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 1cm 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 foul-smelling. Resection of the right uterine horn and right salpingo-oophorectomy was performed. The woman made a full recovery and was discharged on the seventh post-operative day.
After a further year she was reviewed when she had failed to conceive. An ultrasonic hysterosalpingography showed a blocked left fallopian tube. After in vitro fertilisation she conceived with twins. Her pregnancy was uncomplicated initially, and serial ultrasound scans for growth were performed. At 30 weeks of gestation one twin showed an absence of growth from her previous scan at 28 weeks, and Doppler examination of the umbilical artery showed no end-diastolic flow. In view of these findings the woman was given steroids and transferred to a regional centre. An emergency caesarean section was performed. At operation there was a left unicornute uterus with normal left tube and ovary with filmy adhesions around the tube. The right uterine horn and adnexa were absent. Twin 1, a boy, weighed 1.44 kg, and Twin 2, a girl, weighed 830 gm. Both twins were transferred to the neonatal unit and made good progress.