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Cornual Pregnancy

Cornual pregnancy is a rare type of ectopic pregnancy wherein the gestational sac develops within the cornua of a bicornuate or septate uterus or in the interstitial part of the fallopian tube. Despite the availability of modern modalities like ultrasonography and pregnancy tests, it is difficult to diagnose early and as a result, it can present with life-threatening internal abdominal hemorrhage.


Presentation

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].

Atrial Septal Defect
  • The infant was discharged on hospital day 83 with chronic lung disease, stage 1 retinopathy of prematurity, atrial septal defect and a right clubfoot; there were no additional findings at the 4-month follow-up.[ncbi.nlm.nih.gov]

Workup

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].

Treatment

  • A single MTX injection as medical treatment is an alternative to surgical treatment of cornual pregnancies.[ncbi.nlm.nih.gov]
  • In experienced hands, laparoscopy is a safe and effective treatment for cornual pregnancy.[ncbi.nlm.nih.gov]
  • The serum beta-hCG level was 2,260 and increased to 3,060 IU/l on the 5th day after treatment before it fell precipitously to below 250 IU/l 15 days after methotrexate treatment. No side effects were experienced by the patient.[ncbi.nlm.nih.gov]
  • In the case of heterotopic pregnancy, the rate of progressive intrauterine pregnancy after treatment of the ectopic pregnancy is encouraging.[ncbi.nlm.nih.gov]
  • We include a review of the literature, underlining the feasibility of a laparoscopic approach and new treatment options combining medical and surgical tools with specific attention to their impact on future fertility and on risk of uterine rupture in[ncbi.nlm.nih.gov]

Prognosis

  • 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]
  • Management of ectopic pregnancies with poor prognosis through ultrasound guided intrasacular injection of methotrexate, series of 14 cases.[connection.ebscohost.com]
  • MRI gestational sac is eccentric to the junctional zone Treatment and prognosis The morbidity and mortality are higher (15x) due to a later presentation and associated complications.[radiopaedia.org]
  • Two thirds of these maternal deaths are associated with substandard care. [ 2 ] Women who are less likely to seek medical help have a worse prognosis.[patient.info]

Etiology

  • 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]

Epidemiology

  • 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]
  • 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]
  • 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]
  • Am J Obstet Gynecol 159(5):1191–1194 PubMed CrossRef Google Scholar Regan L, Rai R (2000) Epidemiology and the medical causes of miscarriage.[link.springer.com]
Sex distribution
Age distribution

Prevention

  • Close monitoring of pregnancies in these patients is important to prevent a deleterious delay in treatment of a cornual pregnancy.[ncbi.nlm.nih.gov]
  • A nitrocellulose barrier (Gynecare Interceed, Johnson & Johnson, NY, USA) was left in the surgical area in order to prevent adhesions.[dx.doi.org]
  • Routine dating through transvaginal ultrasound scanning should diagnose and allow prevention of rupture in most of these cases.[ncbi.nlm.nih.gov]
  • 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]

References

Article

  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.

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Last updated: 2018-06-22 07:26