A rare case of term pregnancy with a live fetus in a non-communicating

rudimentary horn of uni-cornuate uterus

Mohideen Fathima.,Chitra.,

Abstract
A case report of a live birth following a term pregnancy located in a non-communicating rudimentary
horn of a unicornuate uterus is presented. A 31-year old G2P1L1 who was registered for antenatal
care at a PHC got admitted in Kanyakumari Government Medical College Hospital with labour
pains. She had an emergency cesarean section at 38 weeks gestational age on account of a persistent
breech presentation with oligohydramnios .Intra-operatively, the pregnancy was found in a non-
communicating rudimentary horn. A female baby, weighing 3.5 kg with no gross deformity was
delivered. Resection of the rudimentary horn and repair were done.But due to brisk hemorrhage
from the margins of the uterus, hysterectomy was done, leaving behind both ovaries.A thorough
ultrasonographic examination should be performed in the first trimester on the aspects of the
pregnancy and the pelvic anatomy to reduce maternal morbidity and mortality.
Keywords: Live birth, Rudimentary horn, Term pregnancy, Unicornuate uterus

Introduction
Congenital anomalies of female genital tract usually results from abnormalities in the
embryogenesis of mullerian duct system. The prevalence of congenital uterine anomalies is 6.7 %. In
women with a history of repeated pregnancy loss, the rate of mullerian anomalies increases to 3
25 %. Unicornuate uterus with a rudimentary horn is a very rare type of Mullerian duct anomaly and
in up to 80% of cases there is no communication between the unicornuate uterus and the rudimentary
horn. Pregnancy in such a rudimentary horn is extremely rare. Diagnosis of rudimentary horn
pregnancy is challenging. In only 29% of cases are diagnosis made prior to surgery.1 The natural
course of a rudimentary horn pregnancy is rupture during the first or mid-second trimester majority
occuring before 20 weeks of gestation with potentially life-threatening bleeding . This case report
highlights an unruptured term rudimentary horn pregnancy resulting in an intra-operative diagnosis
and a live birth.

CASE REPORT
Mrs. X was a 31-year old G2P1L1 , EDD 20/12/16 from Boothapandy, Kanyakumari district
.She was a booked case in a primary health centre. Her antenatal period was uneventfull. Around 38
weeks, she was admitted in Kanyakumari Government Medical College Hospital with labour pains.
On admission, the patient was found to be stable. Her pulse was 88/m and BP was 110/70 mm Hg.
On obstetric examination, she was 38 weeks pregnant, breech presentation, the uterus was term,
acting, not tense, not tender. FHS was 132/m regular. As per speculum examination, the cervix was
posterior, and her cervical os was closed. Her Hb% was 9.4 g/dl. Ultrasound in our center was
suggestive of 38 weeks pregnancy with , breech presentation and oligohydramnios (AFI = 6.5).

Cesarean section was done for breech with oligohydramnios. The abdominal cavity was
entered through a Pfannenstiel incision. The baby was delivered through a low transverse uterine
incision . AMSTL carried out. Placenta was removed in toto. Uterus was contracted. After
exteriorization of the uterus, intraoperatively, we found that the uterine incision was made in the
large left-sided uterine horn, with a normal sized right sided uterus. There was no communication
between the rudimentary horn and the main uterine cavity. The left rudimentary horn and the left
tube was excised en bloc. After the removal of the rudimentary horn, brisk hemorrhage occurred
from the margins of the uterus, and to control it, hysterectomy was done, leaving behind both
ovaries. Patient delivered a live-term female baby, weighing 3.5 kg with good APGAR score of 7and
9 at 1 and 5 min, respectively, and no apparent gross deformity. Four units of packed red cells were
transfused to the patients along with 2 units FFP intra and post operatively.

A pregnancy in a non-communicating rudimentary horn was confirmed only at the time of

surgery. Pathological and histological findings confirmed a left-sided non-communicating
rudimentary horn with cavity. The next day her temperature, pulse and blood pressure were all
normal , except that her hemoglobin was 8.2mg/dl.. Post-op recovery was uneventful. Patient was
discharged on the 9th postoperative day in stable condition.

