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PREGNANCY in a RUDIMENTARY HORN of a UTERUS DIDELPHYS with Concealed Accidental Haemorrhage

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PREGNANCY in a RUDIMENTARY HORN of a UTERUS DIDELPHYS with Concealed Accidental Haemorrhage PREGNANCY IN A RUDIMENTARY HORN OF A UTERUS DIDELPHYS With concealed accidental haemorrhage by VIMAL V. PARIKH*, M.D. (Born.) I Amongst all the malformations of own corresponding uterus - the right I ' ~ ( the female genital tract, perhaps the uterus and the cervix were well de­ ) rarest is a completely paired uterus veloped, but the left uterus was rudi­ I with each member of the pair having mentary and was attached to its cor­ its own cervix, opening into the cor­ responding vagina with an atretic responding member of the paired non-canalised cervix. There was a vaginae- that is uterus didelphys recto-vesical fold of peritoneum con­ (pseudo) with double vagina. (Very necting the rectum, with the bladder rarely still the uterus, the vagina and in between the two uteri. also the vulva ' are absolutely distinct There are 3 possible ways by which on the two sides - which is describ­ pregnancy can occur in a rudimentary ~d as true uterus didelphys). The horn- ( 1) through a small micro­ tubes, uterus and vagina are develop­ scopic cervical canal, (2) through a . ed from the two Mullerian ducts; the transperitoneal migration of the sper­ two ducts usually become fused, matozoa, or (3) through a trans­ except the uppermost parts which peritoneal migration of the fertilized form the two fallopian tubes. The ovum. varieties of malformation encounter­ The usual termination of a preg­ ed are very numerous and depend up­ nancy in a rudimentary horn is rup­ on the extent to which development ture, but few pregnancies are on re­ and fusion of the two halves, which cord which have continued to term I I should become blended, fail. In also. Torsion of a gravid horn is an I uterus didelphys there is a complete occasional complication. ~ failure of fusion of the two Mullerian This case records pregnancy in a I ducts. ' rudimentary horn of a uterus didel­ I The case to be presented as under phys (pseudo) which continued to 28 had complete duplication of the weeks of pregnancy and was com­ uterus, cervix and the vagina along plicated by the occurrence of conceal­ with a normally developed fallopian ed accidental haemorrhage. tube and an ovary arising from its Case Report: * Honorary Assistant Obstetrician and Mrs. A. F. M. Para 3, 24 years of age, Gynaecologist, Cama and Albless Hospi· was admitted on the 9th March 1963 as an tals, Bombay, India. emergency case for 7 months' amenorrhoea Received for publication on 11-11-63. with severe pain in abdomen. 192 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA Her past menstrual periods occurred at in the labour ward itself under local in­ regular intervals, every 28 days, and were filtration anaesthesia with 2% procain hy­ of normal strength and duration without . drochloride solution. any dysmenorrhoea. She had had 2 full­ After all the usual aseptic precautions, term normal deliveries conducted by a mid­ the abdomen was opened by a subumbilical wife at home. There was no history of any median incision of about 4 inches long. As vaginal bleeding occurring during the last soon as the peritoneum was opened, a large two pregnancies. sac, with dark portwine colour resembling The patient was in a condition of severe couvelaire uterus, was visualised. The size shock, with cold extremities and extreme . was about 30 weeks of pregnancy. A small pallor. Her blood pressure was 70/ 40 mms. vertical nick was made on the anterior wall of mercury, and pulse was very feeble with by a knife and was extended vertically by a rate of 140 per minute. The patient had scissors to about 3 inches. The wall of the not passed any Urine for about 24 hours and ·sac was made up of thin muscular tissue. on catheterization about 4 ounces of con­ As soon as the incision was made a large centrated urine was collected, which was amount o{ blood gushed out with plenty of loaded with albumin. clots. The amniotic sac was then opened Per abdomen, on examination, uterus was up and a 28 week sized dead male foetus, of 30 weeks' size of pregnancy, and was of 2 pounds weight, which was lying trans­ very tense, tender and rigid. Neither versely, was extracted by breech. The foetal parts could be palpated, nor foetal placenta was lying completely separated in heart heard. There was no coagulation the sac. After emptying, the rudimentary defect in the blood and the clotting time horn failed to contract and remained flabby was 1 minute and 17 seconds. and atonic. On vaginal examination, the cervix was The rudimentary horn with foetal sac was only one finger dilated with thick lips. It connected by a thin band