Laparoscopic management of 4 cases of recurrent cornual ectopic pregnancy and review of literature

The objectives of this retrospective case series were to report our experience with laparoscopic management of recurrent cornual ectopic pregnancy in a tertiary care center and to present a review of the literature. Four patients experienced recurrent cornual ectopic pregnancy, and 1 patient had 2 consecutive recurrences. Laparoscopic surgery was performed to treat recurrent cornual ectopic pregnancy in all 4 patients. These 4 cases together with 10 cases collated from the literature review confirm that this entity is rare. Cornual ectopic pregnancy can recur as early as 4 months and as late as 5 years after the first ectopic pregnancy. There seems to be no correlation between the treatment method of the first ectopic pregnancy and the risk of recurrence. The etiology of recurrent cornual ectopic pregnancy is not fully understood, although it shares similar risk factors with tubal ectopic pregnancy. Both medical therapy and surgery are used to treat recurrent cornual ectopic pregnancy, with surgery often performed via laparotomy. These 4 cases constitute the largest case series of recurrent cornual ectopic pregnancy treated laparoscopically. Our experience with laparoscopic management of recurrent cornual ectopic pregnancy in a tertiary care center reveals that it is effective and safe.     

Recurrent cornual pregnancy after heterotopic cornual pregnancy successfully treated with systemic methotrexate

This report concerns a recurrent spontaneous cornual pregnancy 2 years after selective feticide of a heterotopic cornual pregnancy which occurred after IVF for tubal pathology. The recurrent cornual pregnancy was treated successfully with systemic methotrexate. Assisted reproductive techniques, especially in patients with tubal pathology, and non-invasive management of cornual pregnancies may lead to a higher incidence of recurrence.     

Heterotopic pregnancy after in vitro fertilization-embryo transfer.

OBJECTIVE: A ruptured cornual pregnancy is a rare and challenging problem. We present two cases of cornual pregnancies after in vitro fertilization and embryo transfer (IVF-ET) treated by cornual resection, with an excellent perinatal outcome for the intrauterine pregnancy in both cases. A literature review of cornual pregnancy after IVF-ET is also included. CASE REPORTS: Two women had undergone IVF-ET because of tubal problems. Emergent laparotomy was performed because of internal bleeding at 12 weeks of gestation in one case and 17 weeks in the other, and in both cases, ruptured cornual pregnancies were found. Cornual resection and primary repair were performed. The women were discharged on the 6th and 7th postoperative day, respectively, and they underwent an elective cesarean delivery at 37 weeks of pregnancy. They were delivered of healthy babies, one weighing 2700 g and the other 2310 g. CONCLUSION: These cases illustrate that good perinatal outcomes can be achieved by surgical intervention in heterotopic pregnancies, even in the event of a ruptured cornu.     

Molar cornual ectopic pregnancy

BACKGROUND: Few cases of ectopic molar pregnancies have been reported. We present one such case of a molar cornual pregnancy.CASE: A woman at 12 weeks’ gestation by last menstrual period presented with ultrasound evidence of a molar pregnancy and a surgical abdomen. Diagnostic laparoscopy revealed a large amount of free intraperitoneal blood. Laparotomy revealed villous-appearing tissue with numerous fluid-filled cysts erupting from the posterior aspect of the right uterine cornu. A cornual resection was performed, followed by a suction dilation and curettage (D&C). The pathologic findings from the cornual resection were consistent with a partial molar pregnancy, while the material from the suction D&C demonstrated no villi or trophoblastic tissue.CONCLUSION: A molar cornual ectopic pregnancy is presented.     

Survival of cornual (interstitial) pregnancy.

We report a case of a singleton cornual (interstitial) pregnancy following spontaneous conception in a primigravida with no risk factors for ectopic pregnancy. She presented at 30 weeks gestation with haemoperitoneum, due to a small rupture on the posterior surface of the cornual pregnancy. At laparotomy, an incision was made in the cornu, the baby was delivered and survived after spending 39 days in a special care baby unit.     

