A cornual pregnancy is a type of ectopic pregnancy in which the gestational sac develops within the cornua of a bicornuate or septate uterus or in the interstitial part of the fallopian tube. It accounts for less than 1% of all ectopic pregnancies and as the interstitial portion of the myometrium is more distensible, 20% of cornual pregnancies advancing up to 12 weeks of gestation tend to rupture [1]. Despite the availability of modern diagnostic tests, the early detection of a cornual pregnancy remains challenging [2].

Patients with cornual pregnancy can present with acute abdominal pain following intrabdominal rupture of the gestational sac and an adnexal mass accompanied by features of hemodynamic compromise (hypotension, tachycardia, and shock). Other features of early pregnancy such as amenorrhea, breast tenderness, fatigue, cramps, dyspareunia, and shoulder pain (in the case of peritoneal irritation) may also be present. Occasionally, a cornual gestational sac may be noticed in a patient with amenorrhea during a pelvic ultrasound.

The risk factors for a cornual pregnancy are endometriosis with peri and intra-tubular adhesions, pelvic inflammatory disease, transfer of too many embryos, transferring embryos close to the uterine horn, exerting pressure during embryo injection, problems during embryo transfer [3], congenital rudimentary uterine horn [4], or bilateral salpingectomy [5].

• Collapse

  Clinical acumen and suspicion of ectopic pregnancy in a woman presenting with acute abdominal pain, amenorrhea, adnexal tenderness or mass and hemodynamic collapse form the crux of early diagnosis. [symptoma.com]

  I was almost 8 weeks along and was fine until that day when I collapsed out of nowhere. So please be careful and do not ignore any symptoms. [community.babycenter.com]

  Before we hit surgery, I remember things starting slowly, then building... collapsing, relief someone was listening, scan after scan, diagnosis, then midwife clearing the room to help me into a gown, then the tiny little cubical filling with people, the [ectopicireland.proboards.com]

• Severe Pain

  Sunday morning I went to the emergency room with severe pain and was diagnosed with a ruptured right cornual pregnancy and had to have the pregnancy removed with surgery. [justmommies.com]

  Symptoms of ectopic pregnancy include severe abdominal pain on one side of the body cramps and spotting vaginal bleeding shoulder pain nausea and vomiting fainting spells or dizziness If you have severe pain or bleeding, go to the emergency room right [bestonlinemd.com]

  Some of these patients will still need surgery, either because of persistent or severe pain, hemorrhage, or failure of the HCG to resolve completely. Recovery using this method may require up to several months. [brooksidepress.org]

  The symptoms of such a tubal rupture are vaginal bleeding and severe pain in one side of the abdomen. Prompt surgery is necessary to remove the damaged tube and the fetus, and to stop the bleeding. [medical-dictionary.thefreedictionary.com]

  Abdominal pain -- a frequent finding, this is strongly indicative if severe but may be moderate, mild or even absent in 9% of the cases. Tachycardia, hypotension, low grade fever -- present with severe pain, rupture and internal hemorrhage. [womenshealthsection.com]

• Anemia

  Diseases that increase the risk of obstetrical complications include diabetes, heart disease, hypertension, kidney disease, and anemia. rubella (German measles) can be responsible for many types of birth defects, particularly if the mother contracts it [medical-dictionary.thefreedictionary.com]

  Before administering MTX, a woman should have a confirmed normal serum creatinine level, normal liver transaminases, and no bone marrow dysfunction indicated by significant anemia, leucopenia, or thrombocytopenia. [womenshealthsection.com]

  Contraindications to the use of methotrexate generally include desired pregnancy (when used in the first trimester, methotrexate has a 30% major malformation rate) severe anemia (low red blood cell count), leukopenia (low white blood cell count), or thrombocytopenia [drdaiter.com]

• Dentist

  A visit to a dentist early in pregnancy is a good idea to forestall any possibility of infection arising from tooth decay. Pregnancy does not encourage tooth decay. [medical-dictionary.thefreedictionary.com]

• Weight Gain

  There is now less emphasis on severe restriction of the mother's dietary intake to maintain a limited weight gain. [medical-dictionary.thefreedictionary.com]

• Tachypnea

  […] show some of these findings: Pelvic mass (either from the enlarged ectopic, or from the corpus luteum cyst that accompanies many early pregnancies of all types) Pelvic tenderness, localized or geeralized Abdominal distension Hypotension, tachycardia, tachypnea [brooksidepress.org]

• Morning Sickness

  Nausea, or morning sickness, usually begins in the fifth or sixth week of pregnancy. [medical-dictionary.thefreedictionary.com]

• Tachycardia

  Patients with cornual pregnancy can present with acute abdominal pain following intrabdominal rupture of the gestational sac and an adnexal mass accompanied by features of hemodynamic compromise (hypotension, tachycardia, and shock). [symptoma.com]

