Cornual ectopic pregnancy is described as the implantation of the gestational sac to the part of the fallopian tube within the myometrial part of the uterus [1]. Approximately 2-4% ectopic pregnancies are cornual [2]. Because of the rare location of cornual pregnancy, both diagnosis and treatment are very challenging [3]. On the contrary of other ectopic pregnancies, cornual ectopic pregnancies tend to be ruptured in the later weeks of pregnancy due to the distensibility of the myometrium [4]. Therefore maternal mortality ratio due to massive hemorrhage is reported as 2-2.5% [5].

[enlarge]

Figure 1. Ultrasonographic appearance of cornual ectopic pregnancy.

Cornual ectopic pregnancies are usually diagnosed during laparoscopy. Most gynecologists are switching to laparotomy due to the uncontrollable bleeding and the difficulty of restoration the uterus [1]. In our case report, a successful management of a patient diagnosed with cornual pregnancy is presented.

[enlarge]

Figure 2. A: Right cornual ectopic pregnancy (yellow arrows). B: Laparoscopic repair of the uterus.

A 31 year old case whose last menstrual bleeding was 8 weeks ago, (gravida 4, parity 2, abortus 1), consulted with lower abdominal pain and vaginal bleeding complaints. Case did not have a history of ectopic pregnancy, cesarean section, IVF and pelvic surgery. General physical examination was evaluated as normal and patient was hemodynamically stable. (systemic blood pressure 100/70 mmHg and heart rate 85 /min). Slight vaginal bleeding as “spotting” and slight sensitivity without rebound or defense was determined. Serum β-hCG was measured as 14.155 mIU/mL. Hematocrit was 35% and hemoglobin was 11.4gr/dl. During transvaginal ultrasound examination, a 25.6x48.8 mm sized gestational sac was detected. Endometrial cavity was monitored as empty (Figure 1). Pre-diagnosis of a cornual pregnancy was made and laparoscopy was planned for the patient. During laparoscopy, right cornual region was seen as compatible with approximately 5x6 cm sized cornual pregnancy (Figure 2A). 30 W monopolar point diathermy and laparoscopic wedge resection was performed and the defect in the uterus was repaired with polyglactin suture material (Figure 2B). Serum β-hCG was measured as 11.705 mIU/mL in the 24th hour, post operation. (17.30% decreasing ratio). Pathological specimen of the collected material during operation was noted as pregnancy material in myometrial tissue.

Cornual ectopic pregnancy is described as the abnormal implantation of the gestational sac to the cornual region of the uterus and reported as one in 2500-5000 live births [4]. Pelvic inflammatory disease, peri and intratubal adhesions, endometriosis, history of bilateral salpingectomy, making multiple embryo transfer and making the transfer too close to the cornual region can be calculated as the risk factors [6].

Diagnosis of the cornual pregnancy is usually made due to the monitoring of the gestational sac with an excentric location in the fundal region of the uterus during transvaginal ultrasonography. Empty uterine cavity, less than 1 cm distance between gestatitional sac and uterine cavity’s lateral side and a thin myometrial layer around the gestational sac are counted as the diagnosis criteria [3, 6]. The important thing which should be kept in mind is that the patients with uterine subseptus can be mistaken for cornual pregnancies [3]. Therefore, the possibility of uterine anomaly should be considered while making a diagnosis. In our case report, it is determined that above mentioned ultrasonographic findings are existing.

The management of cornual pregnancy may vary depending on the patient being stable or unstable and the ectopic pregnancy being ruptured or not. If the ectopic pregnancy is small and non-viable, the possibility of rupture will be low and therefor expectant management can be considered. If the size of the cornual pregnancy is smaller than 5 cm, methotrexate treatment can be administered as the conservative method [7]. However, fail rate being 9-65% is the biggest issue about this treatment modality [3]. If ectopic gestational sac is bigger than 5 cm, due to the increasing risk of a rupture, surgery should be considered as the first option. Laparotomy, laparoscopy and hysteroscopy can be counted as the surgical modalities. During laparotomic and laparoscopic surgery, a cornual wedge resection, cornuostomy or hysterectomy can be performed. A cornual wedge resection is suggested if the gestational sac is bigger than 4 cm and a cornuostomy is suggested if it is smaller than 3.5 cm. However, organ-preserving surgery should be considered with laparoscopy for the patients wishing to preserve their fertility. Laparoscopy with cornual resection was performed due to our case’s wish of remaining fertile and the gestational sac being 5X6 cm.

In conclusion, cornual ectopic pregnancy can be a life threatening, urgent clinical situation. If diagnose can be made before the rupture, uterus preserving surgery can be performed. A laparoscopy performed by experienced hands should be considered as the first plan for managing the cornual ectopic pregnancy.

References

Dr. Ahmet Uysal, Department of Obstetrics and Gynecology, School of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey and Dr. Dagistan Tolga Arioz, Department of Obstetrics and Gynecology, Afyon Kocatepe University, Afyon, Turkey recommend publication of this article.