Spectrum of Rudimentary Horn Pregnancy: A Case Series

Prerupture Diagnosis of RHP with Laparoscopic Resection of the Noncommunicating Rudimentary Horn

A 30-year-old G₃P₁D₁A₁ was referred from a subdistrict hospital to our obstetric casualty with a referral letter stating uterine anomaly with the missed abortion of 8 + 2 weeks gestation with patent ductus arteriosus (PDA). She had history of amenorrhea for 2 months with complaints of bleeding per vaginum on and off since 5 days and lower abdominal pain since 2 days. She was married sin ce 7 years. All her previous conceptions were spontaneous. She had a full-term cesarean section before 4 years for severe preeclampsia with abruptio placentae. Intraoperative notes from discharge card suggested unicornuate uterus without rudimentary horn, followed by a spontaneous abortion at 2 months before 2 years. The patient has been regularly following up with a cardiologist and on regular medications for PDA (2 mm with L to R shunt). No other significant medical history. On admission, her vitals were stable. On per abdominal examination 4 × 4 cm vague tender mass palpable in the right iliac fossa. On per speculum examination, altered color brownish discharge seen coming through os, single cervix is seen. Bimanual examination revealed soft cervix, uterus corresponding to 8 weeks gestation deviated more toward the left and 4 × 4 cm right adnexal mass present. Cervical excitation present. Her investigation revealed Hb 10.3 g/dL and the rest of the blood counts, urea and creatinine were within normal limits. USG reveals uterus 9 × 4.1 × 5.8 cm with no gestational sac in the cavity or the cervical canal. A complex mass of 6 × 5.5 cm separate from the right ovary with increased vascularity was present suggesting an ectopic pregnancy and left ovary and fallopian tube were normal. No free fluid present. The decision of laparoscopy was taken after anesthetic and cardiologist fitness. Intraoperative findings were as follows:

• Omentum found adhered to anterior abdominal wall, adhesiolysis done.
• Bulky unicornuate uterus.
• Left ovary with fallopian tube normal.
• Right-sided noncommunicating RHP (Fig. 1A) attached to the lateral pelvic wall through a small band of fibrous tissue extending from the body of the uterus (Fig. 1B).
• Right ovary normal attached to the right lateral pelvic wall.
• No hemoperitoneum.

Products of conception were suctioned through a small incision over the rudimentary horn (Fig. 1C), rest of the horn was excised and removed through the umbilical port. Postoperative recovery was uneventful.

Ruptured Rudimentary Horn Pregnancy in Second Trimester—An Acute Obstetric Event

A 26-year-old primigravida was referred to our emergency department from rural health center with a diagnosis of 18 weeks gestation with ruptured ectopic pregnancy of the right fallopian tube.

She had a history of vague lower abdominal pain on and off since 1 month with acute abdominal pain and three episodes of vomiting since last 12 hours and syncopal attack with shoulder tip pain since 30 minutes. No other significant medical and surgical illness. She was married since 2 years, spontaneously conceived. Urine pregnancy test done at home at 60 days of amenorrhea. Unregistered for antenatal care (ANC) with no dating scan.

On examination, she was anemic and dehydrated. Pulse rate 126 bpm, rapid feeble, systolic BP 80 mm Hg, and diastolic BP not recordable. Respiratory rate 22/minute. On per abdominal examination, uterus size could not be made out, guarding and rigidity present. Per speculum examination reveals small blood clots through os. Bimanual examination shows fullness in fornices with cervical tenderness. Abdominopelvic ultrasound from the referral center shows a fetus corresponding to 16 weeks gestation with no cardiac activity in the right adnexa. Gross hemoperitoneum present. Diagnosis of ruptured ectopic pregnancy was made. The decision of exploratory laparotomy was taken after resuscitation. Intraoperative findings are as follows:

• Unicornuate uterus
• Left ovary and fallopian tube normal
• Right ovary appears normal, attached to lateral pelvic wall
• Ruptured right-sided communicating RHP (Fig. 2A)
• Fetus (140 g) with placental tissue present free in peritoneal cavity (Fig. 2B)
• Hemoperitoneum of 1500 mL present

Rudimentary horn excised.

Her postoperative recovery was good. Patient discharged home on postoperative day 7. Patient counseled regarding contraception and the need for early ANC and elective cesarean section in forthcoming pregnancies.

Ruptured Rudimentary Horn Pregnancy with Secondary Abdominal Pregnancy

A 29-year-old G₂P₁L₁ with 8 months amenorrhea was seen in our obstetric casualty with a referral from suburban health center with renal colic. She came with complaints of acute lower abdominal pain radiating to the right loin since 2 days with burning and increased frequency of micturition. She also had complaints of constipation on and off. She had no complaints of bleeding per vaginum or leaking. Rest of her antenatal period was uneventful except for the painful fetal movements. She had a full-term cesarean section before 3 years for meconium-stained liquor with fetal distress in the first stage of labor. Her antenatal and puerperal periods were uneventful. No discharge notes available with the patient. In the present pregnancy, she was booked case at a suburban district hospital with six to seven antenatal visits. She gave a history of admission at the same hospital at 3 months gestation with acute abdominal pain and vomiting. Her complaints were relieved and her condition improved with symptomatic treatment.

She had multiple ANC USG reports from different ultrasound centers. Her first antenatal ultrasound was done at 14 + 5 weeks gestation suggestive of bicornuate unicollis uterus with pregnancy in the right horn and left horn empty. Placenta found developing posterior in the upper segment. Following that, she had done her second ultrasound at 27 + 3 weeks gestation suggestive of bicornuate uterus with globular placenta covering internal os. AFI—18 cm. Her third ultrasound report suggested single live intrauterine gestation in changing presentation with placenta covering internal os with AFI 7 cm.

On examination, she was moderately nourished. On abdominal examination, uterus corresponding to 34 weeks gestation. Fetus in an oblique lie with head on maternal right. Uterine contour not well maintained. Fetal parts were easily palpable. FHS 138 bpm heard with hand Doppler.

The patient was advised admission, her complete blood count and MSU were done. Blood count was within normal limits and MSU showed gram-negative bacilli. Urine alkalinizer and antibiotics were given. The patient felt better after 48 hours of admission. Routine antenatal growth scan was done, suggested single live fetus corresponding to 33 weeks gestation in transverse lie (head towards maternal left), placenta present over the anterior wall with e/o multiple hypoechoic islands within, with loss of hypoechoic zone between the uterus and bladder s/o placenta accreta.

On day 5 of admission, the patient had complaints of reduced fetal movements since morning. Nonstress test suggested suspicious trace. Ultrasound by senior obstetrician done for AFI—2 cm with placenta seen in the upper segment not related to the internal os. Decision of emergency cesarean section was taken. Neonatalogist informed for the high-risk preterm neonate. Adequate blood products arranged.

Under regional anesthesia, the abdomen was opened by midline vertical incision.

Intraoperative findings are as follows:

• Single live fetus was found in transverse lie in the abdominal cavity with no amniotic cavity and liquor. Baby delivered by breech and cord clamped.
• Uterus unicornuate intact, enlarged to 12 weeks size.
• On further exploration, Placenta was found attached to the ruptured rudimentary right horn (Fig. 3A).
• Placenta was vascular and fragile with hyperplacentosis (Fig. 3B). Edges carefully palpated to determine its insertion.
• Rudimentary horn along with the placenta was removed.
• Abdomen thoroughly examined. Intestine liver and splenic surfaces were examined.
• Abdomen closed after hemostasis.

Postoperative recovery was uneventful. Healthy mother and newborn (2.25 kg) were discharged on the tenth postoperative day.