Live birth after treatment of a heterotopic cornual pregnancy with fetal intrathoracic KCI. A case report

BACKGROUND: Heterotopic pregnancy, in which an ectopic gestation coexists with an intrauterine one, occurs more frequently following in vitro fertilization than with spontaneous conception. However, it is rare to find an ectopic gestation in the interstitial (or cornual) portion of the fallopian tube. This scenario poses challenges in diagnosis as well as difficulties in managing the cornual pregnancy while maintaining the viability of the intrauterine gestation. CASE: A 29-year-old nulligravida with stage IV endometriosis completed in vitro fertilization for primary infertility. A heterotopic pregnancy involving the right interstitial portion of the fallopian tube as well as a viable singleton intrauterine pregnancy was diagnosed using serial ultrasound. Successful termination of the cornual pregnancy was accomplished by transabdominal fetal intrathoracic injection of KCl under ultrasound guidance. CONCLUSION: Pregnancy reduction of a heterotopic cornual gestation using KCl is a treatment alternative for this uncommon but potentially devastating complication of in vitro fertilization.     

Laparoscopic management of cornual pregnancy without sutures

Introduction Cornual pregnancy is a rare form of ectopic pregnancy. The incidence is reported as 3% of all ectopic pregnancies accounting 20% of deaths due to ectopic pregnancy. When an unruptured cornual pregnancy is diagnosed, there are a variety of management options. Many successful endoscopic management options for cornual pregnancy have been reported. Case report In this case, cornual resection was performed. Discussion The other possible treatment options were reviewed.     

Successful management of interstitial pregnancy with fetal cardiac activity by laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization

Introduction  Interstitial pregnancy is a rare but dangerous form of ectopic pregnancy. Although various forms of minimally invasive management for this disorder have been previously reported, optimal treatment regimen has not been yet unknown due to its rarity. Case report  A 29-year-old married woman with no previous disease history was referred under suspicion of ectopic pregnancy. Serum hCG value was 95,365 mIU/mL. On ultrasonographic examination, gestational sac with a viable embryo was identified in the left cornual region. Three-dimensional computed tomographic angiography showed prominent vascular mass in the left cornual region. Preoperative transcatheter uterine artery embolization followed by laparoscopic-assisted cornual resection with local methotrexate injection was successfully performed. Conclusions  Laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization for interstitial pregnancy with prominent vascular flow is a safe and reliable minimally invasive procedure for woman wishing fertility preservation.     

Molar Ectopic Pregnancy in the Uterine Cornus

Cornual pregnancy is a rare form of ectopic pregnancy. The incidence of hydatiform molar pregnancy is 1 in 1000 to 2000 pregnancies. Molar cornual ectopic pregnancy is extremely rare. A 41-year-old nulliparous woman was admitted via the emergency department because of vaginal bleeding for 2 weeks. Transvaginal sonography exhibited a heterogeneous hypoechoic shadow in the endometrium that suggested a hematometra including blood clots and tissue, and a multicystic echogenic mass, with flow at color Doppler ultrasonography, in the lateral wall of the uterus. A laparoscopic cornuostomy was performed. Pathologic analysis demonstrated placental tissue with features consistent with a partial molar pregnancy. Systemic methotrexate therapy was administered to treat the possible remnants of the molar pregnancy. Molar cornual ectopic pregnancy can be successfully treated with laparoscopic cornuostomy and systemic methotrexate therapy.     

Curetaje cornual como tratamiento conservador del embarazo ectópico accidentado

The classical treatment of cornual ectopic pregnancy is cornual resection or hysterectomy. Currently, a more conservative approach is feasible. We describe a case of cornual ectopic pregnancy treated with tubal cornual curettage and review the various options in the management of this entity. This technique may reduce the risk of uterine rupture in future pregnancies, even though studies on this topic are lacking.     

Sonographic evolution of cornual pregnancies treated without surgery.

Transvaginal sonography allows early and accurate diagnosis of cornual pregnancy, as well as providing a means for puncture injection treatment of certain ectopic pregnancies. We describe four cases of cornual pregnancy managed nonsurgically and followed with transvaginal sonography for 47-64 weeks. Sonographic evidence of cornual pregnancy persisted throughout the period of follow-up, despite resumption of normal menstrual cyclicity. We conclude that some early live cornual pregnancies can be managed by puncture injection, and cornual pregnancies in which the embryo has died can be followed conservatively.     

