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DOI 10.1007/s00404-009-1013-4
O R I G I N A L A R T I CL E
Received: 14 December 2008 / Accepted: 12 February 2009 / Published online: 13 March 2009
© Springer-Verlag 2009
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908 Arch Gynecol Obstet (2009) 280:907–910
Preoperative diagnosis
screening committee.
Placenta previa
Rupture uterus
Rupture uterus
Results
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
G1
G1
G1
20
25
24
32
24
39
28
24
22
28
29
24
123
Arch Gynecol Obstet (2009) 280:907–910 909
Laprotomy and excision of the horn was done in all 88% [13], and 90% of deaths occurred within the Wrst
cases; with 75% found to have a non-communicating horn. 10–15 min of the onset of symptoms [14]. The most recent
Rudimentary horn was found on the left side in 58.3% of estimates of maternal mortality are less than 0.5%, despite
the cases. Rupture of the rudimentary horn was present in rupture rates of 50% [15]. In our study there were no mater-
majority (83.3%) of the women. In ten women salpingec- nal deaths despite the rupture of the rudimentary horn
tomy was done on the side of the rudimentary horn, and, occurring in 83.3% of the cases because of timely diagnosis
bilateral salpingectomy was done in two women who had and management.
completed their families. Mean hemoglobin level at the Pre-gestational diagnosis of rudimentary horn requires
time of admission was 6.80 § 1.72 gm/dl and majority of hysterosalpingography, hysteroscopy and laparoscopy,
them required multiple blood transfusions (mean 2.82 § 1.17 whereas prenatal diagnosis is attempted with ultrasonogra-
units per patient). 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
Discussion close monitoring is warranted due to the risks of rupture
and its complications [17]. Pre-gestational diagnosis was
Pregnancy in the rudimentary horn is always an emergency, not made in our patients; so they presented as emergencies
as rupture of the pregnant rudimentary horn can occur, as it during the index pregnancies in our series.
does mostly between 10 and 15 gestational weeks [6]. Early diagnosis of a rudimentary horn pregnancy is diY-
Although there are sporadic case reports of producing a live cult, particularly because women often have a history of
infant, the prognosis of pregnancy in the rudimentary horn previous normal pregnancies. Abdominal pain and collapse
is often poor for the patient [4, 7]. Rupture of the pregnant with hemoperitoneum can occur suddenly [15]. Pelvic
rudimentary horn causes heavy bleeding and threatens examination may suggest an adnexal mass, causing devia-
patient’s life. This study highlights the dilemma in early tion of the uterus and cervix to one side [18, 19]. Ultra-
diagnosis of these cases as preoperative diagnosis was pos- sound examination may reveal bicornuate uterus. An extra
sible only in four cases and majority of the women pre- uterine pregnancy with well deWned placenta diVerentiates
sented to emergency in shock requiring blood transfusions. an abdominal pregnancy from rudimentary horn pregnancy.
Rudimentary horn results from arrest in development of Thin endometrial lining which is not seen in continuity with
one of the mullerian ducts and incomplete fusion with con- the internal os, visualization of the sac separately form the
tralateral side. Pregnancy in the rudimentary horn is uterus and the greater distance from the horns may help to
extremely rare. Because the horn is noncommunicating in identify the rudimentary horn pregnancy [15]. It may be
approximately 80% of cases, fertilization is thought to take diYcult to diVerentiate placenta form pregnancy in the low
place by transperitoneal migration of gametes or in the anterior rudimentary horn by ultrasonography; as in one of
pouch of douglas [5, 7]. In a large prospective study involv- the cases in the present series [6]. Pre-operative diagnosis
ing unicornuate uteri, the unicornuate uterus with non-com- of the rudimentary horn was made in only six women by
municating horn was the most common type, with ultrasonography after an earlier diagnosis of intrauterine
prevalence of 83% [8]; which was also common in the pres- pregnancy in the present study. Magnetic resonancy
ent series with a prevalence of 75%. The mean age at pre- imaging can aid in the localization of the pregnancy in a
sentation in our study was 26 § 5.11 years which was rudimentary horn if ultrasonography is unable to conWrm
similar to the previous reported literature with majority of that the pregnancy is intrauterine [15]. Laparotomy will
the patients presented in the third decade with obstetric conWrm as well as cure this condition in case of a rupture.
complications. Conservative management during pregnancy is also
There is an increased risk of miscarriage, ectopic preg- reported in the literature in selected cases; in these cases
nancy, preterm labor, intrauterine growth retardation and access to immediate operative intervention is vital. Exci-
malpresentation [1, 8–10]. Failed termination of pregnancy sion of the rudimentary horn and ipsilateral salpingectomy,
and uterine evacuations have been reported [7, 11, 12]. In preferably conserving the ovary, is the surgical procedure
the present series, there were two women who had failed recommended for patients desiring to preserve the fertility
termination of pregnancy by medical method and were sub- potential; though hysterectomy may be necessary in life
sequently found to have rudimentary horn pregnancy. threatening hemorrhage. Laparoscopy can be used in
Most important danger of rudimentary horn pregnancy is unruptured cases [6, 20].
the risk of rupture because of poorly developed muscula- In conclusion, management of the rudimentary uterine
ture. Rupture occurs in 80–90% at mid trimester, and only horn continues to be a challenge to this day. Many women
10% reach term, with a fetal salvage rate of 2% [7]. Mater- having non communicating horns with endometrial activity
nal mortality in the 19th century was reported to be around may present with acute uterine rupture in pregnancy. Early
123
910 Arch Gynecol Obstet (2009) 280:907–910
diagnosis is the key to successful management, regardless 8. Heinonen P (1997) Unicornuate uterus and rudimentary horn.
of whether it is conservative or not. Maintaining a higher Fertil Steril 68:224–230
9. Soundararajan V, Rai J (2000) Laparoscopic removal of a rudi-
degree of alertness, especially in high risk groups, by mentary uterine horn during pregnancy. J Reprod Med 45:599–
medical and radiological staV and is required to prevent the 602
morbidity associated with this condition. 10. Suri V, Dhaliwal L, Prasad G, Pathak N, Gupta I (2002) Pregnancy
in a noncommunicating horn of a unicornuate uterus with fetal
ConXict of interest statement There is no actual or potential salvage. Acta Obstet Gynecol Scand 81:473–474
conXict of interest in relation to this article. 11. Ghosh N (1966) Pregnancy in the rudimentary horn of a bicornuate
uterus. Int Surg 46:567–572
12. Ural S, Artal R (1998) Third trimester rudimentary horn preg-
nancy. J Reprod Med 43:919–921
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