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Pregnancy in a noncommunicating rudimentary horn
PREGNANCY IN A NONCOMMUNICATING RUDIMENTARY HORN* Report oi a Case ELMER GERGELY, M.D., AND DANIEL BROOKLYN,
J.
MASON, M.D.,**
N.Y.
(From the State University of New York, College of Medicine at New York City, and the Department of Obstetrics and Gynecology at Maimonides Hospital)
T
HE obstetrical literature has numerous reports concerning the association o:f malformation of the female genital tract and pregnancy. The complications arising from pregnancies in anomalous uteri are rarely diagnosed. This communication reports a case in which a pregnancy occurred in a noncommunicating rudimentary horn of a uterus bicornis unicollis.
Review Uterine anomalies can be responsible :for many complications that may occur during pregnancy, labor, or puerperium. It is, therefore, essential to make the diagnosis of a congenital uterine anomaly early in pregnancy. The uterus didelphys and the more common uterus bicornis offer no diagnostic problem if a thorough vaginal and speculum examination has been done. In those patients with a history of sterility, repeated abortions, recurrent premature labors, or abnormal presentations, hysterosalpingography should be performed. Jarcho, 6 Fenton and Singh/ and Baker1 have shown that between 18 and 53 per cent of pregnancies associated with uterine anomalies will spontaneously abort, and between 13 and 15 per cent will go into premature labor. Between 10 and 30 per cent will have a malpresentation such as a breech or a transverse lie with the latter occurring more :frequently in the uterus subseptus and uterus bicornis unicollis than in other types of anomalies. During labor there is the possibility of uterine rupture but this rarely occurs. A nonpregnant horn may become incarcerated and cause failure of descent by obstructing the presenting part. A vaginal septum may also impede progress and may have to be excised. During the third stage of labor the placenta may :fail to separate spontaneously and may have to be removed manually. There is also an increased incidence of postpartum hemorrhage. Tkese complications have raised the fetal mortality to between 23 and 43 per cent and the maternal mortality to between 2 and 2.5 per cent. The fetal and maternal risks are greatest in the uterus bicornis unicollis and uterus subseptus and least in didelphys and in uterus unicornis. 5 Pregnancy in a rudimentary horn of a uterus bicornis has particular relevance to this report. Eastman 3 stated that by the year 1900 84 cases had *Presented at a meeting of the Brooklyn Gynecological Society, May 15, 1957. ••Present address: .Jericho, N. Y.
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PREGNANCY IN NONCOMMUNICATING RUDIMENTARY HORN
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been collected by Kehrer from ~ermany, and in 1945 Stander'! stated that this was the most common abnormality. Since 1911, however, only 13 cases had been reported in the American, British, and Indian literature. 2 • 7 • 9 • 10 Of these 13 patients, one died from a ruptured horn at 4% months' gestation and in another the pregnant horn ruptured but the patient survived. A pelvic mass was diagnosed incorrectly in 3 patients before operation, an ectopic pregnancy in one and missed abortion in 5. Two of the cases were difficult to evaluate. In no case was a correct preoperative diagnosis made. The patient was a 33·year·old white woman with one living child following a normal pregnancy and delivery in 1954. Her past history did not reveal any abnormality in the menstrual cycle. Her last period was Sept. 1, 1955. The initial examination, during the eighth week of amenorrhea, revealed a palpable mass, approximately 5 em. in diameter, in the right adnexal region. The uterus was felt to be enlarged to the size of a 6 weeks' gestation. A diagnosis of intrauterine pregnancy complicated by a right ovarian cyst was made. During the fourth month of gestation she began to have irregular vaginal bleeding which occurred once a month until the seventh month. Fetal movements were said to be present in the fifth month and the fetal heart was heard on one occassion during the fifth month. Fig. 1.
Fig. 2. Fig. 1.-Gross specimen: the rudimentary born with attached ovary, tube, and corpus luteum. Fig. 2.-The amniotic sac is opened showing the ma.cerated fetus.
1204
G-ERGELY AND MASON
Am. J. Obst. & Gyner. December, 1919
By tho sixth month a diagnosis of missed abortion was made on the basis of the absent fetal heart sounds and failure of the uterine size to e.orrcspowl with the period of gpstation. X-ray examination in the sixth and eighth months of arn••norrhor with intravenou~ Pitocin wa;; unsuccessful and 3 months later a laparotomy \\'as performed. The uterus was found to be of normal size. 1'he lE>ft ovary, tube, anft round ligament were JHn'nml. Thl~ uterus was displaced to the left hy a mass approximately 10 em. in dianwtPr, oH it8 right side. A fibrous band, 3.25 em. in length, ~mnwcterl this mass to Uw mid-portio11 of t.hP uterus. The right tube, ovary, and right round ligament wpre attaclwrl to tlw uppPr right surface of this mass, \Yhieh proved to be a rudimentary hom. 'rhe horn awl thp atta.-Jwd tuho and ovary with its visible corpus luteum were removed (Fig. 1). Subsequent x·ray examination of the horn revealed a fetus within. A <·an,ful ~earch for a ehannel lervling to the nHlimPntarr horn was unsucrrssful (l<'ig. ~).