Cornual heterotopic pregnancy: conservative treatment with transvaginal embryo reduction

Objective The objective was to discuss a case of heterotopic cornual pregnancy managed with transvaginal embryo reduction.Methods A 22-year-old woman with heterotopic cornual pregnancy was treated with ultrasonographically guided transvaginal injection of potassium chloride into the thorax of ectopic fetus.Results Sixteen days after the procedure, the patient presented with pelvic pain and miscarriage ensued. Control examination 1 month and 3 months later revealed normal uterine cavity and partially resorbed ectopic material.Conclusion This minimally invasive approach in a hemodynamically stable patient can be considered in the management of a first trimester heterotopic cornual pregnancy. However the patient must be informed for the risk of abortion related to the procedure. Nevertheless this approach can be a treatment option in cornual pregnancies without a simultaneous intrauterine gestation.     

各孕周宫角妊娠38例临床分析

目的 探讨各孕周宫角妊娠的临床特点、诊断和治疗方法.方法 对2006年1月至2010年8月郑州大学第一附属医院收治的38例宫角妊娠的患者进行回顾性的分析.结果 38例宫角妊娠的患者中,停经38例(100%)、不规则阴道出血27例(71.1%)和腹痛22例(57.9%).宫角妊娠术前诊断困难,误诊率近50%.38例患者中...     

Diagnosis and laparoscopic management of 11 consecutive cases of cornual ectopic pregnancy

Objective  To determine the pre-operative diagnosis by two dimensional ultrasound scan and the outcome of the laparoscopic management of cornual ectopic pregnancy. Design  Prospective database cohort study. Setting  Whipps Cross University Hospital, UK (District General Hospital). Patients  Eleven patients with cornual ectopic pregnancy presenting in our hospital between January 2003 and December 2007. Interventions  Laparoscopic cornuostomy or cornual resection. Outcome measures  Pre-operative diagnosis by ultrasound scan, conversion rate to laparotomy, successful laparoscopy (not requiring further treatment), complication rate and duration of hospital stay. Results  The mean gestational age was 8 ± 2 weeks. All 11 patients presented with abdominal pain and vaginal bleeding and two (18%) patients became haemodynamically unstable before laparoscopy. There were five (45%) patients with risk factors for ectopic pregnancy. The mean serum β-human chorionic gonadotropin (β-hcg) was15,263 ± 12,045 μm/ml. One patient did not have a transvaginal scan as it was decided to proceed to surgery on clinical grounds. The diagnosis of ectopic pregnancy was correct at initial scan in nine (90%) of the ten patients who had transvaginal scans as one patient was misdiagnosed at the first scan. However, an ectopic pregnancy was diagnosed on a second ultrasound scan assessment. Initial laparoscopy was negative in one of the nine patients diagnosed as having an ectopic pregnancy. The diagnosis was later confirmed following serial serum β-hcg monitoring, a repeat scan and a second laparoscopy. Ten (91%) of the 11 patients had successful operative laparoscopy as one (9%) patient had conversion to laparotomy. Among patients who had laparoscopic surgery, cornuostomy was performed in three (30%) patients while cornual resection was performed in the other seven (70%) patients. One (10%) of the patients who had laparoscopic surgery needed further treatment with systemic methotrexate. This patient had a cornual resection and was the only complication following laparoscopic surgery. The mean hospital stay was 2 days. Conclusion  This presentation of one of the larger series of patients with cornual ectopic pregnancy managed by laparoscopic surgery reveals that experience at ultrasonography and laparoscopic technique can lead to earlier diagnosis and few cases requiring laparotomy or further treatment. In addition laparoscopic surgery for cornual ectopic is safe and lends itself to conservative approach (cornuostomy) in selected cases.     

Cornual heterotopic pregnancy: contemporary management options

This review covers the clinical presentations, treatments, and outcomes of cornual heterotopic pregnancies reported in the literature. Infertile women with a history of ectopic pregnancy, tubal surgery, or disease are at increased risk for cornual heterotopic pregnancy when they undergo in vitro fertilization. Women who have undergone bilateral salpingectomy also seem to be predisposed to this condition when they undergo in vitro fertilization. We recommend that these patients be followed up closely after a successful in vitro fertilization cycle with monitoring of serum beta-human chorionic gonadotropin levels and serial transvaginal ultrasonography because of the high associated morbidity. Laparotomy remains the treatment of choice for rupture of a cornual heterotopic pregnancy. In the absence of cornual rupture, however, medical management is an option that eliminates the risk of surgery and anesthesia and results in outcomes similar to those associated with surgical treatment. Currently there is insufficient evidence to recommend any single treatment modality, and the decision should be based on such factors as clinical presentation, surgeon's expertise, side effects, overall cost, and the patient's preference.     

