ment of ruptured tubal pregnancy. Am I Obstet Gynecol 115: 995, 1973 3. THELIN TJ, VAN NAGELL JR JR: Rup-
tured ectopic pregnancy after bilateral tubal ligation. Obstet Gynecol 39: 589, 1972 4. SHUTE WB: Transvaginal sterilization:
use of a new uterine retroverter and method. Am J Obstet Gynecol 115: 998, 1973 5. MATTINGLY RF: Te Linde's Operative Gynecology, 5th ed, Lippincott, Philadelphia, 1977, p 339 6. Ibid, p 343
7. SThPTOE PC: Recent advances in surgical methods of control of fertility and infertility. Br Med Bull 26: 60, 1970 8. SHEIKR HH: Hysterosalpingographic follow-up of laparoscopic sterilization. Am J Obstet Gynecol 126: 181, 1976
A rare cause of massive intraperitoneal hemorrhage JOHN T. BATE, MD, FRCSIIC]
In the human female, failure of development or lack of fusion of the paired miillerian ducts gives rise to a variety of genitourinary anomalies. When implantation occurs in a rudimentary horn of a uterus didelphys that does not communicate with the vagina, nonoperative delivery is impossible and serious complications may ensue. As early as 1699 Mauriceau and Vassal reported such a case.1 Unfortunately most of the early cases were diagnosed at autopsy when maternal death had resulted from intraperitoneal hemorrhage. In 1900 Kehrer reported a maternal mortality of 47.6% associated with this condition.1 Currently, with prompt surgical intervention and availability of blood transfusion, death should be prevented in such cases. In 1965 Rolen, Choquette and Semmens1 noted that in the past 50 years 65 cases had been reported in the English and American literature. Ninety percent of the patients present with spontaneous rupture early in the second trimester, around the 16th week of gestation.2 In 1976 Zervoudakis, Lauersen and Saary' reported a case of twin pregnancy occurring in the two horns of a uterus didelphys; the rudimentary horn did not communicate with the vagina or with the other horn. Below is described a case of massive intraperitoneal hemorrhage secondary to spontaneous rupture of a From the department of obstetrics and gynecology, York Central Hospital, Richmond Hill Reprint requests to: Dr. John T. Bate, Department of obstetrics and gynecology, York Central Hospital, 10 Trench St., Richmond Hill, Ont. L4C 4Z3
rudimentary uterine horn containing a developing embryo.
Case report On July 1, 1976 a 24-year-old woman, gravida 1, para 0, was seen in the emergency department with severe abdominal pain of 2 hours' duration. Her last menstrual period had begun Mar. 8, 1976. Early in June her family physician had palpated a mass adjacent to the enlarged uterus, which was assumed to be a corpus luteal cyst. She had been well until the evening of admission, when she experienced severe midabdominal pain; signs of clinical shock - restlessness, air hunger, marked pallor and a rapid thready pulse developed rapidly. The blood pressure was 80/60 mm Hg. The abdomen was rigid and distended, and pelvic examination revealed a tender mass arising from the right side of the pelvis. Movement of the cervix produced extreme pain. A diagnosis of intraperitoneal hemorrhage of unknown cause was proposed and emergency laparotomy arranged. The abdomen was entered through a paramedian incision in the right lower quadrant, and 2000 mL of blood was removed by suction and sponging. A uterus didelphys was enlarged to a size compatible with 15 weeks' gestation. Profusely bleeding placental tissue was protruding through a rupture 6 cm long in the superior surface of the enlarged rudimentary right horn. This horn did not communicate with the left horn or the vagina. The left uterine horn was connected to the cervix, and the left fallopian tube and ovary were normal. The ruptured uterine horn and the right tube and ovary were excised and hemostasis was attained. Palpation revealed normal kidneys. The wall of the rudimentary horn was 1.0 cm thick. Attached to the extruded placenta was a male fetus with
a crown-rump diameter of 11 cm. During the operation the patient received 5 units of whole blood. Her postoperative hemoglobin concentration was 13.4 g/dL. Recovery was uneventful and she was discharged 8 days later.
Discussion This case has several interesting points for speculation. Because the embryo was developing in a rudimentary horn a functioning endometrium must have existed. Since there was no communication of the horn with the vagina, what happened to the menstrual flow? There was no evidence of hematometra, hematosalpinx or pelvic endometriosis, and no history of dysmenorrhea. The fertilizing spermatozoon must have entered the peritoneal cavity via the left uterine horn, travelled transperitoneally to the right fallopian tube, where fertilization occurred, then implanted itself in the right uterine horn. In June 1977, after an uneventful pregnancy, the patient was delivered vaginally of a healthy boy weighing 3200 g. My thanks to Dr. M. Kirby for his assistance in the management of this patient.
