Rupture of a Gravid Non-Communicating Horn with 18-Weeks Pregnancy

Introduction

Pregnancy in a rudimentary horn of a unicornuate uterus is rare [1]. An incidence of 1 in 76,000–150,000 pregnancies is reported in the literature [2].We have come across one rare case in which there was rupture of gravid non-communicating horn of the uterus after carrying the pregnancy up to 18 weeks of gestation.

Case Presentation

An 18-year-old patient was referred from a private hospital at 11 pm in the casualty as a case of Primigravida with 18-weeks pregnancy with ‘splenic rupture’ in shock.

On Admission

• General Condition was Poor

• Pulse: 100/min

• BP: Systolic 70 mmHg

• Severe pallor

Per Abdominal Examination

The abdomen was uniformly distended with a dull note all over it. The abdomen was tense, and vague tenderness was present all over. Uterine height could not be made out as there was tenderness all over the abdomen.

On admission, the patient was in shock and so was shifted to the ICU for intensive care. 1st unit of PCV was started. The decision of urgent sonography was taken to find out the cause of haemoperitoneum.

On USG

Single live intrauterine pregnancy with average gestational age of 18 weeks.

• Foetal bradycardia

• Uterine contour was normal

• Gross haemoperitoneum

• No visceral organ injury noted on the scan

Investigations

• Haemoglobin: 3.2 gm%

• Platelets 2,40,000/cumm

• WBC count was 55,000/-

• PT 23 Mins and APPT was 47 min

• BT: 3 min and CT was 5 min 20 s

To search for the cause of bleeding, surgery reference was done and they prompted to do further CT scan of the abdomen with contrast. On CT scan, the radiologist diagnosed it to be a case of uterine rupture which was thought to be unlikely in previously unscarred uterus and with no h/o trauma or illegal termination of pregnancy (Fig. 1).

Fig. 1.

CT scan image. Foetal calcified skull lying in the abdominal cavity in the background of haemoperitoneum

We further transfused two points of packed cell volume and four points of fresh frozen plasma. Four points of blood were kept ready. The decision of urgent laparotomy was taken.

On opening the abdomen, gross haemoperitoneum was noted; almost 2.5 l of blood was drained along with clots. To our surprise, it was rupture of non-communicating horn of the uterus with the baby lying in the abdomen, placenta still attached to the uterus (Fig. 2).

Fig. 2.

Intraoperative picture. Rupture of non-communicating horn

Excision of the ruptured non-communicating horn of the uterus was done. We had to remove the ipsilateral ovary as there was continuous oozing from the raw surface of the ovary in background of deranged coagulation.

Discussion

Rudimentary horn with a unicornuate uterus results from failure of complete development of one of the mullerian ducts and incomplete fusion with the contralateral side. In 83 % of cases, the rudimentary horn is non-communicating.

Pregnancy in a non-communicating rudimentary horn occurs through transperitoneal migration of sperm or fertilized ovum. It is associated with a high rate of spontaneous abortion, preterm labour, intrauterine growth retardation, intraperitoneal haemorrhage and uterine rupture. Diagnosis prior to rupture is unusual, but could be made with ultrasonography and MRI.

Tsafrir et al. [3] outlined a set of criteria for diagnosing pregnancy in the rudimentary horn. They are: (1) a pseudo pattern of asymmetrical bicornuate uterus; (2) absent visual continuity tissue surrounding the gestation sac and the uterine cervix; (3) the presence of myometrial tissue surrounding the gestation sac. Nonetheless, most cases remain undiagnosed until it ruptures and presents as an emergency.

Conclusion

'Things we don’t think, don’t see' is true to the clinical practice. High index of suspicion is the only thing which will prevail in the scenario of rising litigation. Any patient in the first and early second trimester of pregnancy who comes with haemoperitoneum with a gestational age of more than 12 weeks should be ruled out for uterine anomalies and the associated rupture of the uterus.