Surgical management of an ectopic pregnancy in the setting of an unexpected Müllerian anomaly - intraoperative and postoperative implications.

OBJECTIVE: To describe the intraoperative and postoperative implications arising from the unexpected diagnosis of a Müllerian anomaly during the surgical management of an ectopic pregnancy. DESIGN: Video article. SETTING: Academic Center. SUBJECT(S): A 39-year-old nulligravid woman with anovulation and irregular menstrual cycles presented to the office. Her urine pregnancy test was incidentally positive; serum ß-human chorionic gonadotropin (ß-hCG) level was 5,644 mIU/mL. Outpatient transvaginal ultrasonography (TVUS) demonstrated a 2.1 x 1.7 x 2.2-cm thick-walled structure in the left adnexa without an intrauterine pregnancy. These findings were highly suspicious for a left tubal ectopic pregnancy. The patient was consented for laparoscopy with planned left salpingectomy. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. INTERVENTION: Diagnostic laparoscopy did not show an obvious left tubal ectopic pregnancy. Instead, a right unicornuate uterus with a dilated rudimentary left uterine horn was seen. Both fallopian tubes and ovaries appeared normal. These laparoscopic findings were consistent with an ectopic pregnancy in the rudimentary horn. However, in the absence of informed consent for a hemi-hysterectomy and no evidence of ectopic rupture or bleeding within the pelvis, we decided to proceed with excision of the ectopic pregnancy from the uterine horn. An incision was made over the anterior surface of the uterine horn, and the pregnancy sac was dissected from the underlying myometrium and excised in its entirety. Left salpingectomy was also performed. The patient was discharged home the same day, and her ß-hCG levels decreased to <5 mIU/mL within 28 days of surgery. MAIN OUTCOME MEASURES: Complete resolution of a left rudimentary uterine horn ectopic pregnancy through surgical excision of the pregnancy sac without hemi-hysterectomy. RESULTS: Postoperative hysterosalpingography (HSG) demonstrated a right unicornuate uterus with normal fill and spill of the right fallopian tube. Magnetic resonance imaging (MRI) of the pelvis confirmed the findings of a right unicornuate uterus with a non-communicating left rudimentary uterine horn that did not contain any endometrial tissue. Thus, the patient did not require an interval hemihysterectomy. She underwent letrozole and intrauterine insemination treatment 5 months after the initial surgery, which resulted in a clinical intrauterine pregnancy. However, this pregnancy was terminated in the early second trimester due to findings of trisomy 18. She conceived naturally one year later, and this pregnancy resulted in a full-term vaginal birth at 39 weeks gestation. CONCLUSION: Undiagnosed or unexpected Müllerian anomalies can impact the standard intraoperative and postoperative management of ectopic pregnancies.

Imaging diagnosis of rudimentary horn pregnancy: a case report.

Background: Rudimentary horn pregnancy (RHP) is a special type of ectopic pregnancy and its pathophysiological basis is an abnormal fusion of the bilateral accessory mesonephric duct during the embryonic period. If sonographers lack experience to this disease, it is easily to be misdiagnosed in the early period, which often leads to rupture of the pregnant horn and life-threatening bleeding. Therefore, a high index of vigilance is required. Case Description: We present a case of a 27-year-old female who went to the department of emergency due to menopause, pelvic pain and elevated human chorionic gonadotropin (hCG) (above 200,000 IU/L). Sonographic examination showed uterus only had the right horn and endometrium was thickened about 1.7 cm without gestational sac (GS) in the uterine cavity. Besides, a 3.5×3.0 cm GS was found between the left ovary and corpus uteri. RHP was suspected by sonographer, and the patient underwent laparoscopy. Obstetricians and gynecologists removed the rudimentary horn and the left fallopian tube. The patient made a good recovery and was soon discharged home after surgery. Conclusions: This article analyzed one case and summarized ultrasonic characteristics of RHP which may help to improve the early diagnosis of RHP. If necessary, other imaging such as magnetic resonance imaging (MRI) can be combined to make a clear diagnosis and treatment as soon as possible.

Rupture of non-communicating rudimentary horn at 35 weeks ending with a live birth: A case report.

