Ectopic pregnancy occurs in 2% of all pregnancies. Cornual ectopic pregnancy is a rare variant, found in 2-4% of all ectopic pregnancies. We present a case of left cornual ectopic pregnancy which ruptured at 4th day of admission. It was the 10th case of ectopic pregnancy in our setting over last year and the first case of Cornual Pregnancy noted till date. Prior to rupture, two doses of intramuscular Methotrexate injection had already been administered on the first and third day of admission.
25 years old female, G3 P2 A1 L1 with history of self induced medical abortion one year back presented to our out patient department with complaints of cessation of menstruation for 2.5 months and nausea for 15 days. She had confirmed her pregnancy by using urine pregnancy test kit at home. Her gestational age by date was 10 weeks. There was no history of vomiting, pain abdomen, increased frequency of urination, fever, fainting attacks, per vaginal bleeding or discharge. Past history and family history was insignificant.
At the time of admission, her general condition was fair with absence of palor, icterus and edema. Vitals were stable. Systemic examination of Chest and Abdomen were normal. Per speculum examination showed normal looking cervix with no discharge. Per vaginal examination findings were consistent with closed cervical os, normal sized anteverted uterus and free bilateral fornices.
Obstetric Ultrasonography revealed left cornual ectopic pregnancy in 7 weeks of gestation with cardiac activity. Gestational sac of 3.7 mm was surrounded by thin rim of myometrium. Complete Blood Count, Renal Function Tests and Liver Function Tests were within normal limits. A diagnosis of G3P2A1L1 at 10 weeks of gestation with unruptured left cornual ectopic pregnancy was made.
Counseling regarding the patient’s condition and medical management was done and the patient was admitted to Gynaecology ward. Drip was started with two pint of Ringers Lactate to keep vein open and Foley’s catheterization was done. Without much delay, medical management was initiated with intramuscular Methotrexate and serum βHCG level was sent. Serum βHCG level was increased to 61490.5 mIU/ml.
At 4th day of admission, she complained of severe pricking pain in lower abdomen. Tenderness was present over suprapubic region. Vitals was stable. She was given intramuscular Methotrexate Stat, Intravenous fluids and Injection Drotaverine intravenously. Urgent Ultrasonographic Scan revealed absence of cardiac activity. On re-assessment, pain was increasing and lower abdominal tenderness was persistent. Patient was directly shifted to the OT. Emergency laparotomy with left wedge cornual resection was done. Intraoperatively, about 200 ml of Hemoperitoneum was present with left sided ruptured cornual ectopic pregnancy of about 2×2 cm. Bilateral tubes were edematous.
Post operative Hemoglobin was 7 g/dL for which two pint of whole blood was transfused. Post transfusion Hb was 9.8 g/dL. Apart from these, the post operative course was uneventful. Patient was discharged on 5th post operative day.
REVIEW OF CORNUAL ECTOPIC PREGNANCY
The history of Ectopic Pregancy dates back to 1731 when Gifford described implantation of a pregnancy outside the uterine cavity. Until mid 19th century, Ectopic Pregancy was considered to be a universally fatal condition. The frequency of ectopic pregnancy has increased by 6 fold since 1960s. It represents a serious hazard to a woman’s health and reproductive potential, requiring prompt recognition and early aggressive intervention. Tubal pregnancy is the most common variant of ectopic pregnancy. Cornual pregnancy poses a significant diagnostic and therapeutic challenge and carries a greater maternal mortality risk than tubal pregnancy.
Ectopic: In an abnormal place ( From Greek- ektopos ‘Out of Place’)
Cornual pregancy is a rare variant with an estimate incidence of one in every 2500 to 5000 deliveries. It occurs following passage of spermatozoa through normal half of uterus and tube. The implantation occurs in rudimentary horn of bicornuate uterus.
The risk factors for cornual ectopic pregnancy are similar to those for tubal ectopic pregnancy. One common factor for the development of an ectopic pregnancy is a pathologic fallopian tube. Causes for such pathology include tubal surgery, genital tract infections leading to pelvic inflammatory disease, previous ectopic pregnancy. A number of factors have been identified that increase individual risk of cornual ectopic pregnancy.
