{"paper_id":"2ee11c46-0b10-4715-9be6-ffc84b6dd95f","body_text":"Submit Manuscript | http://medcraveonline.com\nIntroduction\nUnicornuate uterus with rudimentary horn is a type of Mullerian \nduct malformation and its incidence has been reported as 1 in 1000. 1 \nThis malformation results from the defective fusion of the duct with \nthe contra-lateral side. The cavity of this malformed duct is usually \nfound to be noncommunicating with the main uterine cavity. A fibrous \nor fibro-muscular band connects the two but there is no communication \nin 80-90% of the cases. The rudimentary horn may have a functional \nendometrial cavity or it may be a small solid lump of uterine muscle \nwith no functional endometrium. 2 This rudimentary horn can create \nsome obstetrical and gynecological clinical manifestations; or remain \nasymptomatic.3 Three cases with different clinical manifestations are \npresented.\nCase 1\n22 yrs old primigravida was admitted with five months of \namenorrhoea accompanied by mild pain abdomen of few days \nduration, pain was limited to upper abdomen and was associated with \ntwo episodes of vomiting. She was hospitalized for observation. Her \nvital parameters were stable and general examination was essentially \nnormal. Uterus was corresponding to 22-24 weeks size and was \nnon tender; fetal heart sounds were heard normally. Her routine \nantenatal investigations done earlier were normal. This being a small \nhospital; bedside ultrasound facilities were not available hence it was \nscheduled for next day as that day it was Sunday and there was no \nemergency. She was managed with antacids and other supportive \nmeasures. After about three hours her pain had increased and she \nhad developed tachycardia and fetal heart had disappeared. Urgent \nultrasound showed free fluid in peritoneal cavity and absent fetal \nheart sounds. In view of free fluid in the abdomen she was shifted to \nOT for exploratory laparotomy which revealed hemoperitoneum and \nrupture of rudimentary horn of uterus on left side along with extrusion \nof fetus and placenta (Figure 1). The rudimentary horn was attached \nto right side of the uterus which was unicornuate (Figure 2). The \nruptured rudimentary horn along with corresponding fallopian tube \nwas excised. She was transfused two pints packed red cells and she \nmade uneventful postoperative recovery. \nCase 2\n27 years old lady, para 2 reported with pain abdomen of many \nmonths duration. Pain was intermittent initially but had become \nalmost continuous and was dull aching in character. She had two \nnormal vaginal deliveries. Her general and systemic examination \nwas normal. Gynecological examination revealed a normal size \nuterus with adnexal mass of 10 to 12 cm, globular mass which had \nrestricted mobility. Ultrasound suggested large endometriotic cyst. \nShe was posted for diagnostic laparoscopy which showed an enlarged \nand distended rudimentary horn on right side (Figure 3) (Figure 4). \nSince the mass was big size and endoscopic surgical expertise was not \navailable, hence laparotomy was done and rudimentary horn along \nwith ipsilateral fallopian tube was excised. The cavity contained \na large quantity of chocolate material. She made an uneventful \npostoperative recovery.\nFigure 1 Ruptured rudimentary horn with fetus and placenta extruded out.\nFigure 2 unicornuate right horn of uterus after removal of rudimentary horn.\nObstet Gynecol Int J. 2018;9(6):440‒442. 440\n©2018 Kathpalia. This is an open access article distributed under the terms of the Creative Commons Attribution License , which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nRudimentary horn – different clinical presentations\nVolume 9 Issue 6 - 2018\nSukesh Kathpalia\nAndaman Nicobar Islands Institute of Medical Sciences, India\nCorrespondence: Dr. Sukesh Kathpalia, Andaman Nicobar \nIslands Institute of Medical Sciences, Port Blair, India, 744104, T el \n9599600375, Email \nReceived: August 01, 2017 | Published: November 21, 2018\nAbstract\nUnicornuate uterus with rudimentary horn is a type of Mullerian duct malformation. This \nrudimentary horn may or may not have functional cavity. This cavity is usually found to \nbe noncommunicating with main cavity of unicornuate uterus. This rudimentary horn can \ncreate certain obstetrical and gynecological problems. Pregnancy in rudimentary uterine \nhorn is a dangerous kind of ectopic pregnancy; its rupture causes massive hemoperitoneum. \nCollection of menstrual blood in the rudimentary horn will result in hematometra and can \ncause chronic pelvic pain and subsequent endometriosis. Three cases with different clinical \npresentation are being presented.\nKeywords: rudimentary horn, hematometra, rupture\nObstetrics & Gynecology International Journal\nCase Series\n Open Access\n\n\nRudimentary horn – different clinical presentations\n441\nCopyright:\n©2018 Kathpalia\nCitation: Kathpalia S. Rudimentary horn – different clinical presentations. Obstet Gynecol Int J. 2018;9(6):440‒442. DOI: 10.15406/ogij.2018.09.00382\nFigure 3 Hematometra along with non distended uterine body on laparoscopy.\nFigure 4 Hematometra on right side on laparoscopy.\nCase 3\n21 years old primigravida, a booked case was detected to \nhave breech presentation at 32 weeks gestation. All her antenatal \ninvestigations including anomaly scan were normal. Presentation did \nnot undergo spontaneous version and remained breech till 37 weeks \nof gestation. She underwent elective CS; baby and placenta were \ndelivered without any difficulty. At the time of section it was found \nto be a case of unicornuate uterus along with small rudimentary horn \non left side. The rudimentary horn along with ipsilateral fallopian \ntube was excised to prevent any future complication like ectopic \npregnancy. She made uneventful postoperative recovery.