INTRODUCTION AND IMPORTANCE: the rudimentary horn pregnancy frequently ruptured in the second and third trimesters during the normal process of rudimentary horn pregnancy (RHP) which results in a hemoperitoneum that may be fatal, however in very rare cases and under close observation, the pregnancy may continue and end with a live birth. CASE PRESENTATION: A 30 years-old woman gravida 3, para 4 with no symptoms presented to the hospital at 30 weeks gestation for a routine examination and misdiagnosed as an abdominal ectopic pregnancy. The pregnancy continued for approximately 35 weeks, when a ruptured rudimentary horn pregnancy was discovered accidently during an emergency surgery, the left fallopian tube and ovary and the ruptured rudimentary horn were removed. CLINICAL DISCUSSION: Unicornuate uterus is a result of abnormal or failed development of one of the paired müllerian ducts, Spontaneous abortion in women with rudimentary horn pregnancy may occurs in the first and second trimester. Rudimentary horn pregnancies are associated with high maternal morbidity and mortality, And because of the risk of life-threatening complications, early diagnosis before rupture is essential for the successful management and prevention of these complications. CONCLUSION: The diagnosis of most cases of rudimentary horn pregnancy is considered challenging, and could be diagnosed after rupture, during emergency surgery. Although rudimentary horn pregnancy mostly ends in the first and second trimester, in some cases it may continue until term and end with a live healthy child.

Successful pregnancy outcome via in-vitro fertilization and laparoscopic resection of non-communicating rudimentary horn pregnancy containing early pregnancy: a case report.

BACKGROUND: Non-communicating rudimentary horn pregnancy (NCRHP) lead to life-threatening condition for both mother and fetus. Early diagnosis of NCRHP and laparoscopic resection is important to prevent catastrophic conditions. However, delayed diagnosis until the second or third trimester makes it difficult to accurately diagnose between NCRHP and bicornuate uterine pregnancy, as both conditions present uterine rupture and massive hemoperitoneum. Furthermore, these rare cases are challenging in pregnancy trials and associated with adverse outcomes in subsequent pregnancies. CASE PRESENTATION: A 31-year-old gravida 1 para 0 Korean woman visited our infertility center with a confirmed positive urine pregnancy test after timed intercourse. Before she was scheduled to have timed intercourse, a unicornuate uterus with a non-communicating right uterine horn was suspected based on an ultrasound scan and hysterosalpingography during the initial infertility workup. A gestational sac was observed in the right non-communicating rudimentary horn at 5 weeks of gestation. Serum beta-human chorionic gonadotropin (b-hCG) level was 2052.0mIU/mL. An elective laparoscopic resection of the right rudimentary horn containing a gestational sac, along with ipsilateral salpingectomy, was performed with no adverse event. After 3-month of recovery period and three cycles of conceptional trials involving timed intercourse and intrauterine insemination, in-vitro fertilization (IVF) was performed using the antagonist protocol, and successful pregnancy was confirmed. The patient had been hospitalized from 21 + 6 weeks to 35 + 6 weeks of gestation, underwent cerclage placement and tocolytics with corticosteroid treatment. She delivered an early-term male baby by cesarean section. CONCLUSION: In this rare case, the successful pregnancy achieved through IVF following the appropriate management of NCRHP under laparoscopy underscores the critical importance of early diagnosis and intervention in cases of NCRHP. Timely identification and management of NCRHP are vital to prevent the occurrence of catastrophic conditions and to enhance the prognosis of a successful pregnancy through assisted reproductive technology (ART). Therefore, a high index of suspicion for NCRHP is important and employs a range of diagnostic modalities.

Intact non-communicating rudimentary horn pregnancy in a patient with a history of two cesarean sections: A case report.

This article reports a case of an unruptured rudimentary horn viable pregnancy at 18 weeks of gestation. The diagnosis was missed at two previous cesarean sections and on a second-trimester ultrasound scan of the index pregnancy. The condition is extremely rare, life-threatening and difficult to diagnose. This case report highlights the importance of checking the anatomy of the uterus and appendages during cesarean section.

Non-communicating rudimentary horn mimicking a degenerated subserous leiomyoma: A case report

@#Unicornuate uterus with a rudimentary horn is a rare Müllerian anomaly, with an incidence of 0.06%. Due to this relative rarity, an accurate preoperative diagnosis of unicornuate uterus with rudimentary horn still remains to be a diagnostic challenge. Reported here is a case of a 27-year-old nulligravida who complained of severe debilitating dysmenorrhea 5 months prior to admission, necessitating frequent visits to the emergency department for administration of intravenous pain medications and antiemetics. She was misdiagnosed preoperatively with subserous leiomyoma, mainly based on clinical presentation, and findings on ultrasound and pelvic MRI. On exploratory laparotomy, a definitive diagnosis of unicornuate uterus with an enlarged rudimentary horn was established, and patient underwent resection of rudimentary horn, with enterolysis, due to dense adhesions in the left adnexa and cul de sac. We emphasize the need for early diagnosis and prompt management of cases like this to prevent complications, and optimize fertility and quality of life of affected patients.

