*Corresponding Author:
Dr. Adinarayana Makam, MBBS, MD (OBG), FRCOG (LON) CCT
(UK)
ADI’s Advanced Centre for Fetal Care, Sparsh Hospital, Yeshwanthpur,
Bangalore, India - 560022
Phone: 9945880437
Email:
adimv2001@yahoo.com
Introduction: Cornual gestation is one of the most hazardous types of
ectopic gestation. The diagnosis and treatment are challenging and
frequently constitute a medical emergency. Cornual pregnancy accounts
for 2–4% of ectopic pregnancies and is said to have a mortality rate
in the range of 2.0–2.5%. (1)
The interstitial part of the fallopian tube is the proximal portion that
lies within the muscular wall of the uterus. It is 0.7 mm wide and
approximately 1–2 cm long, with a slightly tortuous course, extending
obliquely upward and outward from the uterine cavity. Pregnancies
implanted in this site are called interstitial (cornual) pregnancies.
(2) Because of myometrial distensibility, they tend to present
relatively late, at 7–12 weeks of gestation. Significant maternal
haemorrhage leading to hypovolaemia and shock can rapidly result from
cornual rupture. (1)
Risk factors are as for other types of ectopic pregnancy: contralateral
salpingectomy, previous ectopic pregnancy and in vitro fertilization.
(2)
The gestational sac is usually in the lateral portion of the uterus
early in gestation but in advanced cornual pregnancy it can be located
above the uterine fundus and can be confused with an eccentric
intrauterine pregnancy. This is referred to as the ‘interstitial line’
sign. (4) A thin echogenic line extends directly up to the centre of the
cornual gestational sac: this represents either the endometrial cavity
or the interstitial portion of the fallopian tube, depending on the size
of the cornual pregnancy.
Features that are helpful with the use of 3- dimensional TVS include a
live embryo in a gestational sac, surrounded by myometrium below the
cornu lying outside the endometrium.(5)
Case Report:
A 38 year old patient, G2P0+1, with a
married life of 10 years, married in a non consanguineous marriage, came
to us with a IVF conception at 6 weeks period of gestation.
She was a known case of Primary infertility and her previous pregnancy
was an IUI Conception which ended in a spontaneous first trimester loss.
Her early pregnancy scan showed a tetra chorionic Tetra amniotic
pregnancy with all four gestational sacs outside the uterine cavity in
cornual region. Yolk sac and fetal pole were seen in three out of four
sacs. Refer to figure 1, it shows a 3D image of the location of the sacs
and the empty endometrical cavity with decidual reaction. Bilateral
adenexa was normal.
=============Figure 1 about here =============
On the day of presentation, we could see 4 sacs all of them in the
cornual region with one sac containing live fetus of 6 weeks. Her beta
HCG on the day of presentation was 82500 IU/ML.
Patient was counseled regarding the risks of continuation of pregnancy
and need for termination. Detail counselling about medical and surgical
management was given; As the patient wanted to conserve her uterus and
was hemodynamically stable, with her liver and renal fuction normal, she
was counseled about the risks and procedure of medical methods and after
her consent we decided to go for the same.
Ultrasound guided cornual ectopic aspiration with local infiltration of
60 mg methotrexate and KCL to all the sacs under local anaesthesia.
There were no post procedure complications, and the patient withstood it
well.
A follow up sonogram was done after 2 weeks in which empty gestational
sacs and reduced vascularity was noted.
Day 4; beta HCG being high (76500IU/ML); she was given an additional
doses of 60 mg of methotrexate intramuscularly. Another dose of
methotrexate was repeated after 20 days as beta HCG levels plateaued
(63150 IU/ML). Serially the beta HCG follow up was done and there was a
gradual fall from the initial level. After 10 days (day 30) the beta HCG
was around 10765. A follow up scan done after one month showed a
decreased vascularity but one empty gestation sac was still noted. Refer
to table 1 to see the trend of beta HCG after each dose of methotrexate.
This case is peculiar as the patients beta Hcg was very high and still
as the size of gestational sacs measured only 6 weeks it was medically
managed. We gave two repeat doses of methotrexate as the value of beta
hcg didn’t have an expected fall. After the second dose the fall was
consistent and was more than 15%.
=============Table 1 about here =============
Discussion:
TREATMENT- The Royal College of Obstetricians and Gynaecologists
recommends that the women with tubal pregnancy who are most suitable for
methotrexate therapy are those with a serum hCG level of <3000
IU/L and with more than 5000 IU/L required two doses.(6) Methotrexate
has been given by intramuscular injection in most studies in the
literature. However, the intravenous route has also been used
successfully.(15)
e main advantages of local injection of methotrexate include smaller
drug dosage, fewer systemic side effects and higher tissue
concentration. Many types of unruptured live ectopic pregnancy can be
successfully managed without surgical intervention through TVS guided
local injection of potassium chloride or methotrexate. (8) d a
TVS-guided route of local methotrexate injection by traversing the
myometrium and approaching the gestational sac from the medial aspect, a
technique that may enable the wider use of this treatment modality by
lowering the complication rate caused by bleeding at the puncture site
if the lateral approach is used. (14)
Many studies (12) have reported the use of laparoscopy for local
methotrexate injection into a cornual pregnancy. Onderoglu et al. (13)
reported the successful management of a cornual pregnancy with a single
high-dose laparoscopic methotrexate injection (100 mg).
In this case despite beta HCG being high and the peculiar multiple
pregnancy implantation in cornual region, the case was successfully
managed with medical management. Follow up of the patient after one
month gave a positive result with complete resolution of the gestation
sacs and reduced vascularity. Does this opens a new window for
management of cornual pregnancy? Is the possibility of multiple cornual
pregnancy increased after ART? Do we need to apply for medical
management that surgical for management of ectopic pregnancy to increase
the chances of future pregnancy? Future studies are needed for framing
recommendations.
FUTURE PREGNANCY- Wittich(11) reported an association of recurrent
ectopic pregnancy with uterine fibroids. Tubal pathology is often the
primary factor blamed for recurrence. Tubal pathology, together with
assisted conception and non-invasive management of cornual pregnancy,
have been shown to contribute to a higher risk of recurrence of cornual
pregnancy. (7)