An advanced rudimentary horn pregnancy (A case report)

Amaç

Rudimenter horn gebelik çok nadir gözlenmesi, fertilizasyon metodu, eğer tanı konulamaz ve uygun tedavi edilmez ise fetus ve anne için yüksek mortalite oranlarından dolayı her zaman dikkat çekmiştir. N.B., 23 yaşında, 29 haftalık multipar gebe Temmuz-1995'de son birkaç aydır giderek artan pelvik ağrı yakınması ile başvurmuştur. 

Olgular

Ultrasonografide fetal kalp aktivitesinin olmadığı, femur 42,9 mm; 23 hafta, minimal amniotik sıvı gözlendi ve intrauterine "morte de fetus" olarak ya-tırıldı. Sırasıyla misoprostol, rivanol, oksitosin uygulamaları yapıldı ancak yanıt alınamaması üzerine histerotomi yapılmasına karar verildi. 

Sonuç

Laparatomide rudimenter horn gebelik olduğu, patolojik seksiyonda ise uterus ile ilişkili kanal gözlenmedi. Bu olgu sunumunda, uterus ile ilişkisi olmayan, son adet tarihine göre 29 hafta, ultrasonogram ölçümlere göre ise 23. haftalık rudimenter gebelik literatür gözden geçirilerek tartışıldı

Anahtar Kelimeler

Rudimenter horn gebelik.

Giriş

Rudimentary horn pregnancy because of its rarity has frequently been considered of sufficient interest to warrant reporting. Mauriceau reported first case of rudimentary horn pregnancy in 1669- As with any rare condition a true incidence is difficult to ascertain. Taylor states that a normal pregnancy occurs in the double uterus once in every 5000 pregnancies (1); Eastman reports an incidence of 1 per 15000 for abdominal pregnancy (2). It is safe to assume that rudimentary horn pregnancies far exceed in rarity these estimates of more common complications. In a detailed review of deliveries at the New York Hospital, Smith was able to uncover one case of a rudimentary horn pregnancy in 141,946 deliveries. Therefore, one might safely conclude that rudimentary horn pregnancies are 10 times less frequent than abdominal pregnancies (3).

Olgular

N.B., 23-year-old multiparous woman applied to the prenatal outpatient clinic in July-1995 at the twentyninth week of gestation with a history of progressively increasing low abdominal and pelvic pain for last two months. There was a four weeks discordance between last menstrual gestational we-eks (29 weeks) and funduspubic height (25 weeks)and was no audible fetal heart sound with Doppler. During ultrasound (USG) examination, femur length and the fetal age were found as 42,9 mm and 23 weeks respectively and were no detectable fetal cardiac activity, minimal amniotic fluid. No other remarkable findings were observed with USG. So accordingly, patient was hospitahlized with diagnosis of intrauterine fetal death.
Her past history was uneventful. Her Menses began at age 13, and occur every 30 days, lasting 7 days. There was no history of irregularity or dysmenorrhea. Two years ago she gave birth a term female baby weighed 3200 grams spontaneously with the vaginal route.
The earlier months of pregnancy were unremarkable. Her complaint was progressively incerasing low abdominal and pelvic pain during last month..
On admission the vital signs were normal; cervix displaced, closed and firm; hemoglobin 10,5 gram/dl; hematocrit 32%; thrombocyte count 257,000; fibrino-gen 498 mg/dl; bleeding time 1,15 minutes; clotting time 4,50 minutes; aPTT 31,5 seconds; PT 13 seconds, blood 0 (+) type and no remarkable abnorma-lity in the blood biochemistry.
Misoprostol (Cytotec) 100 micro-gram vaginally and following 12x100 microgram/gun p.o. for one day; 250 cc extra-amniotic Rivanol; 2 % Oxytocin 500 cc; one more day Misoprostol protocol described above respectively were applied to patient and there were no response in regarding of uterine contraction, no change in Bishop score of cervix and USG findings. Patient's condition were discussed and were agreed of performing hysterotomy.
At laparotomy; there was no free blood and fluid in the peritoneal catviy. On the right side uterus unicollis was two times normal size, with the right round ligament, tube and ovary. Left ovary, tube, round ligament were attached to intact rudimentary corn sized as 20 cm x 21 cm x 24 cm which fused with left upper corner of uterus unicollis by a liga-mentous like fibrous pedicule. Fibrous pedicule, left round ligament, left tube were clamped and totaly extirpated.
At pathological section, in rudimentary horn wall uterine musculature was observed. Third degree macerated male fetus weighting 670 grams and plasenta were totaly inside of the intact horn.
The rudimentary horn was not communicating with uterus (Picture 1). The patient's postoperative course was uneventful and leaving the hospital in good condition on the postoperative fifth day. From the history, the operative and pathologic findings, it was concluded that we were dealing with an intact 29.th weeks rudimentary corn gestation.