of tissue of about was displaced posteriorly towards the 3/ 4 of an inch size to the vaginal wall. sacral promontary and a sense of fullness This band of tissue was the non-canalised was noted both anteriorly and in the lateral rudimentary cervix. The rudimentary horn fornices. It was very difficult to assess the with foetal sac had its own fully develop­ size of the uterus, as the fundus could not ed fallopian tube, ovary and round liga­ be defined because of the extreme rigidity ment which were found to be stretched an­ and tenderness of the abdomen; but it could teriorly (on the foetal sac). The rudi­ be assumed, by assessing the side walls of mentary horn with foetal sac could be the uterus with the finger, that the size was easily removed by clamping the thin band not more than of about 10 weeks' preg­ of fibro-muscular tissue, cutting and ligat­ nancy. No foetal parts, placenta or mem­ ing it. The band was solid without any branes could be located by the examining canalization. The rudimentary horn with finger through the dilated canal. The foetal sac and placenta is shown in patient soon after passed an intact trian­ Figs. 2 A, and B. A 10 weeks' sized healthy gular decidual cast (Fig. 2 C), which strong­ uterus was visualized on the right side ly suggested the presence of an ectopic with a normal cervix attaching it with the pregnancy. vagina. It had a normal fallopian tube, The condition of the patient was deter­ ovary and round ligament. There present­ iorating very rapidly. Her blood pressure ed a peritoneal fold connecting the rectum had fallen to below 60 mms. of mercury and the bladder in between the right-sided (systolic) with non-recordable diastolic normal uterus and left-sided rudimentary pressure and the pulse became quite imp­ horn with foetal sac (the recto-vesical perceptible and extremely rapid. ligament) Fig. 1. An immediate exploratory laparotomy As soon as the rudimentary horn with was decided upon. The patient being in foetal sac was removed, the condition of very poor condition to be shifted to the the patient improved rapidly. The blood operation theatre, it was decided to do the pressure rose to 110!70 mms of mercury and laparotomy immediately on the labour "Qed pulse also settled down. The whole pro- PREGNANCY IN RUDIMENTARY HORN OF UTERUS DIDELPHYS 193 tion and the patient had a very satisfactory progress. The sutures were removed on the 7th day and the wound union was good. On the 9th post-operative day, a thorough clinical check up (per vaginam) was done. A torn sickle-shaped vaginal septum was present at the vault and a ridge of tissue was felt running medially on the anterior and posterior vaginal wall. The remnants of a vaginal septum must have been torn during the two previous full-term normal deliveries. A small nodule of tissue on the left side of the torn sickle-shaped septum without any hole or canal was noted. This was the rudimentary atretic non-canalized cervix. ' - The normal cervix was l?een at the right side of the septum. A uterine sound could be easily passed into the right normal uterus. Thus there was a right normal uterus with normal cervix and a vagina of its own- and a left rudimentary horn with Fi9- . 1 a rudimentary cervix and a patent vagina of its own, a case of uterus didelphys Uterus pseudo-didelphys with pregnant rudi­ (pseudo) of which the left uterine horn was mentary horn. The characteristic recto-vesical rudimentary. ligament is shown. The pregnancy was in the rudimentary horn and was complicated by concealed accidental haemorrhage. An intravenous pyelography to exclude any urinary tract anomaly could not be done as the patient took discharge from the hospital against medical advice before it could be arranged. Discussion Although pregnancy in a rudi­ mentary horn is rare, it can neverthe­ / less prove disastrous to the patient and should be kept in mind when ectopic pregnancy is suspected. Fig. 2 In the majority of cases the foetal A-Rudimentary horn :with foetal sac. Size 9-k sac of a rudimentary horh ruptures inches x 7 inches. in the 4th or 5th month of pregnancy. B-Placenta with cord and clots. Placenta size 6 inches x 4~ inches. Cord length 16 inches The time of rupture depends on how C-Decidual cast. Size 4 inches x 1i inches. rudimentary the born is, for the more rudimentary the horn the less will be cedure lasted for less than 20 minutes. Throughout the operation blood was being the resistence to the chorionic villi transfused, about 900 mls. of blood being and to distention. A correct diag­ thus replaced. nosis is extremely difficult, as great There was no post-operative complica- similarity exists between such cases 25 194 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA and cases of extra-uterine pregnan- of toxaemia, except oliguria with al­ cy.
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