Ectopic Pregnancy :: Bilaternal Cornual Ectopic Pregnancy

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A 28 year old gravida 2 para1 was presented at the period of gestation of 8weeks and 2 days of pregnancy with lower abdominal pain of one day duration. She had no vaginal bleeding, urinary or bowel symptoms. Her systemic enquiry was normal. She was underwent laparoscopic cholecystectomy 5 years ago. Her first pregnancy was an uncomplicated normal vaginal delivery 4 years back. She was using CuT intrauterine contraceptive device (IUCD) since her post partum period which has been removed a month prior to the current pregnancy. She has no significant allergies.On examination, she was not pale; her blood pressure was 110/80 mmHg; and the pulse rate was 78/min. Her abdomen was not distended and non tender. Vaginal examination did not reveal any adenexal mass and there was no cervical excitation. Investigations showed haemoglobin 9.5g/dl ; bloodgroup was B positive. A trans-vaginal ultrasouns scan (TVS) was performed. There was a gestational sacnoted at right cornu with a live fetus (CRL= 8w +3d).Another sac was seen at left interstitial portion (GS=2.7cm) but no fetal pole. Uterine cavity was empty and endometrial thickness was 4.4mm (fig.01).She was managed with close monitoring in the ward. A repeat TVS was performed in one week time confirmed the right corneal pregnancy was progressing (CRL=9w+4d) while left corneal sac was regressing in size (fig.02). A laparotomy was performed.There was a 5cm X 6cm size right corneal sac with minimal haemoperitonium. However, in the left cornual region the sac was not seen prominently. Right cornual resection and reconstruction was done(fig.03,04).The patient was followed up with TVS in two weeks time to assess the left corneal sac which was confirmed as an early fetal demise.She was reassuredand advised regarding the risk during next pregnancy. Discussion

Ectopic pregnancy occurs 22 in 1000 live births1. It is very unpredictable and its incidence is increasing over time. Interstitial pregnancies are the rare variety among extra uterine pregnancies (2.4%). These ectopics grow in the portion of the tube that pass through the uterine cornu. So these tend to rupture violently with sudden catastrophic haemorrages. Thus they are more hazardous and are medical emergencies. Many of the fatalities due to ectopic pregnancies are from cornual pregnancies (mortality rate 2-2.5%). A hand full of risk factors are attributed for its aetiology such as advanced maternal age, increased number of sexual partners, use of CuT IUCD, previous pelvic inflammatory disease(PID), previous ectopic pregnancy, pelvic surgery, and in vitro fertilization(IVF). Interstitial portion of fallopian tube is 1-2cm in length; and 7mm in width. It has slightly tortuouscourse. When the gestational sac implanted they lie within the muscular wall. Cornual ectopic has least myometrial distensibility. Thus they present relatively late (7-12 weeks)2.Concerning our case, the patient did not have any obvious risk factors. Though she had IUCD in situ for 4 years, that was removed one month prior to this conception. However, a sub-clinical PID cannot be excluded since the pre-pregnancy existence of IUCD. Laparoscopic cholecystectomy cannot be considered as a risk factor because it hardly causes any pelvic adhesion.Conservative management for one week has been adopted after ultrasound diagnosis in our case. The reasons for this approach are two. One is diagnostic confusion. The second reason is to study the behavior of this rare bilateral condition. Cornual pregnancy is always a diagnostic puzzle. There are 3 criteria adopted in the ultra sound diagnosis. i. in an empty uterus; ii. A gestational sac seen separately and less than 1cm from the most lateral edge of the uterine cavity; iii. A thin myometrial layer surrounding the sac. Interstitial line sign is a useful sign used to diagnose the condition. It is a thin echogenic line extends directly upto the centre of cornual sac2. A recent study has evaluated various ultrasound signsto diagnose ectopic pregnancy. It has been noted interstitial line sign had better sensitivity (80%) and specificity (98%) than eccentric gestational sac(40% sensitivity and 80% specificity) and myometrial thinning (40% sensitivityand 93% specificity)3. However, sonographic appearance of interstitial pregnanciesare complex and varied, making an accurate diagnosis difficult and thorough clinical correlation is necessary4.Diagnosis of cornual pregnancy is confused with 2 important differential diagnosis. Firstly, pregnancy in bicornuate uterus, in which uterine cavity appears shorter first and then longer. But, in cornual ectopics uterine cavity remains same in length. Second one is angular pregnancy in which embryo is implanted in lateral angle medial to the utero-tubal junction and round ligament. But, in cornual pregnancy embryo is implanted lateral to round ligament.Surgery is the corner stone in the management. It is done by laparotomy or laparoscopy or hysteroscopy. Cornual resection and reconstruction is usually performed as in this case. However, this mode is associated with decrease fertility rates and increased rates of uterine rupture in future pregnancies. One school of thought is ipsilateral uterine artery ligation before attempting repair that will reduce blood loss. Radical surgery is necessary in cases where haemorrhage is life threatening.Laparoscopic treatment of cornual pregnancy can be safely carried out with good results in an institution with trained laparoscopist and adequate facilities5. Laparoscpic cornual resection is carried out if ectopic sac size is more than 4cm while cornuostomy will be performed if it is less than 4cm. An endoloop method and the encircling suture method is simple, safe, effective and nearly bloodless.Laparoscopic and ultrasound guided transcervical evacuation of cornual ectopic is also an alternative approach which carries a decreased morbidity and may less likely to compromise future reproductive function6. Hysteroscopic removal under sonographic guidance after methotrexate is a conservative option for the treatment of cornual ectopic in some patients7. Hysteroscopic endometrial resection under laparoscopic control is safe inexpert hands. Conservative surgical techniques applied to the management of cornual ectopics offer management with less morbidity and a quicker recovery. Avoiding myometrial entry also allows the option for a trial of labour with future pregnancies8.Combined local sonographically guided and systemic injection of methotrexate is associated with successful outcome in asymptomatc patients presenting with ectopic and fetal cardiac activity9. Selective uterine artery embolisation associated with methotrexate can be used successfully in treating selected cases of early cornual pregnancy.In treatment of cornual pregnancy, a uterine tourniquet in addition to vasopressin may allow for more conservative surgical procedure with reduced blood loss10. Acknowledgements

