Site of pregnancy obstetrician’s dilemma


  • Rudrika Chandra Department of Obstetrics and Gynaecology, 9 Air Force Hospital, Halwara, Ludhiana, Punjab, India Pin: 141106
  • Sanjay Singh Department of Obstetrics and Gynaecology, Base Hospital, Delhi Cantt, New Delhi, India



American Society of Reproductive Medicine, Bicornuate uterus, Mullerian anomaly, pregnancy, Unicornuate uterus.


A 28-yr-old P2L2 lady, with history of two previous caesarean deliveries and tubal ligation, presented at 6weeks of amenorrhea with pain lower abdomen. The operative notes from her previous caesarean section stated that she had a unicornuate uterus without a rudimentary horn (ASRM Class II D Mullerian anomaly)5 and only right fallopian tube was visualised, which was ligated by Parkland’s method.

On workup, she had a positive urine pregnancy test and ultrasound showed a left adnexal mass without any evidence of intraperitoneal collection, possibly an unruptured left ovarian ectopic pregnancy secondary to failed tubal ligation. Further investigation by MRI revealed an entirely new finding. The suspicious left adnexal mass was the left horn of bicornuate uterus which had an intrauterine gestational sac. Hence, her revised diagnosis was G3P2L2, post LSCS, bicornuate uterus (ASRM class IV B) with 6 weeks of intrauterine left horn pregnancy following failed tubal ligation.

She underwent a medical followed by surgical evacuation of intrauterine pregnancy as patient was unwilling to continue the pregnancy.

This case highlights the importance of a comprehensive evaluation, whenever a lady is diagnosed with a Mullerian anomaly, in order to correctly classify the patient and identify associated anomalies of urogenital tract which would avoid such erroneous diagnosis of site of pregnancy as illustrated in our case.


Chan YY, Jayaprakasan K, Tan A, Thornton JG, Coomarasamy A, Raine-Fenning NJ. Reproductive outcomes in women with congenital uterine anomalies: a systematic review. Ultrasound Obstet Gynecol. 2011 Oct;38(4):371-82.

Nwosu B, Ogboaja JO, Obi-Nwosu A. Spontaneous rupture of the gravid horn of bicornuate uterus at term. Nig Med J. 2010;5(4):184-5.

Heinonen PK. Uterus didelphys: a report of 26 cases. Eur J Obstet Gynecol Reprod Biol. 1984;15(5):345-50.

Rock JA, Breech LL. Surgery for anomalies of mullerian ducts. In: Rock JA, Jones HW III, editors. Telinde’s Operative Gynaecol. 11th ed. Wolters Kluwer; 2015:506-49.

The American Fertility Society classifications of adnexal adhesions, distal tubal obstruction, tubal occlusions secondary to tubal ligation, tubal pregnancies, Müllerian anomalies and intrauterine adhesions. FertilSteril. 1998;49(6):944-55.

Buttram VC, Gibbons WE. Mullerian anomalies: a proposed classification (an analysis of 144 cases) Fertil Steril. 1979;32:40-6.

Lin PC. Reproductive Outcomes in Women with Uterine Anomalies. J Women Health (Larchmt) 2004;13(1):33-39.

Kakou C, Garba I, Kasse R, Gondo D, Mian B, Adjoby R, et al. Bicornuate uterus and obstetrical complications repeated: what’s solution for a better obstetrical prognosis into a developing country of Africa?. Int J Reprod Contracept Obstet Gynecol. 2018 Apr;7(4):1631-4.

Fengbing Liang, Wensheng Hu. Pregnancy complications and obstetric outcomes among women with congenital uterine malformations. Int J Gynaecol Obstet. 1991;(2):159-60.

Olpin JD, Heilbrun M. Imaging of müllerian duct anomalies. Clin Obstet Gynecol. 2009;52(1):40-56.

Bermejo C, Martínez Ten P, Cantarero R, Diaz D, Pérez Pedregosa J, Barrón E, et al. Three‐dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging. Ultrasound in Obstet Gynecol. 2010 May;35(5):593-601.

Li S, Qayyum A, Coakley FV, Hricak H. Association of renal agenesis and mullerian duct anomalies. J Comput Assist Tomogr. 2000;24(6):829-34.






Case Reports