References 1. ROLEN AC, CHOQUErrE AJ, SEMMENS
JP: Rudimentary uterine horn: obstetric and gynecologic implications. Obstet Gynecol 27: 807, 1966 2. LATTO D, NORMAN R: Pregnancy in a rudimentary horn of a bicornuate uterus. Br Med J 2: 926, 1950 3. ZERvoUDAKIs IA, LAUER5EN NH, SAARY Z: Unusual twin pregnancy in a double uterus. Am J Obstet Gynecol
124: 659, 1976
CMA JOURNAL/JULY 22, 1978/VOL. 119 157
tured ectopic pregnancy after bilateral tubal ligation. Obstet Gynecol 39: 589, 1972 4. SHUTE WB: Transvaginal sterilization:
use of a new uterine retroverter and method. Am J Obstet Gynecol 115: 998, 1973 5. MATTINGLY RF: Te Linde's Operative Gynecology, 5th ed, Lippincott, Philadelphia, 1977, p 339 6. Ibid, p 343
7. SThPTOE PC: Recent advances in surgical methods of control of fertility and infertility. Br Med Bull 26: 60, 1970 8. SHEIKR HH: Hysterosalpingographic follow-up of laparoscopic sterilization. Am J Obstet Gynecol 126: 181, 1976
A rare cause of massive intraperitoneal hemorrhage JOHN T. BATE, MD, FRCSIIC]
In the human female, failure of development or lack of fusion of the paired miillerian ducts gives rise to a variety of genitourinary anomalies. When implantation occurs in a rudimentary horn of a uterus didelphys that does not communicate with the vagina, nonoperative delivery is impossible and serious complications may ensue. As early as 1699 Mauriceau and Vassal reported such a case.1 Unfortunately most of the early cases were diagnosed at autopsy when maternal death had resulted from intraperitoneal hemorrhage. In 1900 Kehrer reported a maternal mortality of 47.6% associated with this condition.1 Currently, with prompt surgical intervention and availability of blood transfusion, death should be prevented in such cases. In 1965 Rolen, Choquette and Semmens1 noted that in the past 50 years 65 cases had been reported in the English and American literature. Ninety percent of the patients present with spontaneous rupture early in the second trimester, around the 16th week of gestation.2 In 1976 Zervoudakis, Lauersen and Saary' reported a case of twin pregnancy occurring in the two horns of a uterus didelphys; the rudimentary horn did not communicate with the vagina or with the other horn. Below is described a case of massive intraperitoneal hemorrhage secondary to spontaneous rupture of a From the department of obstetrics and gynecology, York Central Hospital, Richmond Hill Reprint requests to: Dr. John T. Bate, Department of obstetrics and gynecology, York Central Hospital, 10 Trench St., Richmond Hill, Ont. L4C 4Z3
rudimentary uterine horn containing a developing embryo.
Case report On July 1, 1976 a 24-year-old woman, gravida 1, para 0, was seen in the emergency department with severe abdominal pain of 2 hours' duration. Her last menstrual period had begun Mar. 8, 1976. Early in June her family physician had palpated a mass adjacent to the enlarged uterus, which was assumed to be a corpus luteal cyst. She had been well until the evening of admission, when she experienced severe midabdominal pain; signs of clinical shock - restlessness, air hunger, marked pallor and a rapid thready pulse developed rapidly. The blood pressure was 80/60 mm Hg. The abdomen was rigid and distended, and pelvic examination revealed a tender mass arising from the right side of the pelvis. Movement of the cervix produced extreme pain. A diagnosis of intraperitoneal hemorrhage of unknown cause was proposed and emergency laparotomy arranged. The abdomen was entered through a paramedian incision in the right lower quadrant, and 2000 mL of blood was removed by suction and sponging. A uterus didelphys was enlarged to a size compatible with 15 weeks' gestation. Profusely bleeding placental tissue was protruding through a rupture 6 cm long in the superior surface of the enlarged rudimentary right horn. This horn did not communicate with the left horn or the vagina. The left uterine horn was connected to the cervix, and the left fallopian tube and ovary were normal. The ruptured uterine horn and the right tube and ovary were excised and hemostasis was attained. Palpation revealed normal kidneys. The wall of the rudimentary horn was 1.0 cm thick. Attached to the extruded placenta was a male fetus with
a crown-rump diameter of 11 cm. During the operation the patient received 5 units of whole blood. Her postoperative hemoglobin concentration was 13.4 g/dL. Recovery was uneventful and she was discharged 8 days later.
Discussion This case has several interesting points for speculation. Because the embryo was developing in a rudimentary horn a functioning endometrium must have existed. Since there was no communication of the horn with the vagina, what happened to the menstrual flow? There was no evidence of hematometra, hematosalpinx or pelvic endometriosis, and no history of dysmenorrhea. The fertilizing spermatozoon must have entered the peritoneal cavity via the left uterine horn, travelled transperitoneally to the right fallopian tube, where fertilization occurred, then implanted itself in the right uterine horn. In June 1977, after an uneventful pregnancy, the patient was delivered vaginally of a healthy boy weighing 3200 g. My thanks to Dr. M. Kirby for his assistance in the management of this patient.
References 1. ROLEN AC, CHOQUErrE AJ, SEMMENS
JP: Rudimentary uterine horn: obstetric and gynecologic implications. Obstet Gynecol 27: 807, 1966 2. LATTO D, NORMAN R: Pregnancy in a rudimentary horn of a bicornuate uterus. Br Med J 2: 926, 1950 3. ZERvoUDAKIs IA, LAUER5EN NH, SAARY Z: Unusual twin pregnancy in a double uterus. Am J Obstet Gynecol
124: 659, 1976
CMA JOURNAL/JULY 22, 1978/VOL. 119 157
