ABSTRACT

CORRESPONDING AUTHOR:
Dr. Shakun Singh,
#R-2, LLRM Medical College Campus,
Meerut, Uttar Pradesh.
E-mail: singhshakun77@gmail.com

ABSTRACT: Cornual pregnancy is a rare form of ectopic pregnancy that usually lead to uterine rupture with resultant life threatening haemorrhage. The mortality of interstitial pregnancy is more than twice than that of other tubal pregnancies. Cornual pregnancy usually rupture later than other tubal pregnancies because the myometrium is more distensible than the fallopian tube. We report a case where a patient presented at 8 weeks of gestational age with ruptured cornual ectopic pregnancy and haemoperitoneum. Emergency laprotomy was done and cornual rupture was sutured successfully.

KEYWORDS: Cornual Ectopic preg, laprotomy.

INTRODUCTION: The interestitial 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 approx. 1-2cm long with a slightly tortuous course extending obliquely upwards and outwards from the uterine cavity. Pregnancies implanted on this site are called as interstitial or cornual pregnancies. Cornual pregnancies account for 2-4% of ectopic pregnancies & have 2-2.5% mortality risk. Cornual gestation is one of the most hazardous type of ectopic gestation which may often require hysterectomy. Risk factors are as for other type of ectopic pregnancies eg. Contralateral salpingectomy previous ectopic pregnancy, smoking, IUCD and progesterone only pills, in utero DES exposure, increasing age. Until recently, cornual ectopic or interstitial pregnancies have been treated by laprotomy with cornual excision or hysterectomy. But recently now attempts have been made for conservative approach where cornual repair in being done.

CASE REPORT: A 30 year old G₃P₂L₂ presented to labour room with the complaint of amenorrhoea of one and half month, weakness, pain in lower abdomen since 1 day. She has done her urine pregnancy test which was positive.

Per abdominal examination revealed severe tenderness in lower abdomen with positive shifting dullness. Pelvic examination revealed severe tenderness in left fornix, uterus was soft, retroverted cervical motion tenderness was present. Emergency USG was done which showed A heterogenous area with fluid and products of size 95×74×39 mm and volume 149 cc in left adenexa? Ruptured ectopic pregnancy.

Findings were suggestive of ruptured ectopic pregnancy. Her immediate laboratory test included Hb -4 gms%, BT/CT within normal limits. Blood group B positive& HIV & HBsAg Negative. Past obstetric H/o Full term normal vaginal delivery.

Consent was taken for emergency laparotomy and 2unit blood was arranged. Emergency laprotomy was done. About 2000 ml of blood was present in abdominal cavity with 250 gms of blood clots. Ruptured left cornual ectopic seen with bilateral tubes and ovaries normal (fig.1)

Figure-1

Cornual repair was done with vicryl no. 1. Haemostasis attained and instruments and mop counted. Abdominal wall was closed in layers. Postoperatively, 3 units of blood was transfused. Postoperative course was uneventful and she was discharged on 7 day in good condition.

DISCUSSION: Cornual pregnancy is diagnosed with ultrasonographical criteria in presence of positive hCG indicating pregnancy. These criteria include:

1. An empty uterus
2. A gestational sac seen separately and >1 cm from the most lateral edge of uterine cavity
3. A thin myometrial layer surrounding the sac.

A thin echogenic line extends into the cornual region abutting the gestational sac and this is called “The interstitial line sign”. The interstitial line can be either the endometrial cavity or the interstitial portion of the fallopian tube. Early diagnosis of cornual pregnancy with TVS allows for first trimester conservative management with methotrexate.

Tulandi et al reviewed the management of 32 reported cases of cornual pregnancy. Ultrasound revealed an ectopic cornual gestation sac in 40.6% and a hyperechoic area/ mass in the cornual region in another 25%. The diagnosis was established in 71.4% of 32 woman with sensitivity of 80% and specificity of 99%. 4D volume contrast imaging can differentiate between angular and cornual pregnancy. In Angular pregnancy embryo is implanted medial to uterotubal junction and round ligament while in cornual pregnancy embryo is implanted lateral to round ligament.

Pehsson et al reported a case of uterine cornual rupture following attempted mid trimester induced abortion for presumed intra-uterine pregnancy. They stated that physicians should consider pregnancy when attempts at induced abortions do not succeed.

Traditionally, the treatment of cornual pregnancy has been hysterectomy or cornual resection at laparotomy. As all surgical management has been associated with morbidity and unfavorable effects on fertility, more conservative approaches have been introduced into practice. Conservative techniques such as laproscopic cornual resection, laproscopic cornuostomy or hysteroscopic removal of interestitial ectopic tissue, unilateral uterine artery ligation have been tried.

Medical methods such as systemic methotrexate in safe and highly effective treatment for cornual pregnancy so that surgery can be avoided if detected early.

Presentation at a relatively early gestation with cornual rupture, haemostasis can be obtained by just repairing the ruptured area. Early diagnosis added by USG or laparoscopy may help to contribute towards effective conservative management.

REFERENCES:

1.    Submyomatous cornual pregnancy:  Managed surgically after failed medical management.  L Al Kharusi, V Gauri,R Al-Sukarti-Sultan Qaboos,2011- ncbi.nlm.nih.gov                                    
2.    Ruptured cornual monochorionic monoamniotic twin ectopic pregnancy- A case report.   B T Utoo,S O Ojo-Jos Journal of Medicine,2011-ajol.info.          
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