Uso de mifepristona en embarazo ectópico intersticial: un reporte de caso / Use of mifepristone in an interstitial ectopic pregnancy: a case report

Introducción: El embarazo ectópico intersticial es una forma de presentación poco frecuente, con una incidencia del 2-4% de los embarazos ectópicos; sin embargo, a pesar de su baja incidencia la mortalidad es cinco veces mayor, impactando en las cifras de mortalidad materna y representando en torno al 10-15% de los casos. Objetivo: Presentar un caso de embarazo ectópico intersticial, cuya ocurrencia es poco frecuente, así como el abordaje satisfactorio del manejo médico con mifepristona y metotrexato. Caso clínico: Mujer de 28 años con antecedente de resección tubárica por quiste paraovárico derecho, quien acudió a urgencias por hallazgo en ecografía obstétrica de sospecha de embarazo intersticial izquierdo y se le administró manejo farmacológico con dosis de metotrexato y mifepristona, con éxito. Conclusiones: El manejo médico con metotrexato y mifepristona para el embarazo ectópico intersticial parece ser una elección eficaz en los casos con estabilidad hemodinámica y deseo de conservación de la fertilidad.

Background: Interstitial ectopic pregnancy represents a rare form of presentation, with an incidence of 2-4% of all ectopic pregnancies. However, despite its low incidence, it is associated with a five-fold increase in mortality, significantly impacting maternal mortality rates, accounting for approximately 10-15% of cases. Objective: To present a case of interstitial ectopic pregnancy, which is a rare occurrence, as well as the successful medical management approach with mifepristone and methotrexate. Case report: A 28-year-old women with a history of right paraovarian cyst tubal resection presented to the emergency department due to suspected left interstitial pregnancy identified on obstetric ultrasound. The patient was successfully managed with pharmacological treatment using doses of methotrexate and mifepristone. Conclusions: Medical management with methotrexate and mifepristone for interstitial ectopic pregnancy appears to be an effective choice in cases with hemodynamic stability and a desire for fertility preservation.

Embarazo cornual de 31 semanas con ruptura uterina. Reporte de caso / 31-week cornual pregnancy with uterine rupture. A case report

Resumen ANTECEDENTES: El embarazo cornual es un reto diagnóstico debido a que la capacidad de estiramiento del miometrio hace que la manifestación sea tardía y con alta mortalidad debido al riesgo de choque hemorrágico que llega a suceder, incluso, hasta en un tercio de las pacientes. OBJETIVO: Hacer hincapié en la importancia del adecuado control prenatal para el diagnóstico oportuno de embarazo ectópico y la consecuente disminución de complicaciones asociadas. CASO CLÍNICO: Paciente primigesta, de 20 años de edad, originaria y residente de Guadalupe, Nuevo León. Sin antecedentes heredofamiliares o personales médicos o quirúrgicos relevantes. Ingresó a la sala de urgencias de Obstetricia con un cuadro de choque hipovolémico y 31 semanas de embarazo. En la revisión la cavidad abdominal se encontró con un embarazo cornual izquierdo, con ruptura uterina y acretismo placentario. Por lo anterior, se procedió a la histerectomía obstétrica, salpingectomía bilateral y ooforectomía izquierda, con reporte de 1000 mL de hemoperitoneo. La evolución posquirúrgica fue satisfactoria. CONCLUSIONES: El embarazo cornual debe sospecharse en toda mujer con amenorrea, dolor abdominal y sangrado transvaginal, con búsqueda intencionada de los hallazgos ultrasonográficos de cavidad uterina vacía, saco coriónico separado por lo menos 1 cm desde el borde lateral de la cavidad uterina, capa del miometrio delgada (menos de 5 mm) que rodea el saco gestacional y signo de la línea intersticial (visualización de una línea ecogénica que se extiende desde la cavidad endometrial hasta la región cornual, contigua al saco gestacional). El diagnóstico temprano de estos embarazos evita complicaciones y afectaciones al futuro obstétrico.