Unicornuate Uterus and Rudimentary Horn: An Unusual Cause of Recurrent Fetal Malpresentation Identified During a Scheduled Cesarean Delivery.

This case report presents a unique clinical scenario involving a 32-year-old woman with a unicornuate uterus and a rudimentary horn, leading to recurrent fetal malpresentation. The patient, gravida 3, para 1, presented at 36 weeks of gestational age with contractions and vaginal bleeding. Clinical evaluation revealed a breech presentation and nonreassuring fetal heart tracings. An emergency cesarean section was performed, during which a unicornuate uterus with a rudimentary horn was identified and fused to the main uterine cavity on the left posterior aspect. The rudimentary horn bore a functional left tube and ovary. The surgical procedure was successful, resulting in the delivery of a healthy baby girl. This case underscores the importance of meticulous preoperative assessment, multidisciplinary collaboration, and informed consent in managing complex uterine anomalies to ensure optimal maternal and fetal outcomes.

Pregnancy in Rudimentary Horn.

Pregnancy in rudimentary horn is an uncommon presentation of an ectopic pregnancy. It needs a very high degree of suspicion for diagnosis and the diagnosis becomes difficult in cases with previous vaginal deliveries. A 25-year-old female patient with two spontaneous vaginal deliveries and a history of spontaneous abortion at five months visited the obstetric emergency department with a history of five months of amenorrhea with pain abdomen and breathlessness for one day. On abdominal examination abdomen was distended, and rigid, and tenderness was present. Paracentesis was done where blood was present. On bimanual examination, cervical motion tenderness was present, and left-sided fornices fullness was present. The patient was admitted, and her sonography was done for suspicion of a ruptured uterus or ectopic pregnancy. The sonography report showed a bulky uterus with decidual reactions and a well-defined pregnancy of 21 weeks and 6 days in the right adnexal region with hemoperitoneum suggesting suspicion of ruptured ectopic pregnancy. After initial treatment and arrangement of two units of packed red blood cells after proper grouping and cross-matching for the patient, laparotomy was done. At the time of surgery, there was a right-sided rupture of non-communicating rudimentary horn pregnancy with a unicornuate uterus. A dead fetus of 600 grams lies in the peritoneal cavity with two liters of hemoperitoneum. Timely diagnosis and laparotomy saved the life of the patient.

Delayed diagnosis of a non-communicating right uterine horn: A case report and literature review.

Background: Accurate diagnosis of a müllerian anomaly is essential for appropriate management and prevention of complications. However, diagnosis is often missed or delayed. Case: This is a case of a nulliparous woman with a müllerian anomaly diagnosed at the age of 36 despite prior evaluation with ultrasound and laparoscopy. Magnetic resonance imaging (MRI) suggested a unicornuate uterus with a right non-communicating rudimentary horn. Hysteroscopy and chromopertubation confirmed the diagnosis. The rudimentary horn was resected laparoscopically using bipolar energy. Conclusion: An undiagnosed müllerian anomaly should be considered in the setting of persistent dysmenorrhea. Three-dimensional ultrasound or MRI should be used judiciously in patients with refractory dysmenorrhea or when ultrasound raises concern for a müllerian anomaly.

Unicornuate Uterus with a Non-Communicating Rudimentary Horn: Challenges and Management of a Rare Pregnancy.

We present a unique case of pregnancy developed in a unicornuate uterus with a non-communicating rudimentary horn, emphasizing the importance of early identification, careful management, and counseling. Our patient, a 28-year-old woman, presented with abdominal pain and premature rupture of membranes at 37 weeks of gestation. She had a history of one previous normal vaginal delivery and no significant medical or genetic factors. An emergency cesarean section was performed, and a baby boy weighing 2900 grams was delivered without complications. The uterine anomaly was identified as a unicornuate uterus with a non-communicating rudimentary horn. This case report highlights the challenges and risks associated with unicornuate pregnancies, such as fetal growth restriction and preterm labor. Timely identification, meticulous monitoring, and comprehensive counseling are crucial for optimal outcomes in such cases. Further research and larger-scale studies are needed to enhance our understanding of these rare and complex pregnancies.

