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

Distinguishing between cornual, angular and interstitial ectopic pregnancy: A case report and a brief literature review

For all clinical purposes, cornual, angular, and interstitial pregnancies are considered ectopic pregnancies that can have grave consequences for the patient. In this article, we describe and distinguish 3 types of ectopic pregnancies in the cornual region of the uterus. The authors advocate using the "cornual pregnancy" term only for ectopic pregnancies in malformed uteruses. We describe an ectopic pregnancy in a 25-year-old G2P1 patient in the cornual region of the uterus that was missed twice sonographically in the second trimester and had almost fatal consequences in the patient. Radiologists and sonographers should be aware of the sonographic diagnosis of angular, cornual and interstitial pregnancies. Whenever possible, first-trimester transvaginal ultrasound scanning is crucial for diagnosing these 3 types of ectopic pregnancies in the cornual region. In the second and third trimesters, ultrasound tends to become equivocal; hence alternate imaging, such as MRI, might add additional value to the management of the patient. A case report assessment and a comprehensive literature review comprising 61 case reports of ectopic pregnancy in the second and third trimesters are diligently undertaken in the Medline, Embase and Web of Science databases. The major strength of our study is that it is one of the few studies that describe a literature review of ectopic pregnancy in the cornual region exclusively in the second and third trimesters.

Pregnancy in a rudimentary horn: multicenter's MRI features of a rare condition

PURPOSE

To describe the MRI features of rudimentary horn pregnancy (RHP) with surgical correlations.

METHODS

Nine women with a RHP underwent preoperative pelvic MRI. MRI protocol included T2- (n = 9), T1- (n = 7), and fat-suppressed contrast-enhanced T1-weighted sequences (n = 4). Two pelvic radiologists retrospectively analyzed MR images to assess the following MRI features: presence of a myometrium around the gestational sac (GS) and characteristics of its wall, GS surrounded by myometrium in contact with the round ligament, communication of the GS with the endometrial cavity of the main horn, continuity of the GS with the cervix, fibrous or muscular GS attachment to the main horn, lateral deviation, and endometrial thickness of the main horn. Ovaries and tubes were also assessed. MRI features were correlated with surgical findings.

RESULTS

Seven of the nine women [29 ± 6 SD years (range 16-37 years)] underwent surgical management. The first US diagnosed RHP in only 1/9 patients. All pregnancies were diagnosed using MRI. RHP was all located in the rudimentary horn of a unicornuate uterus. All the GS was surrounded by myometrium in contact with the round ligament. None of the RHP displayed communication with the endometrial cavity of the main horn nor with the cervix. An attachment between the RHP and the main horn was seen in 3/9 patients. All the main horns were lateralized and empty.

CONCLUSION

MRI diagnosed RHP in all patients by identifying the GS surrounded by myometrium in contact with the round ligament and the absence of continuity between the GS and the cervix.

LEVEL OF EVIDENCE

IV-retrospective study.

Successful diagnosis and management of prerupture rudimentary horn pregnancy in the second trimester: a case report

Rudimentary horn pregnancy has concerns due to the high incidence of an extreme risk of a life-threatening rupture. Thus, early diagnosis and management are essential to preserving the patient's life. We present a successful diagnosis and management of a prerupture rudimentary horn pregnancy in a 24-year-old woman presented with chronic pelvic pain and amenorrhea for the last 3 months. On physical examination, she had a mobile, nontender mass equals 16 weeks of gestation. Transvaginal ultrasound revealed an empty uterus with signs of a decidual reaction and a gestational sac adjacent to the uterus and surrounded by less than a 2 mm-in-thickness muscular wall with a positive fetal heart rate. The gestational age was 16 weeks based on biparietal diameter and femur length. Based on these findings rudimentary horn pregnancy was suspected. Laparotomy was performed, unicornuate uterus with unruptured, left rudimentary horn pregnancy was observed, and the pregnant horn with the ipsilateral tube was excised. To conclude, an empty uterus and extrauterine gestational sac surrounded by a thin muscular wall (<2 mm) on ultrasound should raise the suspicion of rudimentary horn pregnancy.