Abstract BACKGROUND: Cornual pregnancy is a diagnostic challenge because the stretching capacity of the myometrium makes the manifestation late and with high mortality due to the risk of hemorrhagic shock that occurs in up to one third of patients. OBJECTIVE: To emphasize the importance of adequate prenatal care for the timely diagnosis of ectopic pregnancy and the consequent reduction of associated complications. CLINICAL CASE: Primigestation patient, 20 years old, native, and resident of Guadalupe, Nuevo Leon. No relevant heredofamilial or personal medical or surgical history. She was admitted to the obstetrics emergency room with hypovolemic shock and 31 weeks of pregnancy. On examination the abdominal cavity was found to have a left cornual pregnancy, with uterine rupture and placental accretism. Therefore, obstetric hysterectomy, bilateral salpingectomy and left oophorectomy were performed, with a report of 1000 mL of hemoperitoneum. The postoperative evolution was satisfactory. CONCLUSIONS: Cornual pregnancy should be suspected in any woman with amenorrhea, abdominal pain and transvaginal bleeding, with purposeful search for ultrasonographic findings of empty uterine cavity, chorionic sac separated at least 1 cm from the lateral border of the uterine cavity, thin myometrial layer (less than 5 mm) surrounding the gestational sac, and interstitial line sign (the visualization of an echogenic line extending from the endometrial cavity to the cornual region, contiguous with the gestational sac). The early diagnosis of these pregnancies avoids complications and affects the future obstetrician.

Experiencias en el tratamiento del embarazo ectópico del cuerno uterino / Treatment experiences about uterine horn ectopic pregnancy

Introducción: El embarazo intersticial es poco frecuente y su mortalidad es superior a otras localizaciones. Su diagnóstico cada vez más precoz, permite escoger tratamientos menos agresivos. La piedra angular, es la hemostasia. Objetivo: Describir los resultados del tratamiento de pacientes atendidas por embarazo ectópico del cuerno. Método: Se realizó un estudio descriptivo en 18 mujeres con embarazo ectópico intersticial, atendidas en el Hospital Militar Central Dr. Luis Díaz Soto del 2010 al 2019. Fueron tratadas mediante laparotomía y sutura circular del cuerno, con posterior resección cornual y extracción del material ovular. Se estudiaron las variables edad, factores de riesgo, tiempo quirúrgico, sangramiento transoperatorio, evolución (complicaciones, recuperación, fracción beta de la gonadotropina coriónica, controles ecográficos posoperatorios) y estadía hospitalaria. Resultados: El 72 por ciento de las pacientes estuvo entre 20 - 25 años, el 61,1 por ciento tuvo antecedentes de abortos provocados, seguido de enfermedad inflamatoria pélvica en el 44,4 por ciento. La media del tiempo quirúrgico fue de 36 minutos. Ninguna paciente tuvo sangramiento en el sitio de la cirugía. La fracción beta de la gonadotropina coriónica, se negativizó a la cuarta semana y los controles ecográficos posoperatorios de todas las pacientes fueron normales el día 15. En todas las pacientes se utilizó la sutura en jareta. Conclusiones: Los resultados en el tratamiento de las pacientes atendidas por embarazo instersticial, fueron favorables, la reparación de la pared uterina se realizó mediante un procedimiento seguro que mostró la aplicabilidad de la sutura en jareta. Se evitaron las pérdidas sanguíneas y complicaciones como la histerectomía(AU)

Introduction: Interstitial pregnancy is rare and its mortality is higher than in other locations. Its increasingly early diagnosis allows the choice of less aggressive treatments. The cornerstone is hemostasis. Objective: To describe the results of the treatment of patients treated for ectopic horn pregnancy. Method: A descriptive study was carried out in 18 women with interstitial ectopic pregnancy, treated at the Hospital Militar Central Dr. Luis Díaz Soto from 2010 to 2019. They were treated by laparotomy and circular suture of the horn, with subsequent cornual resection and extraction of ovular material. The variables age, risk factors, surgical time, intraoperative bleeding, evolution (complications, recovery, beta fraction of chorionic gonadotropin, postoperative ultrasound controls) and hospital stay were studied. Results: 72 percent of the patients were between 20 - 25 years old, 61.1 percent had a history of induced abortions, followed by pelvic inflammatory disease in 44.4 percent. The mean surgical time was 36 minutes. No patient had bleeding at the surgery site. The beta fraction of chorionic gonadotropin was negative at the fourth week and postoperative ultrasound controls of all patients were normal on day 15. The drawstring suture was used in all patients. Conclusions: The results in the treatment of the patients attended for interstitial pregnancy were favorable, the repair of the uterine wall was carried out by means of a safe procedure that showed the applicability of the drawstring suture. Blood loss and complications such as hysterectomy were avoided(AU))