  Tachycardia and/or hypotension. Shock or collapse. [patient.info]

  […] however, may show some of these findings: Pelvic mass (either from the enlarged ectopic, or from the corpus luteum cyst that accompanies many early pregnancies of all types) Pelvic tenderness, localized or geeralized Abdominal distension Hypotension, tachycardia [brooksidepress.org]

  Tachycardia, hypotension, low grade fever -- present with severe pain, rupture and internal hemorrhage. Marked abdominal tenderness, especially rebound tenderness, with guarding suggests a diagnosis of ruptured or bleeding ectopic pregnancy. [womenshealthsection.com]

• Hypertension

  Diseases that increase the risk of obstetrical complications include diabetes, heart disease, hypertension, kidney disease, and anemia. rubella (German measles) can be responsible for many types of birth defects, particularly if the mother contracts it [medical-dictionary.thefreedictionary.com]

  Prenat Diagn 24(9):677–684 PubMed CrossRef Google Scholar McDonnell GV, Patterson VH, McKinstry S (1997) Cerebral venous thrombosis occurring during an ectopic pregnancy and complicated by intracranial hypertension. [link.springer.com]

• Heart Disease

  Diseases that increase the risk of obstetrical complications include diabetes, heart disease, hypertension, kidney disease, and anemia. rubella (German measles) can be responsible for many types of birth defects, particularly if the mother contracts it [medical-dictionary.thefreedictionary.com]

• Fear

  That's part of my fear, that they'll terminate unnecessarily. Right now though they're not giving me any hope. Just so heart broken and I feel this is my last chance. [whattoexpect.com]

  Unless the period is more than 10 days late, however, this is not a definite indication, since many factors, including a strong fear of pregnancy, can delay menstruation. [medical-dictionary.thefreedictionary.com]

  Uterine rupture, one of the most feared obstetric catastrophes, may also be a consequence of abnormal placentation (e.g. placenta increta or percreta). [humrep.oxfordjournals.org]

• Tingling

  About 4 weeks after conception, changes in the breasts become noticeable: there may be a tingling sensation in the breasts, the nipples enlarge, and the areolae (dark areas around nipples) may become darker. [medical-dictionary.thefreedictionary.com]

• Amenorrhea

  Occasionally, a cornual gestational sac may be noticed in a patient with amenorrhea during a pelvic ultrasound. [symptoma.com]

  This work presents the case of the cornual ectopic pregnancy of a twenty year old patient who came to be examined due to amenorrhea which had lasted for seven weeks. [ncbi.nlm.nih.gov]

  The player requires Flash Player plugin Case description 20 year old female patient with history of amenorrhea of 9 weeks complaining of abdominal pain. Ultrasound suggested right adnexal mass suggestive of ectopic gestation with right ovarian cyst. [medtube.net]

  This was a young woman with nine weeks of amenorrhea, abdominal cramping for the last few days, nausea and fainting spells. A pelvic. . . [nejm.org]

• Hematuria

  Cameron Doctor 12,910 satisfied customers I'm 52 and have had 5 episodes of painless hematuria since I'm 52 and have had 5 episodes of painless hematuria since age 29 (with the blood in urine disappearing in each episode after about 1 week) with full [justanswer.com]

Clinical acumen and suspicion of ectopic pregnancy in a woman presenting with acute abdominal pain, amenorrhea, adnexal tenderness or mass and hemodynamic collapse form the crux of early diagnosis. Missed diagnosis can result in life-threatening hemorrhage and mortality. A detailed menstrual history is crucial as is a history of embryo transfer. Guidelines [6] based on evidence have been established for the workup and management of ectopic pregnancies and have to be followed rigorously. Serum and urine beta-human chorionic gonadotropin (beta-hCG) levels, blood group and rhesus factor (Rh) antibody screening along with complete blood count, liver function tests should be obtained in all patients.

Using ultrasonographic criteria, a cornual pregnancy can be diagnosed in a patient with positive pregnancy test [7]. The ultrasonography criteria are - an absence of a gestational sac within the uterine cavity; location of an asymmetrical gestational sac in the proximity of the uterus and the presence of a myometrial wall around the gestational sac. A skilled ultrasonographer with a transvaginal ultrasound can identify a cornual pregnancy as a gestational sac located laterally in the uterine fundus with the classic endometrial stripe around 9 to 12 weeks [2]. In addition, advanced radiological techniques like three-dimensional transvaginal ultrasound scanning can detect the exact location of the gestational sac in relation to the uterine cornu by reproducing the coronal plane of the uterus [8].