Combined cornual pregnancy and intrauterine twin pregnancy after in vitro fertilization and embryo transfer: report of a case.

A case of combined cornual pregnancy and intrauterine twin pregnancy after in vitro fertilization (IVF) and transfer of six embryos is presented. The case was diagnosed as intrauterine triplets ultrasonographically at seven weeks of gestation. Unfortunately, the patient suffered from severe lower abdominal pain and hypovolemic shock at 10 weeks of gestation, and an emergent laparotomy was done. During the operation, a ruptured cornual pregnancy with accompanying hemoperitoneum was found. Because fetal heart beats were not detected by intraoperative ultrasonography in the other two intrauterine fetuses, evacuation of the gestational contents through the uterine defect was done, and the rupture site was repaired. The incidence, mechanism and management of heterotopic pregnancies after in vitro fertilization and embryo transfer are discussed.     

Hysteroscopic management of cornual ectopic pregnancy

BACKGROUND:Cornual ectopic pregnancies have traditionally been treated with systemic methotrexate, cornual resection, or hysterectomy.CASE:A 36-year-old newly gravida presented with an 8-week history of amenorrhea and a positive home pregnancy test. A transabdominal sonogram revealed a left cornual ectopic pregnancy. The patient was treated with multiple methotrexate doses, but the gestational sac persisted. Through the hysteroscope, the sac was ruptured, and the placental tissue was removed from the left cornu under sonographic guidance. Two weeks postoperatively, the patient’s β-human chorionic gonadotropin level was negative, and she had a normal pelvic examination and sonogram.CONCLUSION:Hysteroscopic removal under sonographic guidance after methotrexate treatment is a conservative option for the treatment of cornual ectopic pregnancy in some patients.     

Ultrasound diagnosis of interstitial pregnancy.

A case of interstitial pregnancy is reported. The diagnosis was made by ultrasound examination in an asymptomatic patient at risk for ectopic pregnancy following cornual anastomosis. Characteristic sonographic signs are discussed, with a review of the literature.     

Pregnancy rates after reconstructive surgery on the fallopian tubes

Current practices at Johns Hopkins Hospital with regard to surgery for tubal disease are presented. Statistical support for a particular point could not always be provided, but overall end results are given. Between 1965 and 1972, 66 patients at the Johns Hopkins Hospital had tuboplasties: 24 salpingolyses, 18 fimbrioplasties, 6 anastomoses, 8 cornual implantations, and 10 multiple procedures. The average patient age was 29.3. The duration of infertility was between 8 months and 10 years, with an average of 53.2 months. 41 of the patients had primary and 25 had secondary infertility. The operations of lysis of adhesions were done for patients whose hysterosalpingograms or dye studies at endoscopy showed patent tubes where peritubal adhesions were visualized. Fimbrioplasty has proved to be the most frustrating operation. Resection and anastomosis was almost exclusively done for repair of the tubes after surgical ligation. A high percent of good results are expected after cornual implantation. The pregnancy rates after correction of obstruction at various sites were 58% for salpingolysis, 22% for fimbrioplasty, 50% for midtubal obstructure, 38% for cornual implantation, and 20% for multiple procedures. The overall pregnancy rate was 39.4%. These rates depended on the length of the followup: the shorter the duration of followup, the lower the pregnancy rate. In order to circumvent this problem, expectancies of pregnancy, when followed up for an indefinite time, were calculated by computer. By this algorithm, it was found that 50% of patients could expect pregnancy following tuboplasties of all kinds: 66% after tubolysis, 40% after fimbrioplasty, 50% after anastomosis, 38% after cornual implantation, and 21% after multiple procedures.     

Laparoscopic treatment of cornual heterotopic pregnancy

A woman with spontaneous heterotopic pregnancy at approximately 7 weeks' gestation, diagnosed by ultrasound, was treated by laparoscopic cornuostomy. Intrauterine pregnancy continued to develop uneventfully. Two days after laparoscopic surgery, the patient decided to terminate the intrauterine pregnancy. Pathology report confirmed cornual pregnancy, and showed a partial molar gestation of the terminated pregnancy.