Pregnancy in a non-communicating uterine horn mimicking incarceration with sacculation of a retroflexed uterus

Incarceration of the Gravid Uterus - a Rare Condition not to be Missed

BACKGROUND

Incarceration of a gravid uterus (IGU) is a rare manifestation in obstetrics that may be associated with serious complications.

CASE

We report on a 29-year-old patient at 34+2 weeks' gestation who presented with HELLP syndrome. IGU had been initially diagnosed in our department at 23+6 weeks' gestation. Urgent cesarean section was performed taking into account the specific characteristics of IGU. A healthy premature child was born. With the prior knowledge of IGU no complications during delivery occurred and mother and child had favorable outcomes.

CONCLUSION

IGU is a rare condition in pregnancy that should not be overlooked. Early diagnosis and treatment of IGU can prevent serious complications to the mother and child during pregnancy and delivery. In this report, we discuss the specific peculiarities of an incarcerated uterus that need to be considered in this regard.

HINTERGRUND

Ein Uterus incarceratus ist eine seltene Manifestation in der Geburtshilfe, welche mit schwerwiegenden Komplikationen einhergehen kann. FALL: Wir berichten über eine 29-jährige Patientin, die sich mit 34+2 Schwangerschaftswochen (SSW) mit einem HELLP-Syndrom in unserer Klinik vorgestellt hat. Die Erstdiagnose des inkarzerierten Uterus wurde in unserer Klinik mit 23+6 SSW gestellt. Aufgrund unserer Vorkenntnis über diese Diagnose konnte nun die dringend indizierte Sectio caesarea unter Berücksichtigung der spezifischen Merkmale in modifizierter Technik durchgeführt werden. Es wurde ein gesundes Frühgeborenes geboren. Es traten während der Geburt keine Komplikationen auf und Mutter und Kind hatten einen günstigen Verlauf.

SCHLUSSFOLGERUNG

Ein Uterus incarceratus ist eine seltene Manifestation in der Schwangerschaft, welche nicht übersehen werden sollte. Eine frühzeitige Diagnose und Behandlung kann schwerwiegende Komplikationen für Mutter und Kind während der Schwangerschaft und unter der Geburt verhindern. Wir diskutieren die spezifischen Besonderheiten eines Uterus incarceratus, die hierbei zu berücksichtigen sind.

Incarceration of the gravid uterus: a case report and literature review

Background

Incarceration of the gravid uterus is a rare obstetric disorder that contributes to pregnancy-related complications. To understand its clinical characteristics and managements, we have reviewed the etiology, risk factors, clinical characteristics and current treatments of an incarcerated gravid uterus based on 162 cases reported in the English language literature, including our patient.

Case presentation

A 25-year-old primigravida, with a history of lymphatic tuberculosis, infertility due to blocked fallopian tubes and received in vitro fertilization. The patient presented with urine retention and lower abdominal pain in the early second trimester. Uterine incarceration was diagnosed based on pelvic examination and abdominal ultrasound. A Foley catheter was placed and manual reposition was successful. No episode of retention was experienced after the further enlargement of the uterus and its ascent. A healthy infant was delivered vaginally on 38th week of pregnancy.

Conclusions

Uterine incarceration due to pelvic adhesions is rare and, because of it non-specific clinical presentations, is often misdiagnosed. Abdominal ultrasound is instrumental for the diagnosis because it can directly image the disturbed uterine and pelvic anatomy. There are limited treatment options for uterine incarceration, but definitive diagnosis allows procedures to treat and to reduce severe complications of uterine incarceration.

The Presentation and Early Diagnosis of the Rudimentary Uterine Horn

OBJECTIVE

The key to successful management of the rudimentary uterine horn is early detection. This review of the literature seeks to illustrate important aspects of diagnosis and management of this anomaly.

DATA SOURCES

An English language MEDLINE search from 1966 to 2003 was performed, using the search terms "rudimentary uterine horn," "accessory horn," "uterus bicornis unicollis," "hematometra," "unicornuate or bicornuate uterus," and "mullerian anomaly." References from previously published sources were also obtained.