CONCLUSION: A single MTX injection as medical treatment is an alternative to surgical treatment of cornual pregnancies. [ncbi.nlm.nih.gov]

There is no consensus on the dose or number of methotrexate injections that should be used in the treatment of interstitial pregnancies. Single dose intramuscular methotrexate is one of the treatment options. [jsurgacad.com]

Cornual pregnancy is an infrequent pathological condition with severe prognosis if not adequately recognized. Ipsilateral salpingectomy represents a unique risk factor for this clinical entity. [ncbi.nlm.nih.gov]

Ultrasound interstitial line sign eccentric position of sac: gestational sac is surrounded by a thin rim ( Treatment and prognosis Rupture of a cornual pregnancy can cause a catastrophic intra-abdominal bleed. Promoted articles (advertising) [radiopaedia.org]

Its main risk is the rupture of the uterine horn that could threaten mother’s vital prognosis. Our patient is a primip and primiparous 28-year old woman. [ajol.info]

Management of ectopic pregnancies with poor prognosis through ultrasound guided intrasacular injection of methotrexate, series of 14 cases. [connection.ebscohost.com]

Figure 1 Figure 1: Image of ruptured cornual ectopic pregnancy at 18 weeks' gestation Figure 2 Figure 2: Image of fetus and placenta in ruptured cornual ectopic pregnancy at 18 weeks' gestation Discussion The etiologic factors for cornual pregnancy are [ispub.com]

Hum Reprod 12(4):860–866 PubMed CrossRef Google Scholar Stabile I, Grudzinskas JG (1990) Ectopic pregnancy: a review of incidence, etiology and diagnostic aspects. [link.springer.com]

Fertility drugs and treatment may lead to 3% heterotopic pregnancies (concurrent intrauterine and ectopic pregnancy); this may be due to the presence of a pre-existing tubal etiology; Cigarette smoking: Theories include impaired immunity in smokers predisposing [womenshealthsection.com]

Chow WH, Daling JR, Cates W, Greenberg RS: Epidemiology of ectopic pregnancy. Epidemiol Rev. 1987, 9: 70-94. PubMed Google Scholar 3. [link.springer.com]

View Article PubMed Google Scholar Chow WH, Daling JR, Cates W, Greenberg RS: Epidemiology of ectopic pregnancy. Epidemiol Rev. 1987, 9: 70-94. [jmedicalcasereports.biomedcentral.com]

[…] diagnosed it is important to monitor the pregnancy by transvaginal sonography to assure that is it properly located, and that the surgically repaired area remains intact. [9] Cesarean delivery is recommended to avoid uterine rupture during labor. [9] Epidemiology [en.wikipedia.org]

Epidemiology [ 1 ] The rate of ectopic pregnancy in the UK is 11 per 1,000 pregnancies. Although the mortality from ectopic pregnancies in the UK is decreasing, around 0.2 per 100 ectopic pregnancies result in maternal death. [patient.info]

Close monitoring of pregnancies in these patients is important to prevent a deleterious delay in treatment of a cornual pregnancy. [ncbi.nlm.nih.gov]

This is because while conventional laparoscopic surgery is effective More information Preventing unsafe abortion Preventing unsafe abortion Fact sheet N 388 March 2014 Key facts Around 22 million unsafe abortions are estimated to take place worldwide [docplayer.net]

Indigestion and heartburn are best prevented by avoiding foods that are difficult to digest, such as cucumbers, cabbage, cauliflower, spinach, onions, and rich foods. [medical-dictionary.thefreedictionary.com]

1. Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy, Fertil Steril 1999;72: 207-215
2. Walid MS, Heaton RL. Diagnosis and laparoscopic treatment of cornual ectopic pregnancy. Ger Med Sci. 2010; 8: Doc 16
3. Chang Y, Lee JN, Yang CH, Hsu SC, Tsai EM. An unexpected quadruplet heterotopic pregnancy after bilateral salpingectomy and replacement of three embryos, Fertil Steril 2003;80: 218-220.
4. Chopra S, Keepanasseril A, Rohilla M, Bagga R, Kalra J, Jain V. Obstetric morbidity and the diagnostic dilemma in pregnancy in rudimentary horn: retrospective analysis. Arch Gynecol Obstet. 2009;280(6):907–910.
5. Agarwal SK, Wisot AL, Garzo G, Meldrum DR. Cornual pregnancies in patients with prior salpingectomy undergoing in vitro fertilization and embryo transfer, Fertil Steril 1996;65: 659-660.
6. Mol F, van den BoohaardE, van Mello NM, et al. Guideline adherence in ectopic pregnancy management. Hum Reprod. 2011 Feb; 26 (2): 307 -15
7. Graham M, Cooperberg PL. Ultrasound diagnosis of interstitial pregnancy: findings and pitfalls. J Clin Ultrasound 1979;7: 433-437.
8. Valsky DV, Hamani Y, Verstandig A, Yagel S. The use of 3D rendering, VCI-C, 3D power Doppler and B-flow in the evaluation of interstitial pregnancy with arteriovenous malformation treated by selective uterine artery embolization. Ultrasound Obstet Gynecol. 2007;29: 352-355.