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      Timely Identification of Pregnancy in Noncommunicating Horn of Unicornuate Uterus by Three-Dimensional Transvaginal Ultrasonography

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          Abstract

          Pregnancy in the rudimentary horn of a unicornuate uterus is uncommon and needs to be diagnosed at early stages to avoid uterine rupture to avert the high morbidity and mortality. In this case report, we discussed the advantage of three-dimensional transvaginal ultrasonography (3D TV-USG) in assessing the early pregnancy in the noncommunicating rudimentary horn of uterus. A 23-year-old woman approached us for routine pregnancy scan. The location of 5-week pregnancy was confirmed in the right noncommunicating horn of a unicornuate uterus by 3D TV-USG. She has undergone laparohysteroscopy, and excision of a gravid rudimentary horn was done. After an interval of 6 months, the patient received fertility treatment and conceived consequently. Although magnetic resonance imaging (MRI) is an excellent way of diagnosing uterine anomalies, the procedure is expensive, time-consuming, and not widely available. 3D USG is less expensive and more readily accessible for early diagnosis of uterine anomalies, particularly in health-care centers where MRI is not readily available or affordable.

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          The presentation and early diagnosis of the rudimentary uterine horn.

          The key to successful management of the rudimentary uterine horn is early detection. This review of the literature seeks to illustrate important aspects of diagnosis and management of this anomaly. An English language MEDLINE search from 1966 to 2003 was performed, using the search terms "rudimentary uterine horn," "accessory horn," "uterus bicornis unicollis," "hematometra," "unicornuate or bicornuate uterus," and "mullerian anomaly." References from previously published sources were also obtained. One hundred thirty letters, case reports, case series, and review articles featuring rudimentary uterine horn were found. Reports before 1966 were excluded because outcomes before the advent of modern diagnostic techniques were not relevant to this study. Three hundred sixty-six rudimentary horn presentations (210 gynecologic and 156 obstetric) were found. Noncommunicating horns accounted for 92% of cases (95% confidence interval [CI] 88-95%, P < .001), and renal anomaly was found in 36% (95% CI 29-44%). Contrary to the American Fertility Society classification of uterine anomalies, rudimentary horns may occur without a corresponding unicornuate uterus. The mean age of presentation was similar for gynecologic and obstetric presentations (23 and 26 years, 95% CIs 21.2-24.6 and 124.9-27.3 years, respectively). Presentation in the third decade of life or later occurred in 78% of patients (95% CI 70-84%, P < .001). Sensitivity of ultrasound examination for diagnosis was 26% (95% CI 18-36%). Diagnosis before clinical symptoms occurred in 14% (95% CI 7-23%). Many functional noncommunicating horns present during or after the third decade of life with acute obstetric uterine rupture. Surgical removal before pregnancy is recommended. Rates of prerupture diagnosis remain disappointingly low.
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            Rudimentary uterine horn pregnancy. The 20th-century worldwide experience of 588 cases.

            To investigate the outcomes of rudimentary uterine horn pregnancies and to identify trends and opportunities for improvement in patient care. During the period 1900-1999, 588 cases of rudimentary uterine horn pregnancy were identified using both manual and computerized searches of Index Medicus, Excerpta Medica and the Index-Catalogue of the Library of the Surgeon-General's Office of the United States Army as well as standard reference tracing. Nine characteristics of each case were evaluated: (1) fetal status at birth, (2) maternal survival, (3) neonatal survival, (4) gestational age at delivery, (5) whether the rudimentary horn ruptured, (6) communication status of the horn with the contralateral hemiuterus, (7) gravidity and parity, (8) side of the horn, and (9) order of the gestation. Newborn survival ranged from 0-13% by decade and trended upward. Eighty-five percent of pregnancies occupied noncommunicating horns. Thirty percent of gestations progressed to term or beyond. Fifty percent of pregnant uterine horns ruptured, with 80% of these events occurring before the third trimester. There was no trend in either the incidence or timing of uterine horn rupture during the century. Maternal mortality decreased from 6% to 23% during the first half of the century to < 0.5% currently. Twin pregnancies consisted of 5.3% of cases. Neonatal survival has improved greatly for rudimentary horn pregnancies, and maternal mortality has decreased significantly. Such pregnancies are now identifiable early in gestation by obstetric imaging studies, and there can be guarded optimism that favorable trends in outcomes will continue into the 21st century.
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              Rudimentary horn pregnancy: first-trimester prerupture sonographic diagnosis and confirmation by magnetic resonance imaging.

              Two cases of rudimentary horn pregnancy diagnosed in the first trimester by sonography and confirmed by magnetic resonance imaging (MRI) are reported. We suggest criteria for early, prerupture sonographic diagnosis of this rare condition. We report a case in which pregnancy in a rudimentary horn was suspected on routine sonographic examination. In the second case, sonographic examination at 11 weeks' gestation revealed a right unicornuate uterus and a noncommunicating left rudimentary horn containing a gestational sac. In both cases, MRI clearly confirmed the sonographic diagnosis, showing an empty cavity of the uterine body and a pregnant uterine horn without an endometrial communication to the uterine body. Both patients underwent surgery, and the pregnant rudimentary horns were resected with no complications. We suggest the following criteria for sonographic diagnosis of rudimentary horn pregnancy: (1) a pseudopattern of a asymmetrical bicornuate uterus, (2) absent visual continuity tissue surrounding the gestational sac and the uterine cervix, and (3) the presence of myometrial tissue surrounding the gestational sac. Typical hypervascularization of placenta accreta may support the diagnosis. Additionally, MRI can be used to confirm the diagnosis before an invasive procedure is undertaken.
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                Author and article information

                Journal
                J Clin Imaging Sci
                J Clin Imaging Sci
                JCIS
                Journal of Clinical Imaging Science
                Medknow Publications & Media Pvt Ltd (India )
                2156-7514
                2156-5597
                2018
                18 September 2018
                : 8
                : 39
                Affiliations
                [1]Infertility Institute and Research Center, Hyderabad, Telangana, India
                [1 ]Department of Reproductive Medicine, Shreya Sharddha Infertility Clinic, Hyderabad, Telangana, India
                Author notes
                Address for correspondence: Dr. Aarti Deenadayal Tolani, Infertility Institute and Research Centre, 91-1-192, St. Mary's Road, Opp. Prashanth Theatre, Secunderabad - 500 003, Telangana, India. E-mail: draarti@ 123456iirc.in
                Article
                JCIS-8-39
                10.4103/jcis.JCIS_25_18
                6157094
                30283721
                118484ce-6498-4e03-84d1-e707d9d2ae63
                Copyright: © 2018 Journal of Clinical Imaging Science

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 21 April 2018
                : 23 July 2018
                Categories
                Case Report

                Radiology & Imaging
                gestational sac,laparohysteroscopy,three-dimensional ultrasound,transvaginal,unicornuate uterus

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