Ruptured cornual ectopic pregnancy: a case report

A cornual gestation is one of the most hazardous and life-threatening type of ectopic pregnancy with a mortality rate of 2-5 times higher than other ectopic pregnancies. Because of the myometrium stretch ability, they usually present late around 7-12 weeks of gestation. Thus, the diagnosis and treatment of such cases become challenging. In the case of ruptured cornual ectopic pregnancy, the patient usually presents with hemodynamic instability. Presenting a case report of a 28-year-old female who presented to the labour room of ESI hospital, Okhla, New Delhi at 12 weeks of pregnancy in a state of shock. A provisional diagnosis of ruptured cornual ectopic was made based on clinical examination and ultrasound report. Resuscitation followed by emergency laparotomy done as a life-saving procedure for the patient. Ruptured cornual ectopic needs urgent intervention and multidisciplinary approach. However, with the advancement and expertise in the field of radiology and early diagnosis can be made which can contribute towards more conservative management of such cases.

O papel da ressonância magnética na distinção das gestações intersticial, cornual e angular / The role of magnetic resonance imaging in distinguishing interstitial, cornual and angular pregnancies

Apesar da melhora no diagnóstico e tratamento, a gravidez ectópica ainda é a principal causa de mortalidade materna no primeiro trimestre da gravidez. Formas raras podem apresentar um desafio diagnóstico e, sem um diagnóstico adequado, a incidência de complicações e a mortalidade materna estão relacionadas a aumento de seus índices. Os termos "gravidez cornual" e "gravidez intersticial" têm sido utilizados de forma inconsistente na literatura, sendo frequentemente usados como sinônimos do termo "gravidez angular". Uma distinção estrita entre essas entidades pode ter implicações clínicas importantes, porque o curso natural, a propedêutica e os resultados diferem entre eles. A ressonância magnética não é o padrão-ouro para o diagnóstico de gravidez ectópica, no entanto possui relevância significativa no diagnóstico de possíveis complicações decorrentes dessa afecção. Nesse contexto, esta revisão aborda a importância da ressonância magnética na distinção dos tipos de gravidez mencionados, ilustrados por meio de casos do nosso serviço.(AU)

Despite the improvement in diagnostics and treatment, ectopic pregnancies are still the main cause of maternal mortality in the first trimester of pregnancy. Rare forms may present a diagnostic challenge and without adequate diagnosis, the incidence of complications and maternal mortality is greatly increased. The terms "cornual pregnancy" and "interstitial pregnancy" have been used inconsistently in the literature, frequently been used as synonyms and even used interchangeably with the term "angular pregnancy". A strict distinction among these entities can have important clinical implications because the natural course, management and outcomes differ among them. Magnetic resonance imaging is not the gold standard for the diagnosis of ectopic pregnancy, however, it can be useful in the diagnosis of complicated presentations of such ailment. In this context, this review highlights the importance of MRI in distinguishing the aforementioned types of pregnancies, illustrated with few cases from our service.(AU)

Diagnostic dilemmas of an eccentrically located gestation sac: role of 3D ultrasound

