Uterine torsion and ischaemia of one horn of a bicornute uterus: a rare cause of failed second trimester termination of pregnancy

Abstract

A 30 year old woman with a known uterus didelphis bicollis (complete duplication with a midline vaginal septum) booked in her third pregnancy at 16 weeks of gestation. Her first pregnancy had resulted in an elective caesarean section for breech presentation at term, and the second had been a missed abortion at 12 weeks of gestation. The pregnancy had been in the right uterine horn on both occasions. An ultrasound scan had confirmed her dates to be correct, and that the right uterine horn was again the site of the pregnancy. The woman was booked for shared care and consultant review at 34 weeks of gestation.At 21 weeks of gestation she came to the accident and emergency department with a history of lower abdominal pain and absent fetal movements. She described the pain to be acute in onset, severe and sharp. On examination she had a small volume pulse at 64 beats/minute, with a blood pressure of 110/80 mmHg. Her uterus corresponded to the size of a 28-week pregnancy and felt tense and distended. Examination of the right sided vaginal entrance and cervix confirmed an uneffaced cervix. An urgent ultrasound scan showed an absent fetal heart, with a huge mass within the uterus measuring 14.5 cm  12 cm  9 cm, probably a retroplacental clot resulting from placental abruption. Coagulation studies and crossmatching were performed before termination of pregnancy with gemeprost was commenced. However, 24 hours later there was no change in the cervix and her haemoglobin concentration had decreased to 8.4 gm/dL. A repeat ultrasound scan was arranged to check for the site of pregnancy, which was confirmed to be in the right uterine horn. A second course of gemeprost pessaries was started, on completion of which her labour was still not established. Her condition had deteriorated. Vaginal examination showed the right cervix to be uneffaced and undilated, whereas the left cervix was 1 cm dilated.After review it was decided to start an extra-amniotic prostaglandin infusion. Under aseptic conditions a Foley catheter was introduced into the right cervix and the prostaglandin infusion started. Forty hours later there was no change in the cervix and although she complained of continuous pain, there were no discernible contractions.By the fifth day after admission all attempts at termination of her pregnancy had failed. On examination she had oedema of both legs, a generally distended abdomen and shortness of breath. There was no evidence of disseminated intravascular coagulopathy. A laparotomy was performed, when the right uterine horn was found to be distended to the size of a term pregnancy and was quite obviously ischaemic with a torsion (dextrorotation) at the level of the isthmus. The right ovary also appeared to be devoid of its blood supply. The left uterine horn looked normal, although the left adnexa was swollen with fibrinous adhesions. The right horn was opened with a cutting diathermy and the placenta, clot and fetus were evacuated. No bleeding occurred during the uterine incision. The contents of the uterus were fouls...

Late Termination of Pregnancy for Fetal Anomaly

“…62 Cessation of established contractions should raise suspicion of uterine rupture, especially when pain is controlled by epidural analgesia. The use of prostaglandins and oxytocin should be avoided, as discussed above.…”

A Successful Pregnancy Outcome in a Uterus Didelphys a Rarity but a Reality – A Case Report

“…All 26 patients had a longitudinal vaginal septum, occasionally; one hemi vagina is obstructed by an oblique or transverse vaginal septum (3). Multifetal gestation is unusual in these women (4) Majority of women with Mullerian duct anomalies have little problem conceiving, they have higher rates of spontaneous and recurrent abortions, as was noted in our patient. This report describes one case of a successful pregnancy outcome in a uterus didelphys.…”