Diagnosis and management of a heterotopic pregnancy and ruptured rudimentary uterine horn

Rudimentary horn pregnancy, a differential diagnosis of an intraabdominal pregnancy: a case report

BACKGROUND

Rudimentary horn pregnancy is a rare life-threatening obstetric condition with clinical and sonographic presentation resembling that of an abdominal pregnancy. Preoperative diagnosis of advanced rudimentary horn pregnancy is difficult and cases are often identified incidentally during laparotomy for a presumed abdominal pregnancy.

CASE PRESENTATION

We report a case of a 29-year-old African woman, gravida 2 para 1 at 28 weeks of gestation complaining of epigastric pain for 7 days with no other associated gastrointestinal or genitourinary symptoms. On examination, she had normal vital signs and an enlarged abdomen sized at 33 cm with unremarkable fetal lie and presentation. She had normal laboratory blood results with an ultrasound revealing an abdominal pregnancy of 28 weeks. The informed decision for conservative management was planned after informing of the benefit and risks of early termination versus conservative management, however, with worsening symptoms an emergency laparotomy had to be performed in which a left unruptured rudimentary horn pregnancy with a viable fetus was identified incidentally and delivery of the fetus followed by surgical excision of the horn was done. The postoperative period was uneventful, and the patient was discharged home with her newborn.

CONCLUSION

Rudimentary horn pregnancy is very rare and often indistinguishable from an abdominal pregnancy in advanced gestation age. First trimester ultrasound is by far the only noninvasive sensitive diagnostic modality for rudimentary horn pregnancy. Laparotomy with horn excision remains the standard of care for advanced rudimentary horn pregnancy.

Successful pregnancy and term delivery after treatment of unicornuate uterus with non-communicating rudimentary horn pregnancy with local methotrexate injection followed by laparoscopic resection: a case report and literature review

Background

Pregnancy in a rudimentary horn is an extremely rare type of ectopic pregnancy. A rudimentary uterine horn pregnancy is associated with a risk of spontaneous rupture and bleeding during surgery due to the increased uterine blood flow. Recent advances in imaging modalities have enabled laparoscopic surgery to be performed in cases without rupture in the early stages of pregnancy. However, there are few reports of successful pregnancies and deliveries after treatment of rudimentary horn pregnancies. We report the successful management of a case of non-communicating rudimentary horn pregnancy by local injection of methotrexate followed by complete laparoscopic excision along with a review of the literature.

Case presentation

The patient was a 29-year-old Japanese woman, gravida 2, nullipara. She was diagnosed with a left unicornuate uterus with a right non-communicating rudimentary horn on hysterosalpingography and magnetic resonance imaging. A gestational sac with a heartbeat was observed in the right rudimentary uterine horn at 6 weeks of gestation. A diagnosis of ectopic pregnancy in a non-communicating rudimentary horn was made. Color Doppler detected multiple blood flow signals around the gestational sac, which were clearly increased compared to the left unicornuate uterus. Her serum human chorionic gonadotropin level was 104,619 mIU/ml. A 100 mg methotrexate injection into the gestational sac was administered, and laparoscopic surgery was performed on day 48 after the methotrexate treatment. The right rudimentary horn and fallopian tube were successfully excised with minimal bleeding. A spontaneous normal pregnancy was established 6 months after the surgery. The pregnancy was uneventful, and a baby girl was born by elective cesarean section at 38w0d.

Conclusion

Combined local methotrexate injection and laparoscopic surgery are safe treatment options for patients with a unicornuate uterus with a non-communicating rudimentary horn pregnancy.

Case Report: Laparoscopic Management of an Ectopic Pregnancy in a Rudimentary Non-communicating Uterine Horn

Introduction: Ectopic pregnancy in a non-communicating rudimentary uterine horn is a rare gynecological condition associated with a high risk of uterine rupture and important maternal mortality and morbidity. A surgical excision of the rudimentary horn is the standard treatment, usually performed by laparotomy in the second trimester.

Methods: A 36-year-old woman, secundigravida and nulliparous, was admitted to the emergency obstetric unit with acute pelvic pain. The ultrasound found an ectopic pregnancy at 15 weeks gestational age with fetal cardiac activity. As her hemodynamic status was stable, a diagnostic laparoscopy was performed and confirmed the development of the pregnancy in a left rudimentary uterine horn.

Results: We report a total laparoscopic removal of a pre-ruptured rudimentary uterine horn containing a second trimester ectopic pregnancy, using a vessel-sealer device. To our knowledge, only three other cases of successful laparoscopic treatment of second trimester rudimentary horn pregnancies have been reported in the literature.

Conclusion: Laparoscopy is an efficient and safe surgical option for treating rudimentary horn second trimester pregnancy in patients with hemodynamic stability.

Full-term pregnancy in a rudimentary horn with a live fetus: A case report

INTRODUCTION

Rudimentary horns and unicornuate uteri, 2 types of Mullerian duct abnormalities, often lack obvious symptoms. Ultrasonography (US) and magnetic resonance imaging (MRI) are alternative examinations but have low accuracy. Full-term rudimentary horn pregnancies are rather rare but life-threatening.

PATIENT CONCERNS

A 30-year-old Chinese woman complained of lower abdominal pain one year after a full-term unicornate uterus pregnancy and a rudimentary horn pregnancy successively.

DIAGNOSIS

Uterine dysplasia (right rudimentary uterine horn and left unicornate uterus), hematometra and right fallopian tube effusion were diagnosed.

INTERVENTIONS

We performed laparoscopic hysterectomy (rudimentary horn), right salpingectomy, pelvic adhesion release and hysteroscopy.

OUTCOMES

The patient has not complained of specific discomfort during the one-year follow-up so far.

CONCLUSION

The reported case was a rare full-term rudimentary horn pregnancy. The degree of development of the rudimentary horn, such as the endometrial function, muscle layer thickness, and uterine shape and size, is closely related to pregnancy outcome. The rudimentary horn with a functional endometrium must be disposed of once it is definitely diagnosed. Pregnancy in the rudimentary horn with a weak muscular layer should be treated as soon as possible. Detailed and scientific prenatal examination is important.

Successful management of a rudimentary uterine horn ectopic pregnancy by combining methotrexate and surgery: A case report

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The prevalence of rudimentary uterine horn ectopic pregnancy is very low (1 in 76 000–150 000 pregnancies).

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Early diagnosis of a rudimentary horn pregnancy is the key to successful management.

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The medical treatment may be a successful adjuvant therapy to surgical removal in asymptomatic women.

Pregnancy in a non-communicating rudimentary uterine horn is rare but presents a significantly increased risk of maternal and foetal morbidity due to uterine rupture.

We describe a case of rudimentary horn pregnancy diagnosed in the first trimester in an asymptomatic and haemodynamically stable woman. Medical termination of the pregnancy was performed with systemic and intrasacular methotrexate. Laparoscopic uterine horn excision was performed three months after termination.

This case shows that early diagnosis of a rudimentary horn pregnancy is key to the successful management of this condition. Preoperative medical termination in an asymptomatic woman proved to be an effective and safe option that minimized surgical risks.