Background: Differential diagnosis of an eccentrically located sac includes interstitial pregnancy, true cornual pregnancy and angular pregnancy which may all look similar on 2D (two dimensional) ultrasound. Interstitial pregnancy is associated with a higher maternal mortality and needs to be differentiated from true cornual pregnancy and angular pregnancy. This paper is an illustration of the role of 3D (three dimensional) ultrasound in differential diagnosis and management of the three entities.Methods: 2D and 3D ultrasound findings were analyzed in 10 cases of eccentrically located sac. The role of 3D ultrasound in differentiating the three entities had been evaluated.Results: The presence of an eccentrically located gestation sac with incomplete or asymmetric myometrial tissue less than 5 mm in thickness on 2D and the coronal sections obtained from 3D scans were used for diagnosis of interstitial pregnancy in three cases. 2 cases of angular pregnancy were diagnosed based on the finding of sac located in one of the lateral angles of the uterus with broad based connection to the endometrium. 2 cases of cornual pregnancy one intrauterine in a bicornuate uterus and the other in a rudimentary horn has been described. One heterotopic pregnancy and two other cases where a cornual fibroid mimics interstitial pregnancy is also illustrated.Conclusions: The role of 3D ultrasound in differentiating the three entities and the key findings in obtaining the precise diagnosis are emphasized. Routine usage of 3D ultrasound in all cases of eccentrically located gestational sac is recommended.

Misdiagnosis of interstitial pregnancy followed by circlage operation and failed induced midtrimester abortion: a case report

Interstitial pregnancy is rare form of ectopic pregnancy that can expand up to 18 weeks leads to massive haemoperitoneum hence early diagnosis is imperative to decrease mortality and morbidity. Present case diagnosed as interstitial pregnancy at laparotomy when she had taken for hysterotomy after two failed courses of medical abortion. Clinicians should bear in mind the limitations of various investigations and should have a higher degree of suspicion for interstitial pregnancy Any deviation from normal response to administration of medical abortificient, such as failure to abort, should instigate the diagnosis of ectopic (interstitial) pregnancy by expert radiologist.

Embarazo ectópico intersticial tratado con metotrexato y cirugía: caso clínico / Interstitial ectopic pregnancy treated with methotrexate and surgery: clinical case

RESUMEN Antecedentes: El embarazo intersticial es muy inusual y representa <2,4% de todos las gestaciones ectópicas. Objetivo: Se presenta el caso de un embarazo ectópico intersticial tratado de forma médica y quirúrgica. Se realiza una revisión literaria sobre las opciones de manejo y tratamiento. Caso clínico: Paciente primigesta de 36 años con gestación ectópica cornual derecha tras 11 días de la transferencia de un embrión criopreservado. Se decide tratamiento con metotrexato (MTX) sin éxito y con progresión del embarazo, obligándonos por lo tanto a realizar una evacuación quirúrgica de la gestación, exponiendo a la paciente tanto a los efectos secundarios del tratamiento médico como a los del abordaje quirúrgico. Conclusión: El embarazo ectópico intersticial sigue siendo un reto para el ginecólogo. El diagnóstico muy temprano de estas patologías, aunque difícil, podría evitar la opción quirúrgica, siendo el MTX más eficaz en los casos tratados precozmente.

ABSTRACT Background: Interstitial pregnancy is very unusual, and it represents <2,4% of all ectopic pregnancies. Objective: We present the case of an interstitial ectopic pregnancy treated medically and surgically. A literary review is also made about the management and treatment options. Clinical case: A 36-year-old patient with a diagnosis of right cornual ectopic pregnancy after 11 days of a cryopreserved embryo's transfer. Methotrexate (MTX) treatment was applied as the initial step but without lasting results. Because of the progression of the pregnancy, further therapy was focused on its surgical evacuation exposing the patient to the side effects of both medical treatment and surgical approach. Conclusion: Interstitial ectopic pregnancy remains a challenge for the gynecologist. Very early diagnosis of these pathologies, although difficult, could avoid the surgical outcome, being MTX more effective in cases intervened initially.

Gestación ectópica cornual en paciente con dos embarazos ectópicos ipsilaterales previos / Cornual ectopic pregnancy in a patient with two previous ipsilateral ectopic pregnancies

