 and

20 Infertility, pain abdomen, hypotension

Pain abdomen, hypotension, pelvic mass

34 weeks, with majority of them presenting in the late

Pain abdomen, bleeding per vaginum

Wrst trimester or early second trimester (mean-20.25 §
8.6 weeks). Majority of the women (83.3%) presented to Pain abdomen, syncopal attack
Table 1 Characteristics of the women with pregnancy in rudimentary horn

the emergency with acute abdomen and were found to be

Pain abdomen, hypotension
Pain abdomen, hypotension

Pain abdomen, hypotension

Pain abdomen, pelvic mass

in hypotension. Medical termination of pregnancy was

attempted in two women with Mifepristone and Miso-
Presenting feature

prostol prior to admission in our hospital; who were later

diagnosed to have rudimentary horn pregnancy when
Failed MTP

investigated for the method failure. Characteristics of

these women who had rudimentary horn pregnancies are
shown in Table 1.
On admission, hemoperitoneum was present in 83.3%
diagnosis (weeks)

women, with one woman developing disseminated intra-

vascular coagulation. Vaginal examination revealed an
gestation at

adnexal mass in 16.7% of women. Initial ultrasonographic

Period of

examination revealed ectopic pregnancy in 50%, rupture

uterus in 16.6% and the remaining 41.7% were found to
16
15
24
30
24
14
12
15
15
10
34
34

have an intrauterine pregnancy with intrauterine fetal death.

Six women had a repeat ultrasonography and four of them
Obstetric

G 2 P 1 L0

G 4 P 3 L3

G 2 P 1 L1

G 2 P 1 L1

G 2 P 1 L1
G 3 P2 L 2
history

G4 A3

G3 A2

were diagnosed to have rudimentary horn pregnancy. In

G1

G1

G1

G1

one case the rudimentary horn was mistakenly diagnosed as

placenta previa with intrauterine fetal demise. Prerupture
(years)

diagnosis of the rudimentary horn was made only in 16.7%

Age

20
25
24
32
24
39
28
24
22
28
29
24

(2/12) of the cases.

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Arch Gynecol Obstet (2009) 280:907–910
Laprotomy and excision of the horn was done in all
cases; with 75% found to have a non-communicating horn.
Rudimentary horn was found on the left side in 58.3% of
the cases. Rupture of the rudimentary horn was present in
majority (83.3%) of the women. In ten women salpingec-
tomy was done on the side of the rudimentary horn, and,
bilateral salpingectomy was done in two women who had
completed their families. Mean hemoglobin level at the
time of admission was 6.80 § 1.72 gm/dl and majority of
them required multiple blood transfusions (mean 2.82 § 1.17
units per patient).
Discussion
Pregnancy in the rudimentary horn is always an emergency,
as rupture of the pregnant rudimentary horn can occur, as it
does mostly between 10 and 15 gestational weeks [6].
Although there are sporadic case reports of producing a live
infant, the prognosis of pregnancy in the rudimentary horn
is often poor for the patient [4, 7]. Rupture of the pregnant
rudimentary horn causes heavy bleeding and threatens
patient’s life. This study highlights the dilemma in early
diagnosis of these cases as preoperative diagnosis was pos-
sible only in four cases and majority of the women pre-
sented to emergency in shock requiring blood transfusions.
Rudimentary horn results from arrest in development of
one of the mullerian ducts and incomplete fusion with con-
tralateral side. Pregnancy in the rudimentary horn is
extremely rare. Because the horn is noncommunicating in
approximately 80% of cases, fertilization is thought to take
place by transperitoneal migration of gametes or in the
pouch of douglas [5, 7]. In a large prospective study involv-
ing unicornuate uteri, the unicornuate uterus with non-com-
municating horn was the most common type, with
prevalence of 83% [8]; which was also common in the pres-
ent series with a prevalence of 75%. The mean age at pre-
sentation in our study was 26 § 5.11 years which was
similar to the previous reported literature with majority of
the patients presented in the third decade with obstetric
complications.
There is an increased risk of miscarriage, ectopic preg-
nancy, preterm labor, intrauterine growth retardation and
malpresentation [1, 8–10]. Failed termination of pregnancy
and uterine evacuations have been reported [7, 11, 12]. In
the present series, there were two women who had failed
termination of pregnancy by medical method and were sub-
sequently found to have rudimentary horn pregnancy.
Most important danger of rudimentary horn pregnancy is
the risk of rupture because of poorly developed muscula-
ture. Rupture occurs in 80–90% at mid trimester, and only
10% reach term, with a fetal salvage rate of 2% [7]. Mater-
nal mortality in the 19th century was reported to be around
909
88% [13], and 90% of deaths occurred within the Wrst
10–15 min of the onset of symptoms [14]. The most recent
estimates of maternal mortality are less than 0.5%, despite
rupture rates of 50% [15]. In our study there were no mater-
nal deaths despite the rupture of the rudimentary horn
occurring in 83.3% of the cases because of timely diagnosis
and management.
Pre-gestational diagnosis of rudimentary horn requires
hysterosalpingography, hysteroscopy and laparoscopy,
whereas prenatal diagnosis is attempted with ultrasonogra-
phy especially transvaginal [16]. If a woman with a preges-
tational suspicion of rudimentary horn becomes pregnant
and pregnancy in the rudimentary horn is suspected, then
close monitoring is warranted due to the risks of rupture
and its complications [17]. Pre-gestational diagnosis was
not made in our patients; so they presented as emergencies
during the index pregnancies in our series.
Early diagnosis of a rudimentary horn pregnancy is diY-
cult, particularly because women often have a history of
previous normal pregnancies. Abdominal pain and collapse
with hemoperitoneum can occur suddenly [15]. Pelvic
examination may suggest an adnexal mass, causing devia-
tion of the uterus and cervix to one side [18, 19]. Ultra-
sound examination may reveal bicornuate uterus. An extra
uterine pregnancy with well deWned placenta diVerentiates
an abdominal pregnancy from rudimentary horn pregnancy.
Thin endometrial lining which is not seen in continuity with
the internal os, visualization of the sac separately form the
uterus and the greater distance from the horns may help to
identify the rudimentary horn pregnancy [15]. It may be
diYcult to diVerentiate placenta form pregnancy in the low
anterior rudimentary horn by ultrasonography; as in one of
the cases in the present series [6]. Pre-operative diagnosis
of the rudimentary horn was made in only six women by
ultrasonography after an earlier diagnosis of intrauterine
pregnancy in the present study. Magnetic resonancy
imaging can aid in the localization of the pregnancy in a
rudimentary horn if ultrasonography is unable to conWrm
that the pregnancy is intrauterine [15]. Laparotomy will
conWrm as well as cure this condition in case of a rupture.
Conservative management during pregnancy is also
reported in the literature in selected cases; in these cases
access to immediate operative intervention is vital. Exci-
sion of the rudimentary horn and ipsilateral salpingectomy,
preferably conserving the ovary, is the surgical procedure
recommended for patients desiring to preserve the fertility
potential; though hysterectomy may be necessary in life
threatening hemorrhage. Laparoscopy can be used in
unruptured cases [6, 20].
In conclusion, management of the rudimentary uterine
horn continues to be a challenge to this day. Many women
having non communicating horns with endometrial activity
may present with acute uterine rupture in pregnancy. Early
123
910
diagnosis is the key to successful management, regardless
of whether it is conservative or not. Maintaining a higher
degree of alertness, especially in high risk groups, by
medical and radiological staV and is required to prevent the
morbidity associated with this condition.
ConXict of interest statement There is no actual or potential
conXict of interest in relation to this article.
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