Rupture of left horn of bicornuate uterus at twenty weeks of gestation.S Kore, A Pandole, R Akolekar, N Vaidya, VR Ambiye
Department of Obstetrics and Gynaecology, L. T. M. M. C. and L. T. M. G. H., Sion, Mumbai - 400 022, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0010855080
Source of Support: None, Conflict of Interest: None
Rupture uterus in nulliparous patients is generally associated with mullerian anomalies. A case of 23 years primigravida with 19 weeks gestation presenting with features of rupture is reported here. Ultrasound helped in the diagnosis of left horn of bicornuate uterus. After exploration, right ruptured horn was excised. The incidence, diagnosis and management of such cases is discussed.
Keywords: Adult, Case Report, Female, Human, Pregnancy, Pregnancy Complications, diagnosis,surgery,Pregnancy Trimester, Second, Uterine Rupture, diagnosis,surgery,Uterus, abnormalities,
Rupture of gravid uterus is a rare but serious obstetric complication. It is more common in multigravida or with previous uterine scar, mostly in labour. The rupture at early gestation i.e. first and second trimester is mostly associated with uterine anomalies or cornual pregnancy. The early gestation itself may pose a problem in early diagnosis.
A 23-year-old primigravida with six months amenorrhoea was admitted with severe pain in abdomen and distention. There was no history of fever, episodes of vomiting and constipation for last three days. There was no history of bleeding per vaginum. Her previous menstrual cycles were regular. She was known case of pulmonary tuberculosis taking regular treatment.
On general examination, patient was minimally febrile and pulse was 110/min. Blood pressure was 100/70 mm of Hg. There was minimal pallor. Abdomen was distended with tympanic note in epigastric region. There was marked guarding and rigidity. The size of uterus could not be appreciated correctly. On per vaginal examination, the cervix was tightly closed and tubular. Haemoglobin was 9 gms%. Complete blood count (CBC) showed lymphocytosis with raised ESR. Ultrasonography revealed loculated collection above the uterus with distended bowel loops, along with single viable intrauterine pregnancy at 19 weeks of gestation. The clinical and sonography diagnosis was pregnancy with Koch’s abdomen causing intestinal obstruction.
Conservative management was given for one day, but her abdominal distension increased after 24 hours. A repeat ultrasound showed intrauterine foetal death with foetus in abnormal position. An ultrasound guided tap revealed frank blood. Thus the diagnosis of rupture uterus was made.
On exploration, there was haemoperitoneum and foetus was in the abdominal cavity. On removing blood clot, a bicornuate uterus was seen with left horn of normal size and intact and the right horn showing rupture at fundus with placenta posteriorly attached.
The ruptured right horn was cut at its junction with the left horn and then sutured in layers. Patient was transfused with five units of blood. Patient recovered well and was discharged on day ten. She was started on oral contraceptive and was advised to continue for one year.
Rupture uterus is a life threatening obstetric problem. Rupture in primigravida in first or second trimester generally occurs in congenitally malformed uteri like unicornuate or bicornuate uterus with or without rudimentary communicating-noncommunicating horn. In our case it was bicornuate uterus, with rupture of right horn. Similar case has been reported by Mane et al.
Incidence of pregnancy in rudimentary horn is 1/40,000 pregnancies. Rupture in such cases occurs because of inability of malformed uterus to expand as a normal uterus. The rupture in rudimentary horn is likely to occur in late first trimester or even in second trimester. Rarely pregnancy can go on till late second trimester before rupturing. Chang et al reported rupture of rudimentary horn as late as 25 weeks of gestation. A midtrimester rupture generally occurs at fundus as against lower segment rupture during labour. The haemorrhage occurring because of rupture is massive and can be life threatening, unless diagnosed and treated promptly.
Ultrasonography (USG) may be helpful in diagnosing such anomalies before rupture, which will help in decreasing the morbidity and mortality associated with rapid and massive haemoperitoneum occurring because of rupture. Achiron et al reported two cases of pre-rupture USG diagnosis of such cases.
Treatment usually involved is removal of ruptured horn. As it leaves a scar on upper part of the uterus, it is important to avoid pregnancy for at least one year by barrier or hormonal contraceptives. In addition, future pregnancy requires proper monitoring, early hospitalisation, and elective caesarean section at term.
We thank our Head of Department and Dean for allowing us to use and publish the hospital data.