\nDiscussion\nParamesonephric ducts also known as Mullerian ducts are \npaired embryonic structures which fuse craniocaudally and later \nrecanalize and develop into fallopian tubes, uterus, cervix and upper \npart of vagina. Certain malformations can occur during embryonic \ndevelopment;4 which have been classified by the American Society of \nReproductive Medicine. A unicornuate uterus (type II malformation) \nis classified into four groups depending on presence or absence of \nfunctional endometrium and communication.5\nIf pregnancy occurs in unicornuate uterus; then it is associated \nwith high rate of spontaneous abortion, preterm labor, abnormal \npresentation, retained placenta and uterine rupture.6 Pregnancy in non-\ncommunicating rudimentary horn is a rare form of ectopic gestation \nand its incidence is between 1/100,000 to 1/140,000 pregnancies. 7 \nIt occurs following Trans peritoneal migration of sperm or zygote. \nIt is recommended by most that immediate surgery be performed \nwhenever a diagnosis of pregnancy in rudimentary horn is made \neven if unruptured to prevent catastrophic rupture;8 as this can lead to \ntorrential intraperitoneal hemorrhage. The fallopian tube on the side \nof the rudimentary horn must be removed along with the rudimentary \nhorn to prevent future tubal gestation. \nA careful pelvic examination in the 1 st trimester showing \ndeviated uterus with palpable contra-lateral pelvic adnexa should \narouse suspicion of uterine anomaly. 9,10 Ultrasonography can also \npick up this anomaly with reasonable accuracy. 11 A gestational sac \nsurrounded by myometrium by the side of a normal empty uterus \nand non-communication of gestational sac with the endometrial \ncavity differentiates it from pregnancy in one of the horns of a \nbicornuate uterus; 12 MRI and CT scan also can help in diagnosing \nuterine malformations. 13 The menstrual blood may accumulate in \nthe noncommunicating variety of rudimentary horn and result in \nhematometra causing abdominal pain. Second case had similar \nclinical presentation. All cases of uterine malformations should \nundergo detailed investigations to rule out urinary tract malformations \nwhich are commonly associated. None of our cases had any renal \nmalformation. Another long term complication of rudimentary horn \nwhich may occur is endometriosis due to retrograde menstruation as a \nresult of functional cavity without communication. \nA review of the literature shows that operative laparoscopy can be \nused for removal of a rudimentary horn successfully and minimally \ninvasively.14,15 \nAcknowledgements\nNone. \nConflict of interest\nThe author declares that they have no conflict of interest.\nReferences\n1. Heinonen PK. Unicornuate uterus and rudimentary horn. Fertile Steril. \n1997;68(2):224–230.\n2. Goel P, Aggarwal A, Devi K, et al. Unicornuate uterus with non-\ncommunicating rudimentary horn – different clinical presentations. J \nObstet Gynecol India. 2005;55(2):155–158.\n3. Lacin S, Kartal O. Rupture of rudimentary horn pregnancy at the 15th \nweek of gestation: a case report. Eur J Obstet Gynecol Reprod Biol . \n2002;102(2):209–221.\n4. Atmaca R, Germen AT, Burak F, et al. Acute abdomen in a case with \nnoncommunicating rudimentary horn and unicornuate uterus. JSLS.. \n2005;9(2):235–237.\n5. Rusen A, Germen AT, Burak F, et al. Acute abdomen in a case with \nnoncommunicating rudimentary horn and unicornuate uterus. JSLS. \n2005;9(2):235–237.\n6. Shin JW, Kim HJ. Case of live birth in a non-communicating rudimentary \nhorn pregnancy. J Obstet Gynaecol Res. 2005;31(4):329–331.\n7. Johansen K. Pregnancy in a rudimentary horn: two case reports. Obstet \nGynecol. 1969;34(6):805–808.\n8. Jayasinghe Y , Rane A, Stalewski H, et al. The presentation and \nearly diagnosis of the rudimentary uterine horn. Obstet Gynecol . \n2005;105(6):1456–1467.\n\n\nRudimentary horn – different clinical presentations\n442\nCopyright:\n©2018 Kathpalia\nCitation: Kathpalia S. Rudimentary horn – different clinical presentations. Obstet Gynecol Int J. 2018;9(6):440‒442. DOI: 10.15406/ogij.2018.09.00382\n9. Buntugu KA, Ntumy MY , Ameh EO, et al. Rudimentary horn pregnancy: \npre-rupture diagnosis and management. Ghana Med J . 2008;42(2):92–\n94.\n10. Nagarathna G, Mahesha Navada H, Poornima BR. Bhat. Pre-rupture \ndiagnosis and management of rudimentary horn pregnancy in a second \ntrimester. Int J Pharm Biomed Res. 2011;2(3):179–181. \n11. Chopra S, Suri V , Aggarwal N. Rudimentary horn pregnancy: Prerupture \ndiagnosis and management. Indian J Med Sci. 2007;61(1):28–29.\n12. Kriplani A, Relan S, Mittal S et al. Prerupture diagnosis and management \nof rudimentary horn pregnancy in the first trimester. Eur J Obstet Gynecol \nReprod Bio. 1995;58:203–205.\n13. Chang CY , Chang SY , Changchien CC, et al. Hematometra of the \nrudimentary horn of a unicornuate uterus resulting from cesarean section. \nAm J Obstet Gynecol. 2001;185(5):1263–1264.\n14. Zapardiel I, Alvarez P, Perez-Medina T, et al. Laparoscopic management \nof a cavitated noncommunicating rudimentary uterine horn of a \nunicornuate uterus: a case report. J Med Case Rep. 2010;4:215.\n15. Fedele L, Bianchi S, Zanconato G, et al. Laparoscopic removal of the \ncavitated noncommunicating rudimentary uterine horn: surgical aspects \nin 10 cases. Fertil Steril. 2005;83(2): 432–436.","source_license":"CC0","license_restricted":false}