A Case Report on a Left Unicornuate Uterus With Communicating Right Rudimentary Horn Associated With Hematometra and Hematosalpinx.

Congenital uterine anomalies (CUAs) or Müllerian duct anomalies are rare and can be either complete failure or partial failure in the development of the Mullerian duct, and they have a probability to result in a condition known as the unicornuate uterus. Partial development of one of the horns results in a rudimentary horn, which may be communicating consisting of category II A or noncommunicating consisting of category II B. This report illustrates a rare case of a 23-year-old female, unmarried, nulligravida, who presented to the outpatient department with chief complaints of acute abdominal pain and dysmenorrhea associated with an average menstrual flow. Pelvic ultrasound and magnetic resonance imaging (MRI) confirmed the diagnosis of a left unicornuate uterus with communicating right rudimentary horn associated with hematometra and hematosalpinx. As a treatment option, the surgical intervention mainly involved laparoscopic excision of the rudimentary horn and right salpingectomy that was performed by aspiration of blood from the rudimentary horn of around 25cc. Then, the right hydrosalpinx was removed, followed by right salpingectomy and excision of the rudimentary horn to reduce the risk of ectopic pregnancy having an incidence of 10% for which laparoscopic or robotic-assisted removal is preferable and practicable for young girls, compared with the open procedure. The patient adhered well to the surgical intervention.

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.

Post-dated Breech Pregnancy in a Non-obviously Communicating Rudimentary Horn of a Bicornuate Uterus Requiring Hemi-hysterectomy.

Developmental anomalies of the Müllerian duct systems such as the bicornuate uterus are rare globally and hardly do term pregnancies occur in conjunction with these abnormalities. The occurrence of post-dated pregnancy is rarely associated with a bicornuate uterus. We present a 35-year-old un-booked multigravida with post-date pregnancy complicated by breech and intrauterine foetal death (IUFD) in a rudimentary uterine horn. She had caesarean delivery complicated by intractable postpartum haemorrhage (PPH). This together with the risks of poor uterine involution in the postpartum and obstetric outcome in the event that another pregnancy occurs in the same horn subsequently warranted a caesarean hemi-hysterectomy of the rudimentary uterine horn. Uterine bicornuate is an uncommon genital tract anomaly and a rare cause of post-date pregnancy. Postpartum bleeding warranting caesarean hemi-hysterectomy should be anticipated as the pregnant horn may not be responsive to conventional oxytocics.

Successful management of cervical dysgenesis: Case report and review.

Cervical agenesis or dysgenesis is a rare Mullerian anomaly that is usually associated with vaginal aplasia. A literature review revealed reports of 83 cases including ours, of which 57 (68.6%) presented with obstruction of the external OS, 11 (13.2%) had the cervix replaced by a fibrous cord and 5 (6.02%) had a fragmented cervix. A total of 24 (28.9%) were managed by core and drilling technique (CDT), 16(19.2%) patients underwent uterovaginal anastomosis (UVA), 7(8.4%) underwent total abdominal hysterectomy preserving the ovaries and 5 (6.02%) were managed by cervical reconstruction. Unfortunately, 31 failed to return after their clinical and radiological diagnosis was confirmed. Early diagnosis and treatment are necessary to avoid long-term complications.

Non-communicating rudimentary horn pregnancy presenting as sudden unexpected maternal death: an autopsy diagnosis.

Pregnancy on a rudimentary uterine horn is a rare condition that can lead to a catastrophic outcome when it ruptures. The majority of cases are diagnosed late, after the rupture has occurred. We present the case of a 29-year-old female G2 P1 who complained of abdominal pain. She consulted a medical practitioner who prescribed her analgesics. In the next day, she was found dead in her bedroom. The pregnancy was undiagnosed as she was not aware that she was in a gravid state. At autopsy, there was massive haemoperitoneum and a 24-week gestation foetus lying outside the uterus. The uterus revealed an anomaly in keeping with a non- communicating rudimentary horn. Forensic pathologists do encounter undiagnosed ectopic pregnancies in practice. However, abdominal ectopic pregnancy with a uterine anomaly remains uncommon. These cases are often associated with a high maternal and foetal mortality.

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.

Acute late presentation of a functioning non-communicating rudimentary uterine horn containing an adenomyosis: A case report.