Tartışma

In patients with complete or partial atresia of one of the paramesonephric ducts at the time of embriogenesis, the rudimentary part lies as a apendage to the welldeveloped side. The incidence of unicornuate uteri in a series of ll60 uterine anomalies was 14 percent (4). This was likely an underestimate, because the major diagnostic technique used was hysterosalpingoraphy, which can not identify noncommunicating rudemantary horns. O'Leary and O'Leary estimated that in 90 percent of unicomuate uteri with rudimentary horns there was no communication between the horns (3). This information has both gynecological and obstetrical significance. Specifically, the increased incidence of infertility, endometriosis, and dysmenorrhea in such cases is certainly more easily understood (5). In unicomuate patients pregnancy outcome is poor, likely due to anatomical defect; increased abortion, preterm delivery, fetal growth retardation, breech presentation, abnormal uterine function in labor, and cesarrean section (6).
An interesting feature frequently mentioned in discussions of rudimentary horn pregnancy is the mode of fertilization. In 90 percent of cases noncommucinating rudimentary horn, as in our case, is present. In those cases sperm must migrate throuh tran-sabdominal route. Corpus luteium is found in contralateral side to the rudimentary horn in five percent Duration of the pregnancy is directly related to the thickness of the musculature of the rudimentary horn and its ability to hypertrophy and dilate. Rolen and associates (1996) reported that in 70 pregnancies with implantations in rudimentary horns, uterine rupture usually occurred prior to 20 gestational weeks (7). About 10 percent of cases will go to term or form a lithopedion (3).
Less than five percent of the cases reported have been correctly diagnosed preoperatively (2). In our case we diagnosed as an intrauterine fetal death and treated accordingly. We could not observe the endometrial echo or uterus in USG. If endometrial echo can be identified by USG or unusual USG findings, unresponsivness to various medical therapeutic options and patient's feeling of things not quite right, displacement of cervix and unusual painful extraamniotic rivanol application, all of these must raise a suspect of rudimentary horn pregnancy. To verify or to rule out, one may try hydrosonography or may check up endometrial cavity with hysterometry to differentiate rudimentary horn or abdominal pregnancy from intrauterine pregnancy in the case of fetal death. Other findings that may be helpful in diagnosis of rudimentary pregnancy are as follows: history of dyspareunia, sterility, dysmenorrhea (Jarcho); absence of pain and tenderness of examination, in contrast to tubal pregnancy (Abuladase); history of pregnancy and a freely movable tumor (Abramson); in a multipara, the statment that "things are not quite right; I feel different this time" (Eastman); contractions in the sac of teh tumor (Greenhill). In the presence of an unruptured horn, patient must be hospitalized and under the close observation, extirpation should be performed when fetal viability is attained (3). When an abdominal pregnancy develops, prompt operative interference is indicated.

Sonuç

In the case of unusual findins of vaginal examination, USG and unresponsiveness to various therapeutic option we must suspect rudimentary horn pregnancy. When we can not get any response with a therapeutic option during pregnancy termination, before we try another one, we should review the case again. In the first trimester USG, we should view the uterus, the adnexial regions as well as the gestational sac.

 

Kaynaklar

1. Taylor H.C. Pregnancy and the double uterus. Am J Obst & Gynec. 46;88:1943.
2. Eastman N. Obstetrics (ed. 11). Appleton. New York. 1956 3. O'Leary JL, O'Leary JA: Rudimentary horn pregnancy. Obstet Gynecol. 22;37:1943.
4. Zanetti E, Ferrari LR, Rossi G. Classification and radiographic fea tures of uterine malformation: Hysterosalpingographic study. Br J Radiol. 51;161:1978.
5. Heinonen PK. Clinical implications of the unicornuate uterus with rudimentary horn. Int J Gynaecol Obstet.21;145:1983.
6. Fedele L, Zamberletti D, Vcrcellini P Dorta M, Candiani GB. Reproductive performance of women with unicornuate uterus. Fertil Steril. 47;416:1987.
7. Rolen AC, Choquette AJ, Semmens JP: Rudimentary uterine horn: Obstetric and gynecologic implication. Obstet Gynecol. 27;806:1966.

	Dosya / Açıklama
	Resim 1 The rudimentary born was not communicating with uterus.