Ectopic Pregnancy in a Rudimentary Horn: A Case Report скачать в хорошем качестве

Ectopic Pregnancy in a Rudimentary Horn: A Case Report

Ectopic pregnancy in a Rudimentary Horn. A Case Report. We have no disclosures to report. Both verbal and written patient consent were obtained prior to initiation of this case report. This video provides background on the incidence, pathophysiology, diagnosis, and management of rudimentary horn ectopic pregnancies, presents a case from our academic centre, and demonstrates the surgical technique for management. Two thirds of individuals with a unicornuate uterus have a smaller second piece of uterus known as a rudimentary horn, and 85% of these are non-communicating. Pregnancy in a rudimentary horn is extremely rare, occurring in roughly one in 75,000 to 150,000 pregnancies, but carries high maternal risk with a 50–80% rupture rate and significant haemorrhage, and about a 0.5% rate of maternal death if rupture occurs. In a communicating horn, conception occurs as in a normal pregnancy, with sperm accessing the horn through the connecting endometrium. In a non-communicating horn, it is hypothesised that sperm migrates transperitoneally from the opposite tube to enter the horn. Patients may present with amenorrhoea, abnormal bleeding, vague pelvic or back pain, nausea, vomiting, or diarrhoea, but up to 40% are asymptomatic. Beta-hCG confirms pregnancy, but most rudimentary horn ectopics are diagnosed by transvaginal ultrasound. MRI is more sensitive and useful to characterise Müllerian anomalies. Because of the high risk of rupture and severe morbidity, surgical excision of the horn is recommended, performed via laparoscopy or laparotomy. Some reports describe medical management with systemic or intrasacular methotrexate or intracardiac potassium chloride, occasionally followed by delayed horn excision, but surgery remains the standard. We now present a case managed at our centre. A 36-year-old gravida 4 para 1 presented to the emergency department with vague abdominal pain and one day of loose stools after a dating ultrasound questioned a pregnancy in the right adnexa. She had two previous first-trimester miscarriages and one prior term vaginal delivery and was otherwise healthy. Her beta-hCG was 86,900 IU/L. Review of her community ultrasound suggested a seven-week, two-day gestation in the right adnexa. Importantly, a prior MRI in 2020 showed a right unicornuate uterus with a left suspected non-communicating rudimentary horn. Emergency department pelvic and transvaginal ultrasound described a suspected bicornuate configuration with a gestational sac in the left horn. The current ultrasound and prior MRI were reviewed with the staff radiologist, confirming a rudimentary horn ectopic pregnancy. Management options were discussed, with strong recommendation for surgical excision. Risks, including possible hysterectomy, were reviewed and urgent laparoscopic excision was planned. At laparoscopy, the unicornuate uterus and pregnant rudimentary horn were clearly visualised. The left horn was detached from the left adnexa. The connection between the unicornuate uterus and the horn was narrow, allowing efficient desiccation and transection with a bipolar vessel-sealing device. In other cases, a broader or more vascular attachment may require suturing. Haemostasis was confirmed and the horn removed in a specimen bag. In conclusion, rudimentary horn ectopic pregnancy is rare but carries high morbidity and mortality. Presentation may include pain, abnormal bleeding, amenorrhoea, or gastrointestinal symptoms, but many patients are asymptomatic. While ultrasound is often used for diagnosis, MRI or prior imaging can be critical for accurately characterising uterine anomalies. Surgical excision, either laparoscopic or open, is recommended for definitive management.