METHODS OF STUDY SELECTION

One hundred thirty letters, case reports, case series, and review articles featuring rudimentary uterine horn were found. Reports before 1966 were excluded because outcomes before the advent of modern diagnostic techniques were not relevant to this study.

TABULATION, INTEGRATION, AND RESULTS

Three hundred sixty-six rudimentary horn presentations (210 gynecologic and 156 obstetric) were found. Noncommunicating horns accounted for 92% of cases (95% confidence interval [CI] 88-95%, P < .001), and renal anomaly was found in 36% (95% CI 29-44%). Contrary to the American Fertility Society classification of uterine anomalies, rudimentary horns may occur without a corresponding unicornuate uterus. The mean age of presentation was similar for gynecologic and obstetric presentations (23 and 26 years, 95% CIs 21.2-24.6 and 124.9-27.3 years, respectively). Presentation in the third decade of life or later occurred in 78% of patients (95% CI 70-84%, P < .001). Sensitivity of ultrasound examination for diagnosis was 26% (95% CI 18-36%). Diagnosis before clinical symptoms occurred in 14% (95% CI 7-23%).

CONCLUSION

Many functional noncommunicating horns present during or after the third decade of life with acute obstetric uterine rupture. Surgical removal before pregnancy is recommended. Rates of prerupture diagnosis remain disappointingly low.

Posterior Sacculation of the Uterus in a Patient Presenting With Flank Pain at 29 Weeks of Gestation

BACKGROUND

Uterine sacculation is a rare complication of pregnancy and may cause substantial peripartal morbidity.

CASE

A possible diagnosis of posterior uterine sacculation was raised when a 34-year-old Gravida 1 Para 1 presented with bilateral flank pain at 29 weeks. Sonographic and magnetic resonance imaging findings confirmed the diagnosis and demonstrated bilateral dilated renal pelvises. Bilateral nephrostomas were placed, offering the patient considerable relief. A healthy female newborn was delivered by cesarean at 34 1/7 weeks. Operative findings confirmed the posterior sacculation of the uterus.

CONCLUSION

Early diagnosis of sacculation of the uterus is necessary to limit maternal and fetal morbidity and mortality. For a detailed evaluation of the pelvic anatomy, we recommend the use of magnetic resonance imaging in the third trimester.

Colonoscopic release of the incarcerated gravid uterus

BACKGROUND

Incarceration of the gravid uterus occurs in the early second trimester in approximately one in 3000 pregnancies. If conventional manual attempts at restoring the uterine fundus to the anterior position are unsuccessful, correction by an invasive laparotomy procedure is necessary. We describe a minimally invasive technique to dislodge the incarcerated gravid uterus.

TECHNIQUE

Gravid patients with an incarcerated uterus refractory to manual reduction are administered sedation, and one to two enemas. After sedation, manual reduction is attempted again. If unsuccessful, a colonoscope is passed above the level of the uterine fundus generating external anterior forces, which dislodge the uterus from beneath the sacral promontory.

EXPERIENCE

The procedure was performed six times in five patients. One patient required a second procedure because of recurrence of the condition. All procedures were successful. No pregnancy losses occurred after the procedure, and no complications of colonoscopy were encountered.

CONCLUSION

Colonoscopic release of the incarcerated gravid uterus is an option when attempts at manual reduction fail. This procedure may avoid laparotomy to correct this condition.

A case report and review of pregnancies in rudimentary noncommunicating uterine horns

A liveborn and subsequently thriving child was delivered abdominally from a pregnancy in a rudimentary noncommunicating uterine horn. This is the 13th English language report of neonatal survival from such an unusual and life-threatening situation. The case presents some 'clues' in the history and a review of the literature suggests that the previously reported bleak outlook for these pregnancies can now be tempered with cautious optimism. Ultrasound diagnosis of Müllerian abnormalities during pregnancy remains difficult but has been reported in several other cases in the literature and may become more common in the future.

Laparoscopic management of a rudimentary horn pregnancy

Rudimentary horn pregnancies are rare, and are associated with a high rate of maternal morbidity and mortality. The standard treatment is laparotomy, as patients usually experience massive abdominal hemorrhage or pregnancies too large to attempt laparoscopic removal. In our patient, early sonographic discovery facilitated laparoscopic management.