A functioning noncommunicating rudimentary horn is a rare uterine malformation. The presence of rudimentary uterine horn with adenomyosis is even rarer situation. Clinical presentation varies from mild pain that might present late in the clinical course with complications that can be gynecological such as pelvic pain and endometriosis or obstetrical such as preterm delivery, cesarean section, and ectopic pregnancy. We are reporting a case of a young woman who presented with acute abdominal pain that was superimposed by chronic pelvic pain due to endometriosis and deep pelvic vein thrombosis secondary to an enlarging noncommunicating rudimentary uterine horn containing extensive adenomyosis. With the help of MRI, initial diagnosis was given as rudimentary functioning horn containing fibroid and unilateral renal agenesis. The treatment comprised complete laparoscopic excision of the entire horn, and the patient reported significant improvement afterward. Final histopathology was rudimentary horn containing adenomyosis. Our paper is one of few papers reported adenomyosis in function noncommunication rudimentary horn.

Successful Laparoscopic Management of Non-communicating Rudimentary Horn Pregnancy.

Unicornuate uteri are a type of Mullerian duct anomaly and the majority present with rudimentary horns. Rudimentary horn pregnancies are extremely rare and have a high risk of rupture. A high index of suspicion is needed to diagnose them early and unfortunately, the majority of cases are undetected until the patient presents with a ruptured uterus. Early diagnosis and management will reduce morbidities and mortality for patients. We present a case of a 29 year old who had a routine ultrasound scan in the first trimester that raised an index of suspicion for a rudimentary horn pregnancy. An MRI scan was performed and supplemented the ultrasound findings. The patient underwent laparoscopic management, and the non-communicating rudimentary horn, the foetus, and the attached tube were excised. The patient had a smooth recovery and had no complications.  Due to the rarity of rudimentary horn pregnancies, a high index of suspicion is needed for a diagnosis. Timely detection and intervention are crucial to prevent complications. Ultrasound scans and MRIs can aid in the diagnosis. Traditional management involved laparotomy, but with surgical advancements, laparoscopic surgery can be utilized as a less invasive alternative.

Fertility after treatment of a noncommunicating rudimentary horn pregnancy: A case report.

Rudimentary horn pregnancies are rare but are associated with high mortality and morbidity. The diagnosis can be difficult as it may be challenging to distinguish a rudimentary horn pregnancy from an intrauterine pregnancy on ultrasound. Magnetic resonance imaging can often be used to confirm a rudimentary horn pregnancy. When a second-trimester rudimentary horn pregnancy is diagnosed, surgical intervention should be performed to avoid uterine rupture and hemoperitoneum. The correct diagnosis and management of rudimentary horn pregnancies help to preserve the fertility of younger patients. This case report describes a second-trimester rudimentary horn pregnancy that was diagnosed by ultrasound and magnetic resonance imaging. It was then surgically resected via laparotomy. This patient maintained her fertility and was able to conceive naturally, leading to an uncomplicated term pregnancy.

Uterine rupture of a patient with rudimentary horn pregnancy at 26th gestational weeks.

INTRODUCTION AND IMPORTANCE: Pregnancy of Rudimentary Horn is a type of ectopic pregnancy, that is recognized almost always during surgical treatment of a rupture of the rudimentary horn. This is an obstetric case diagnosed preoperatively by magnetic resonance imaging (MRI). CASE PRESENTATION: We report the case of a 19-years-old primigravida patient with rupture of rudimentary horn in 26th gestational week. The patient presented with sudden onset severe abdominal pain in the emergency room. Intraabdominal free fluid is detected. To evaluate the etiology of free fluid and location of the gestational sac, an abdominal magnetic resonance imaging (MRI) scan was planned. The decision of emergent laparotomy is made because of sonographic detection of abdominal excessive -concentrated- free fluid, abdominal tenderness, and 2 points decrease of hemoglobin value in the control hemogram. A rudimentary horn pregnancy and fundal rupture of the rudimentary part of the uterus are diagnosed during the surgical procedure. A baby -live- weighing 450 g was delivered. The ruptured rudimentary horn and same-sided tuba uterina were surgically removed. CLINICAL DISCUSSION: Rudimentary horn pregnancy is a rare ectopic pregnancy. Diagnosis is difficult clinically, even with diagnostic imaging modalities. Identifying both cornuas systematically in all patients increases the detection rate. The absence of continuity between the gestational sac's lumen and the cervical canal on imaging is an important finding. CONCLUSION: Due to the serious maternal and fetal complications, its detection at an early week may be life-saving.