{"paper_id":"a2aaa5cc-824d-4954-a2cb-64dde17046e7","body_text":"C A S E R E P O R T Open Access\nHemiuterus with functional non-\ncommunicating horn in a young female\nM. Venkatesh 1 and Sandeep Singh Awal 2*\nAbstract\nBackground: Mullerian duct anomalies are a broad spectrum of congenital anomalies of the female genital tract\npresenting with variable symptoms like infertility, amenorrhoea, dysmenorrhea, pelvic endometriosis, and poor\nobstetric outcomes. Unicornuate uterus or hemiuterus occurs as a result of abnormal formation or failure of\nformation of the contralateral part.\nCase presentation: We present a rare case report of hemiuterus with functional non-communicating horn along\nwith hematometra in a 15-year-old female who presented with severe dysmenorrhoea since her menarche. Pelvic\nUltrasonography demonstrated inconclusive findings of a heterogenous lesion in the right pelvic cavity adjacent to\nthe uterus. Further, pelvic MRI revealed a hemiuterus on the left side with a normal endometrial cavity and a well-\ndefined functional non-communicating horn on right side. The diagnosis of European Society of Human\nReproduction (ESHRE) Classification U4a uterine anomaly (left hemiuterus with functional non-communicating horn\non right side) was established.\nConclusions: ESHRE Class U4a comprises of hemiuterus with a functional rudimentary horn. This is considered\nclinically significant as it may lead to further complications, such as hematometra or ectopic pregnancy in the\nrudimentary horn. Hence, the correct identification of this entity is essential as laparoscopic removal is the current\nrecommended management.\nKeywords: Mullerian duct anomalies, Hemiuterus, Rudimentary horn, Dysmenorrhea, Case report\nBackground\nMullerian duct anomalies (MDA) belong to a broad\nspectrum of congenital anomalies of uterus and vagina\nwhich occur due to developmental defects in the Muller-\nian ducts [ 1]. These anomalies can present with various\nsymptoms like infertility, amenorrhoea, dysmenorrhoea,\npelvic endometriosis, and associated obstetric complica-\ntions [2]. Hysterosalpingography (HSG) is initially used to\ndiagnose structural anomalies of the female genital tract\n[3]. However, HSG lacks in the capability of characterizing\nthe external morphology of the uterus and classifying the\nsubtype of the anomaly. With the advent of newer modal-\nities, HSG has been supplanted by pelvic ultrasonography\n(USG) and pelvic magnetic resonance imaging (MRI). Pel-\nvic MRI is considered superior to pelvic ultrasonography\nfor the diagnosis and classification of Mullerian duct\nanomalies as it provides excellent soft tissue depiction\nowing to its multiplanar capabilities [4, 5].\nWe present a rare case report of left hemiuterus with\nfunctional non-communicating horn on right side along\nwith hematometra.\nCase presentation\nA 15-year-old female presented with severe dysmenor-\nrhea since her menarche. She attained menarche at the\nage of 13 years with regular menstrual cycles of 22 –25\ndays in duration. The pain was mildly alleviated by\nanalgesics. On general examination, her blood pressure\nwas 120/80 mmHg with heart rate of 78 beats/min. Her\nsecondary sexual characters were well developed.\n© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,\nwhich permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give\nappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if\nchanges were made. The images or other third party material in this article are included in the article's Creative Commons\nlicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons\nlicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain\npermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.\n* Correspondence: jonty3awal@gmail.com\n2Department of Radiology, Brahmananda Narayana Multispecialty Hospital,\nJamshedpur, India\nFull list of author information is available at the end of the article\nEgyptian Journal of Radiology\nand Nuclear Medicine\nVenkatesh and Awal Egyptian Journal of Radiology and Nuclear Medicine\n         (2021) 52:127 \nhttps://doi.org/10.1186/s43055-021-00507-z\n\nUltrasound of the pelvis was done which revealed a\nheterogenous, hypoechoic lesion adjacent to the uterus\non the right side. The above findings on ultrasound were\ninconclusive.\nPelvis MRI with axial T1, T2, T1 FS (3 mm thick-\nness), sagittal T2 (4 mm thickness), axial gradient echo\n(4 mm thickness) sequences were performed. Pelvic\nMRI (Fig. 1a–c) revealed a hemiuterus measuring 5.8 ×\n2.8 × 3 cm in size with a normal endometrial cavity. A\nwell-defined structure measuring 4.5 × 4.2 cm was\nnoted in contact with the hemiuterus on right side and\nshowed endometrial cavity within. The endometrial\ncavity demonstrated loculated T1 hyperintense content\nwithin, suggestive of hematometra. No obvious com-\nmunication was noted with the hemiuterus. Single cer-\nvical cavity was seen (Fig. 2a). No vaginal septum was\nseen (Fig. 2b). Bilateral ovaries and adnexa showed nor-\nmal morphology. The diagnosis of ESHRE Classification\nU4a C0 V0 uterine anomaly (left hemiuterus with func-\ntional non-communicating horn on right side) was\nestablished (Fig. 2c). No associated renal anomalies\nwere present.\nDiscussion\nThe prevalence of Mullerian duct anomalies (MDA)\nranges from 1 to 5% [ 6–9]. However, in women present-\ning with recurrent pregnancy loss, the prevalence is sig-\nnificantly higher (up to 15%) [ 9]. Hence, the correct\nidentification and classification of Mullerian duct\nanomalies is clinically significant. The importance of a\nuniversalized and comprehensive classification for con-\ngenital anomalies of the female genital tract cannot be\nunderstated [ 10].