The authors would like to thank the woman for giving permission for her case to be reported. References

1. D.L.Fylstra. Tubal pregnancy: A review of current diagnosis and treatment. Obstert Gyn survey 1999.2. Radwan Faraj, Martin Steel. Management of cornual (Interstitial) pregnancy. TheObstetrician Gynaecologist , Vol 9, Num 4, 2007, 249-256.3. T.E.Acherman, C.S.Levi, S.M.Danhefsky, S.C.Holt, D.J.Lindsay. Interstitial line: sonographic finding in interstitial(corneal) ectopic pregnancy. Radiology 2009;253(3).4. Chelsey N Wright, RS MIRS. Sonographic evaluation of interstitial (cornual) ectopic pregnancy. Jourl of diagnostic medical sonography Nov1, 2008.5. Selma Nq, Suttha Hamontri, Irene Chua, Bernard Chern, Antoney Sioe. Laparoscopic management of 53 cases of cornual ectopic pregnancy.Fertility Sterility Journl of Am Society of reproductive medicine, Vol 92, issue 2 ; 448-452.6. Y.Thakur, A.Coker,J.Morris, R.Oliver. Journl of Obs Gyn 2004, Vol 24,No 7; 809-810.7. Hysteroscopic management of cornual ectopic pregnancy. Obstetrics Gynaecology 2002. Vol 99, pp941-944.8. Joel D.Larma, Meredith B.Loveless. Laparoscopic guided suction curettage of a cornual ectopic pregnancy in a bicornuate uterus. Journl of Gyn Surgery. Dec 2008,24(4), 163-166.9. Reuvit Halperin, Zvika Vaknin, David Schneider, Michel Yaron, Arie Herman. Conservative management of ectopic pregnanacy with fetal heart activity by combined local systemic methotrexate. Gynaecol. Obstet Invest 2003;56:148-151.10. Gary N.Frishman, Carol L Wheeler. The use of uterine tourniquet in the surgical management of ectopic pregnancy. Journl of Gyn surgery, spring 1995, 11(1): 53-55. Source(s) of Funding

Consent: Written informed consent was obtained from the patient for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journalConflict Interests: There is no conflict interest in this case presentation Competing Interests

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Advanced Maternal Age is not an Independent Risk Factor for Ectopic Pregnancy Posted by Ms. Judy S Cohain on 04 Feb 2013 04:57:07 AM GMT

Bilateral Cornual Ectopic Pregnancy - A Comment on the Published Case Report Posted by Prof. Pralhad Kushtagi on 04 Feb 2013 04:28:21 AM GMT

Case Report Posted by Dr. Mohammad Othman on 14 Jan 2013 06:16:07 PM GMT Comments 0 comments posted so far Post a comment Report Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors. Author Comments 0 comments posted so far

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