CLINICAL FEATURES AND DIAGNOSIS
The classical triad of abdominal pain, amenorrhoea and PV bleeding occurs in 50% of ectopic pregnancies. Rupture is accompanied by features of shock.
Because of its location, early diagnosis of cornual pregnancy has historically been difficult. Serum β HCG levels doesn’t double in 48 hours, doubling time usually is more than 7 days.
The rate of diagnosis can be improved, however, with transabdominal or transvaginal ultrasound, using three criteria:
- An empty uterus
- A gestational sac seen separately and <1 cm from the most lateral edge of the uterine cavity
- Thin myometrial layer surrounding the sac
MANAGEMENT OF CORNUAL ECTOPIC PREGNANCY
All cases of ruptured cornual ectopic pregnancy should be managed on the line of shock followed by laparotomy and cornual resection. Options for unruptured cornual ectopic pregnancy treatment include medical and surgical approaches.
Surgical treatment consists of conservative techniques, such as laparoscopic cornual resection, laparoscopic cornuostomy or hysteroscopic removal of interstitial ectopic tissue, and radical operations such as hysterectomy. Radical Surgery is considered in cases of large ectopics and ruptured ectopic with uncontrolled massive bleeding. Chances of recurrence by conservative surgical approaches is 10-20%.
Indications for medical management include: 1. Haemodynamically stable patient 2. Unruptured ectopic pregnancy 3.Reliable and compliant patient, who can return for follow up 4. Ectopic pregnancy < 4 cm in size 5. Normal blood counts, Liver Function Tests and Renal Function Tests. Medical management involves Methotrexate therapy. Three protocols are currently available for the administration of methotrexate to treat cornual ectopic pregnancy: 1) Single dose 2) Two Dose 3) Fixed Multi Dose .
Methotrexate can be used as orally,intramuscularly, intravenously usually along with folinic acid. The single 50 mg/m2 dose is the simplest and commonest used regimen. The side effects of Methotrexate therapy includes hepatotoxicity, bone marrow suppression, gastroesophageal irritation.
The patient during Methotrexate therapy should be advised not to use folic acid supplements, NSAIDs, or alcohol, to avoid sunlight exposure, and to refrain from sexual intercourse or vigorous physical activity. Liver Function Tests and Complete Blood Counts should be monitored regularly.
Local injections of tropholytic agents through laparoscopy or USG guided tubal cannulization can also be used for treating many cases of live unruptured ectopic pregnancy. The agents commonly used include Methotrexate, Prostaglandin E2 (PGE2), Potassium Chloride (KCl) and Hyperosmolar glucose. Decreased systemic side effects, greater preservation of fertility and minimal hospitalization are the main advantages.
An early cornual ectopic pregnancy can be diagnosed accurately with repeated serum human chorionic gonadotropin tests combined with TVS with sensitivity >90%. Considering the rarity of cornual pregnancy, the best treatment still remains unknown. Thus, laparotomy is essential in the haemodynamically unstable pregnant woman with abdominal pain to treat hemorrhage and avoid diagnostic dilemmas.
- Bonfante Ramírez E et al. Cornual pregnancy Ginecol Obstet Mex. 1998 Feb;66:81-3
- Williams Text book of Obstetrics 24th edition
- ACOG Practice Bulletin- Medical Management of Ectopic PregnancyVOL. 111, NO. 6, JUNE 2008
- Abbott J, Emmans LS, Lowenstein SR. Ectopic pregnancy: ten common pitfalls in diagnosis. Am J Emerg Med 1990;8:515–22
- R. Faraj, M. Steel Management of cornual (interstitial) pregnancy Obstet Gynaecol, 9 (2007), pp. 249-255
- Dewhurst’s Textbook of Obstetrics and Gynaecology 8th Edition
- John E Turrentine , CLINICAL PROTOCOLS in Obstetrics and Gynecology 3rd Edition