\nThe European Society of Human Reproduction (ESHR\nE)/European Society of Gynecological Endoscopy (ESGE)\nconsensus [ 11] classifies congenital anomalies of the fe-\nmale genital tract categories on the basis of anatomical\nvariations as follows:\nClass U0 incorporates normal uterus. Class U1 com-\nprises dysmorphic uterus. Separate uterus is considered\nas Class U2. All fusion defects are classified under U3 or\nBi-corporeal uterus. Unilaterally formed uterus or hemi-\nuterus is included under Class U4. Aplastic uterus is\nconsidered as Class U5. A separate class, U6 is reserved\nfor still classified cases [ 11].\nClass U4 is further subdivided into classes U4a and\nU4b depending on the morphological characteristics of\nthe contralateral poorly formed part. If the rudimentary\nhorn/cavity is functional, it is classified as Class U4a ir-\nrespective of it being communicating or non-\ncommunicating. Non-functional rudimentary horn/cav-\nity is categorized as Class U4b [ 11].\nESHRE Class U4a (hemiuterus with a functional rudi-\nmentary horn/cavity) is associated with obstetric and\ngynecological complications such as hematometra and\nectopic pregnancy [ 11–14]. Due to this reason, laparo-\nscopic removal of Class U4a rudimentary horn is the\ncurrent recommended line of management [ 15].\nFig. 1 a–c Axial T2 ( a) showing cavity with hematometra (white arrow) towards right side and is in continuity with the left hemiuterus (red\narrow). Axial T1 ( b) and T1 fat surpassed images ( c) showing hyperintense fluid in the horn on right side (white arrow and black arrow)\nsuggestive of hematometra\nFig. 2 a–c Sagittal (a) and axial ( b) T2 images showing normal cervix (white arrow) and normal vagina (black arrow). Illustration of our case ( c)\nshowing hemiuterus (white arrow) and functional non-communicating horn with hematometra (red arrow)\nVenkatesh and Awal Egyptian Journal of Radiology and Nuclear Medicine          (2021) 52:127 Page 2 of 3\n\nConclusions\nMullerian duct anomalies incorporate wide spectrum of\ncongenital anomalies of the female genital tract. Imaging\nplays crucial role in the diagnosis and classification of\nthe Mullerian duct anomalies. Class U4a MDA repre-\nsents a hemiuterus with a functional rudimentary horn/\ncavity and has been associated with complications such\nas haematometra and ectopic pregnancy. Hence, the cor-\nrect identification of this rare entity is essential to im-\nprove the morbidity and prevent further obstetric and/or\ngynecological complications.\nAbbreviations\nMDA: Mullerian duct anomalies; ESHRE: European Society of Human\nReproduction; ESGE: European Society of Gynaecological Endoscopy;\nMRI: Magnetic resonance imaging; HSG: Hysterosalpingography;\nUSG: Ultrasonography; FS: Fat saturated\nAcknowledgements\nNot applicable.\nAuthors’ contributions\nVM: conceived of the study, analyzed and interpreted the radiological study,\nparticipated in manuscript design, designed illustrations, and helped in\ndrafting the manuscript. SSA: drafted the manuscript, participated in\nmanuscript design and coordination. The authors read and approved the\nfinal manuscript.\nFunding\nNot applicable.\nAvailability of data and materials\nThe data and materials supporting the findings of this study are available on\nrequest from the corresponding author.\nDeclarations\nEthics approval and consent to participate\nThis study was approved from ethical committee of the institution. Written\ninformed consent was obtained from the patient for publication of this case\nreport and accompanying images.\nConsent for publication\nAll authors read and approved the final manuscript. Patient included in this\nresearch gave written informed consent to publish the data and materials\ncontained within this study.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthor details\n1Department of Radiology, Narayana Medical College & Hospital, Nellore,\nIndia. 2Department of Radiology, Brahmananda Narayana Multispecialty\nHospital, Jamshedpur, India.\nReceived: 12 February 2021 Accepted: 3 May 2021\nReferences\n1. Chandler TM, Machan LS, Cooperberg PL, Harris AC, Chang SD (2009)\nMullerian duct anomalies: from diagnosis to intervention. Br J Radiol\n82(984):1034–1042. https://doi.org/10.1259/bjr/99354802\n2. Kachhawa G, Kriplani A (2017) Management of reproductive tract anomalies.\nJ Obstet Gynaecol India 67(3):162 –167\n3. Simpson WL Jr, Beitia LG, Mester J (2006) Hysterosalpingography: a\nreemerging study. RadioGraphics. 26(2):419 –431. https://doi.org/10.1148/rg.2\n62055109\n4. 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Kumari S, Gupta P, Jyoti PS (2019) A rare case of pregnancy in the\nrudimentary horn of unicornuate uterus (on table diagnosis): a case report.\nInt J Reprod Contracept Obstet Gynecol 8(3):1190\n13. Johansen JK (1969) Pregnancy in a rudimentary horn. Two case reports.\nObstet Gynecol 34(6):805 –808\n14. Kamal S, Roy P (2017) A study of complications in case of unicornuate\nuterus with rudimentary horn. Int J Reprod Contracept Obstet Gynecol\n6(6):2607\n15. Fedele L, Fedele BS, Fedele ZG, Fedele BN, Fedele BV, Fedele (2005)\nLaparoscopic removal of the cavitated noncommunicating rudimentary\nuterine horn: surgical aspects in 10 cases. Fertil Steril 83(2):432 –436\nPublisher’sN o t e\nSpringer Nature remains neutral with regard to jurisdictional claims in\npublished maps and institutional affiliations.\nVenkatesh and Awal Egyptian Journal of Radiology and Nuclear Medicine          (2021) 52:127 Page 3 of 3","source_license":"CC0","license_restricted":false}