Discussion

The unicornuate uterus with a non-communicating rudimentary horn results from the normal
development and maturation of one of the mllerian ducts with concomitant hypoplasia of the
contralateral mllerian duct. According to the American Fertility Society (AFS), unicornuate
uterus mllerian duct anomalies are classified as follows: CLASS A is with cavity, communicating
with the uterus; CLASS B is with cavity, not communicating with the uterine; CLASS C is
without cavity; and CLASS D is without horn.5

Pregnancy in a non-communicating rudimentary horn is considered to be the result of

transperitoneal migration of either the ovum or the zygote from the contralateral side. Previous
reports demonstrated that uterine rupture occurred in 80% of rudimentary horn pregnancies and most
pregnancies in these cases ruptured in the second trimester before the 20th week of gestation.1 Despite
early ultrasonography, it is still difficult to make a clear diagnosis of pre-rupture rudimentary horn
pregnancy. The preoperative diagnosis is provided in only 22% gynecologic and 29% obstetric cases,
so most diagnoses are confirmed only after laparotomy 2. Few cases are diagnosed in the first
trimester and most of them are asymptomatic or have a uterine abnormality as described previously.
Magnetic resonance imaging has proven to be a very effective, noninvasive tool for the diagnosis of
mllerian abnormalities, but this modality is expensive for routine use, except when rudimentary
horn pregnancy is suspected either by history or by early suspicious ultrasound examinations. As a
result, late or wrong diagnosis resulting in uterine rupture is frequent.3

For a precise diagnosis and protect maternal health, routine ultrasonographic diagnosis in the
first trimester is important. However, the overall sensitivity of ultrasonography for diagnosing a
rudimentary horn or rudimentary horn pregnancy is actually low at early pregnancy, especially when
it is used for the differential diagnosis of ectopic pregnancy with other uterine malformations, such as
uterus biconis, uterus duplex and mediastinum uterus, suggesting that clinicians should pay more
attention to pregnancy combined with uterine malformation during routine obstetric examinations,
especially, when there is a possibility of an ectopic pregnancy in a rudimentary horn which is
characterized by malpresentation or other complications. When these circumstances occur, some
necessary measures must be implemented immediately according to symptoms. Termination of
pregnancy should also be performed, if necessary, once a rudimentary horn pregnancy is confirmed
and the horn excised 4.

Firstly, cases of pregnancy in the rudimentary horn with a full-term delivery have rarely been
reported, so far, especially a patient who gave birth to a healthy baby. Secondly, during routine
obstetric examination, our patient had none of the typical manifestations usually found in
rudimentary horn pregnancies. Borderline oligohydramnios should not be due to rudimentary horn,
while malpresentation might be attributed to rudimentary horn because there was less space available
for favorable adaptation of the fetal head in the uterus.3 Thirdly, although such cases are rare,
clinician should be aware of this life-threatening condition and, once it is identified, mandatory life
saving procedures such as timely laparotomy and immediate removal of the horn should be
performed to prevent spontaneous rupture and possible catastrophic consequences. Hysterectomy
may be necessary in case of massive hemorrhage 2.Laparoscopic resection is limited to pre-rupture
first trimester cases and it was reported to be successful in some cases. Last but not least, this case
may shed light on correct diagnosis and differential diagnosis of rudimentary horn pregnancy when
this circumstance occurs in the future, in order to effectively reduce the rate of missed diagnosis and
misdiagnosis of this condition.

Conclusion:
Rudimentary uterine horn pregnancy should always be considered as a differential diagnosis of
intrauterine pregnancy in a bicornuate uterus. A thorough ultrasonographic examination should be
performed in the first trimester on the aspects of the pregnancy and the pelvic anatomy to reduce
maternal morbidity and mortality.
References:
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communicating rudimentary horn of a unicornuate uterus. Ann Med Health Sci Res.
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588 cases. J Reprod Med. 2002;47:15163
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noncommunicating rudimentary horn. Indian J Med Sci. 2007;61:237.