Comment
Of the 18 eases rt>portod since 1911, only~ eases n~vealed a eomnnmication between the rudimentary horn and the uterus. Eastman~ stated that KPhrer found no eommunication in 78 per cent of his 8.! eases, and from this deducPd ''that a pregnancy must have followed external migration of the spermatozoa or the fertilized ovum." Of course, failure to find a communicating- eana l n111~· aiRo result from its apparent obliteration by an enlarging ruclimentar;· horn. The outcome of a pregnancy in a rudimentary horn will drpPnd upon the presence or absence of a channel between the horn and th(' uterus. If a communication is present the result, as a rule, will he a spontaneous abortion and the diagnosis of a rudimentary horn may he missed. If ther(' j.., no communication the prognosis is serious for it may lead to a rupture of the horn or a missed abortion. Conclusions l. A ease of a pregnancy in a noncommunieating rudimentary horn is presented. 3. A missed abortion if unusually prolonged suggests a defect in the em-bryonic development of the genital tract, regardless of the patient's normal obstetrical history.
References 1. Baker, W. t!., Roy, R. L., Bancroft, C., McGaughey, H., and Dickman, H. F.: .\M . •T. OBST. & C+YNEC. 66: 580, 1953. 3. De Nicola, R. R., and Petersen, M. R.: Am. J. Surg. 73: 381, 1947. 3. Eastman, N. J.: Williams Obstetrics, ed. 11, New York, 1956, Appleton-Century-Crofts, Inc., p. 6·l1. 4. Fenton, A. M., and Singh, B. P.: AM. J. 0BS'r. & GYNgc, 63: 745, 1952. 5. Holmes, J. A.: Brit. M. J. 2: 1144, 1956. 6. Jarcho, J.: Am. J. Surg. 71: 106, 1946. 7. Mulsow, F.: AM. J. 0BST. & GYNEC. 49: 77:3, 1945. 8. Stander, H. J.: Williams Obstetrics, Pd. fl, New York, 1945 1 D. Appleton-Century Company, Inc., p. 709. 9. Stander, R. W.: Obst. & Gynec. 8: 232, 195(1. 10. Waters, A.: Indian M. Gaz. 79: 355, 1944.
J.
MASON, M.D.,**
N.Y.
(From the State University of New York, College of Medicine at New York City, and the Department of Obstetrics and Gynecology at Maimonides Hospital)
T
HE obstetrical literature has numerous reports concerning the association o:f malformation of the female genital tract and pregnancy. The complications arising from pregnancies in anomalous uteri are rarely diagnosed. This communication reports a case in which a pregnancy occurred in a noncommunicating rudimentary horn of a uterus bicornis unicollis.
Review Uterine anomalies can be responsible :for many complications that may occur during pregnancy, labor, or puerperium. It is, therefore, essential to make the diagnosis of a congenital uterine anomaly early in pregnancy. The uterus didelphys and the more common uterus bicornis offer no diagnostic problem if a thorough vaginal and speculum examination has been done. In those patients with a history of sterility, repeated abortions, recurrent premature labors, or abnormal presentations, hysterosalpingography should be performed. Jarcho, 6 Fenton and Singh/ and Baker1 have shown that between 18 and 53 per cent of pregnancies associated with uterine anomalies will spontaneously abort, and between 13 and 15 per cent will go into premature labor. Between 10 and 30 per cent will have a malpresentation such as a breech or a transverse lie with the latter occurring more :frequently in the uterus subseptus and uterus bicornis unicollis than in other types of anomalies. During labor there is the possibility of uterine rupture but this rarely occurs. A nonpregnant horn may become incarcerated and cause failure of descent by obstructing the presenting part. A vaginal septum may also impede progress and may have to be excised. During the third stage of labor the placenta may :fail to separate spontaneously and may have to be removed manually. There is also an increased incidence of postpartum hemorrhage. Tkese complications have raised the fetal mortality to between 23 and 43 per cent and the maternal mortality to between 2 and 2.5 per cent. The fetal and maternal risks are greatest in the uterus bicornis unicollis and uterus subseptus and least in didelphys and in uterus unicornis. 5 Pregnancy in a rudimentary horn of a uterus bicornis has particular relevance to this report. Eastman 3 stated that by the year 1900 84 cases had *Presented at a meeting of the Brooklyn Gynecological Society, May 15, 1957. ••Present address: .Jericho, N. Y.