MR imaging findings of ectopic pregnancy: a pictorial review

Because of its lack of ionizing radiation and excellent soft-tissue contrast, magnetic resonance (MR) imaging is being increasingly used in the evaluation of acute abdominal pain in the pregnant patient. Roughly 2% of all pregnancies are ectopic. Although ectopic pregnancy is usually diagnosed on the basis of a combination of clinical, laboratory, and ultrasonographic findings, it occasionally is initially identified at MR imaging. Thus, it is imperative that the radiologist should be familiar with the variable appearance of ectopic pregnancy at MR imaging and should evaluate for ectopic pregnancy at any time when (a) a patient has positive results of a pregnancy test and (b) an intrauterine pregnancy is not definitively seen. Because of potential issues of fetal safety, a conservative approach should be used for MR imaging in pregnancy. An MR imaging protocol for the evaluation of possible appendicitis in pregnant women is detailed. Specific findings that can aid in the diagnosis of ectopic pregnancy are the lack of an intrauterine pregnancy, isolated hemoperitoneum, tubal masses, hematosalpinx, and interstitial masses. In the differential diagnosis of acute abdominal pain in pregnancy, consideration should be given to the more unusual forms of ectopic pregnancy, such as angular pregnancy, cornual pregnancy, and abdominal pregnancy. Potential mimics of ectopic pregnancy include placental abnormalities, ovarian neoplasms, and corpus luteum cysts.

Rudimentary horn pregnancy: a 10-year experience and review of literature

Rudimentary horn pregnancy is rare, but can cause considerable morbidity and mortality. We discuss five cases presented to our hospital in the last 10 years and systematically review the 10-year literature of rudimentary horn pregnancies diagnosed antenatally pre-rupture.

OBJECTIVES OF THE REVIEW

The aim of the review was to find radiologic investigations/criteria to diagnose rudimentary horn pregnancy antenatally pre-rupture.

SEARCH METHODS

A systematic literature review was carried out in Pubmed search for rudimentary horn pregnancies. The radiologic findings of the cases diagnosed before rupture were analyzed.

RESULTS

Ultrasound is the most commonly used technique, though MRI seems to delineate details better. Non-continuity of the lumen of the cervix with the pregnant uterine horn is an important imaging finding. High clinical suspicion and radiologic skill for diagnosis are emphasized.

CONCLUSIONS

The review presents the existing imaging criteria to diagnose rudimentary horn pregnancy and suggests future research to enhance the limited evidence.

Unruptured term pregnancy with a live fetus with placenta percreta in a non-communicating rudimentary horn

Pregnancy in a non-communicating rudimentary horn is rare and such a pregnancy culminating in the delivery of a live fetus is even rarer. Despite advances in ultrasonography, the accuracy of ultrasound in diagnosing rudimentary horn pregnancy at advanced gestation remains elusive. Confirmatory diagnosis is made only at laparotomy. We report a multigravidae who presented at 37 weeks with transverse lie oligoamnios and decreased perception of fetal movement since quickening. Laparotomy for placenta accreta suspected on ultrasound revealed non-communicating unruptured rudimentary horn pregnancy with a live fetus and placenta percreta. Successful extraction of a term live fetus weighing 2.7 kg with excision of the rudimentary horn was carried out.

MR features of ectopic pregnancy

Ectopic pregnancy (EP), in which a fertilized ovum implants outside the uterine cavity, is the leading cause of pregnancy-related death in the first trimester. EP is usually suspected by a positive pregnancy test and an empty uterus on transvaginal sonography (TVS). Although TVS is the initial modality of choice, it may occasionally fail to demonstrate the implantation site. When TVS findings are indeterminate, magnetic resonance imaging (MRI) may provide better delineation of the focus of EP owing to its excellent tissue contrast. The key MRI features of EP include gestational sac (GS)-like structures that typically appear as a cystic sac-like structure, frequently associated with surrounding acute hematoma of distinct low intensity on T2-weighted images. In tubal pregnancy, an enhanced tubal wall on postcontrast images may be another diagnostic finding. Ruptured EP is inevitably associated with acute hematoma outside these structures. In intrauterine EP, recognition of the relationship between GS-like structure and the myometrium can aid in differentiating from normal pregnancy. Diagnostic pitfalls include heterotopic pregnancy, decidual changes in endometrial cyst and theca lutein cysts mimicking GS-like structures. Knowledge of a spectrum of clinical and MRI features of EP is essential for establishing an accurate diagnosis and determining appropriate management.