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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].

Entire Body System

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]

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]

Rigor

Guidelines based on evidence have been established for the workup and management of ectopic pregnancies and have to be followed rigorously.[symptoma.com]

Cardiovascular

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]

Urogenital

Adnexal Mass

Her beta-human chorionic gonadotropin level was 6,398 mIU/mL, and transvaginal ultrasound failed to reveal an intrauterine gestation, adnexal mass or cul-de-sac fluid.[ncbi.nlm.nih.gov]
Ultrasound suggested right adnexal mass suggestive of ectopic gestation with right ovarian cyst. Laparoscopic examination showed it was a cornual ectopic and a right ovarian cyst.[medtube.net]
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]
Keywords Ectopic Pregnancy Pelvic Inflammatory Disease Levonorgestrel Adnexal Mass Intrauterine Device These keywords were added by machine and not by the authors.[link.springer.com]
Neither free fluid nor adnexal mass were noted (Figure 1 ). Chlamydia tests on admission were negative. After informed consent, chemotherapy was preferred by the patient to either dilatation and curettage or laparotomy to preserve fertility.[jmedicalcasereports.biomedcentral.com]

Adnexal Tenderness

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]
Vaginal examination showed mild blood stained and minimal adnexal tenderness. There was no adnexal mass or cervical excitation tenderness. Her vital signs were stable and the first bHCG level was 2954 IU/L.[omicsonline.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]

Dyspareunia

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.[symptoma.com]

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

CONCLUSION: 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]
Abstract Traditional treatment of interstitial pregnancy includes cornual resection or hysterectomy by laparotomy, but advanced minimally invasive surgery allows successful endoscopic management.[ncbi.nlm.nih.gov]

Prognosis

Abstract 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]

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]

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]
[…] 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]
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]
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]
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]

References

Article

Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy, Fertil Steril 1999;72: 207-215
Walid MS, Heaton RL. Diagnosis and laparoscopic treatment of cornual ectopic pregnancy. Ger Med Sci. 2010; 8: Doc 16
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.
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.
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.
Mol F, van den BoohaardE, van Mello NM, et al. Guideline adherence in ectopic pregnancy management. Hum Reprod. 2011 Feb; 26 (2): 307 -15
Graham M, Cooperberg PL. Ultrasound diagnosis of interstitial pregnancy: findings and pitfalls. J Clin Ultrasound 1979;7: 433-437.
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