1202
Volume 78 Number 6
PREGNANCY IN NONCOMMUNICATING RUDIMENTARY HORN
1203
been collected by Kehrer from ~ermany, and in 1945 Stander'! stated that this was the most common abnormality. Since 1911, however, only 13 cases had been reported in the American, British, and Indian literature. 2 • 7 • 9 • 10 Of these 13 patients, one died from a ruptured horn at 4% months' gestation and in another the pregnant horn ruptured but the patient survived. A pelvic mass was diagnosed incorrectly in 3 patients before operation, an ectopic pregnancy in one and missed abortion in 5. Two of the cases were difficult to evaluate. In no case was a correct preoperative diagnosis made. The patient was a 33·year·old white woman with one living child following a normal pregnancy and delivery in 1954. Her past history did not reveal any abnormality in the menstrual cycle. Her last period was Sept. 1, 1955. The initial examination, during the eighth week of amenorrhea, revealed a palpable mass, approximately 5 em. in diameter, in the right adnexal region. The uterus was felt to be enlarged to the size of a 6 weeks' gestation. A diagnosis of intrauterine pregnancy complicated by a right ovarian cyst was made. During the fourth month of gestation she began to have irregular vaginal bleeding which occurred once a month until the seventh month. Fetal movements were said to be present in the fifth month and the fetal heart was heard on one occassion during the fifth month. Fig. 1.
Fig. 2. Fig. 1.-Gross specimen: the rudimentary born with attached ovary, tube, and corpus luteum. Fig. 2.-The amniotic sac is opened showing the ma.cerated fetus.
1204
G-ERGELY AND MASON
Am. J. Obst. & Gyner. December, 1919
By tho sixth month a diagnosis of missed abortion was made on the basis of the absent fetal heart sounds and failure of the uterine size to e.orrcspowl with the period of gpstation. X-ray examination in the sixth and eighth months of arn••norrhor with intravenou~ Pitocin wa;; unsuccessful and 3 months later a laparotomy \\'as performed. The uterus was found to be of normal size. 1'he lE>ft ovary, tube, an
Comment
Of the 18 eases rt>portod since 1911, only~ eases n~vealed a eomnnmication between the rudimentary horn and the uterus. Eastman~ stated that KPhrer found no eommunication in 78 per cent of his 8.! eases, and from this deducPd ''that a pregnancy must have followed external migration of the spermatozoa or the fertilized ovum." Of course, failure to find a communicating- eana l n111~· aiRo result from its apparent obliteration by an enlarging ruclimentar;· horn. The outcome of a pregnancy in a rudimentary horn will drpPnd upon the presence or absence of a channel between the horn and th(' uterus. If a communication is present the result, as a rule, will he a spontaneous abortion and the diagnosis of a rudimentary horn may he missed. If ther(' j.., no communication the prognosis is serious for it may lead to a rupture of the horn or a missed abortion. Conclusions l. A ease of a pregnancy in a noncommunieating rudimentary horn is presented. 3. A missed abortion if unusually prolonged suggests a defect in the em-bryonic development of the genital tract, regardless of the patient's normal obstetrical history.
References 1. Baker, W. t!., Roy, R. L., Bancroft, C., McGaughey, H., and Dickman, H. F.: .\M . •T. OBST. & C+YNEC. 66: 580, 1953. 3. De Nicola, R. R., and Petersen, M. R.: Am. J. Surg. 73: 381, 1947. 3. Eastman, N. J.: Williams Obstetrics, ed. 11, New York, 1956, Appleton-Century-Crofts, Inc., p. 6·l1. 4. Fenton, A. M., and Singh, B. P.: AM. J. 0BS'r. & GYNgc, 63: 745, 1952. 5. Holmes, J. A.: Brit. M. J. 2: 1144, 1956. 6. Jarcho, J.: Am. J. Surg. 71: 106, 1946. 7. Mulsow, F.: AM. J. 0BST. & GYNEC. 49: 77:3, 1945. 8. Stander, H. J.: Williams Obstetrics, Pd. fl, New York, 1945 1 D. Appleton-Century Company, Inc., p. 709. 9. Stander, R. W.: Obst. & Gynec. 8: 232, 195(1. 10. Waters, A.: Indian M. Gaz. 79: 355, 1944.