Resumen ANTECEDENTES: El embarazo ectópico es una de las urgencias ginecológicas más comunes, causa 75% de las muertes maternas que suceden en el mundo durante el primer trimestre de la gestación. Entre las diferentes localizaciones del embarazo extrauterino, el intersticial o cornual supone 2-4% del total de embarazos ectópicos. Una gestación cornual es un embarazo ectópico alojado e implantado en la parte intramural de la trompa de Falopio, cubierta en su totalidad por el miometrio. CASO CLÍNICO: Paciente de 37 años, con amenorrea de 5 semanas y 3 días, antecedentes de un embarazo ectópico tubárico y otro ectópico posterior, ipsilateral, en el remanente tubárico de la cirugía previa. En la ecografía de control se detectó una nueva gestación ectópica, esta vez cornual en el mismo sitio, tratada mediante resección quirúrgica cuneiforme, por vía laparotómica. CONCLUSIÓN: El diagnóstico de embarazo ectópico cornual supone un reto porque las pacientes suelen manifestar síntomas hasta un estado avanzado de esta condición, que origina una rotura uterina (y hemorragia intraabdominal masiva) en 20% de los casos más allá de las 12 semanas. El diagnóstico temprano es decisivo para que el tratamiento sea exitoso y sin consecuencias.

Abstract BACKGROUND: Ectopic pregnancy (EP) is one of the most common gynecological emergencies, and worldwide causes more than three-quarters of maternal deaths produced during the first trimester of pregnancy. Among the different locations of the extrauterine pregnancy, an interstitial pregnancy accounting for only 2-4% of total ectopic pregnancy. A cornual pregnancy is defined as ectopic pregnancy that is implanted in the intramural part of the Fallopian tube, covered in its entirety by the myometrium. CLINICAL CASE: Patient with a history of a tubal ectopic pregnancy and a posterior ipsilateral ectopic pregnancy in the tubal remnant of the previous surgery, diagnosed by ultrasound of a new ectopic pregnancy, this time cornual in the same place, treated by surgical laparotomic cuneiform resection, with good results therapeutic. CONCLUSION: The diagnosis of this entity is a challenge at present, since patients usually present symptoms in an advanced stage of the disease, causing a uterine rupture (and massive intraabdominal hemorrhage) in 20% of cases over 12 weeks . Therefore, early diagnosis is the key to success in the treatment of this rare pathology, while allowing good results for patients with interstitial pregnancy.

Tratamiento con metotrexate para el embarazo ectópico cornual / Metotrexate Treatment Cornual Ectopic Pregnancy

El embarazo ectópico cornual o intersticial es una entidad rara, con alta morbilidad y mortalidad materna. El objetivo del trabajo es presentar un caso de embarazo ectópico cornual y tratado conservadoramente en el Hospital Ciro Redondo García. Artemisa. Cuba. La paciente es una mujer de 26 años que se atiende por infertilidad secundaria, quien acudió a consulta por amenorrea de 7 semanas, con prueba positiva para hormona gonadotrófica coriónica en orina. La ecografía mostró una imagen compatible con saco gestacional en región cornual derecha sin actividad cardíaca. La cavidad endometrial estaba vacía. Es tratada con dos dosis de metotrexate y conducta expectante. No presentó complicación en relación al embarazo ectópico cornual ni al uso del metotrexate y a los seis meses tuvo un nuevo embarazo que cursó sin complicaciones. El diagnóstico precoz del embarazo ectópico cornual y el uso de metotrexate representan una opción de tratamiento médico conservador y eficaz que evita la intervención quirúrgica(AU)

The cornual ectopic pregnancy is a rare entity, with high morbilidad and maternal mortality. The objective of paper is to present a case of cornual ectopic pregnancy treated conservatively at Ciro Redondo García Hospital, Artemisa, Cuba. The patient is a 26-year-old woman who was treated for secondary infertility, she attended the consultation for amenorrhea of 7 weeks, with positive test for HGC in urine. The ultrasound showed an image compatible with a gestational sac in the right cornual region without cardiac activity. The endometrial cavity was empty. She was treated with two doses of methotrexate and watchful waiting. There was no complication in relation to ectopic cornual pregnancy or the use of methotrexate and at six months. She had a new pregnancy with no complications. The early diagnosis of cornual ectopic pregnancy and the use of methotrexate represent a conservative and effective medical treatment option that avoids surgical intervention(AU)

Multiple Faces of the Same Pathology

Ectopic pregnancy is defined as an extrauterine pregnancy. We report three cases where the ectopic pregnancies were implanted in different sites. The first case was a 28-year-old in her second pregnancy at 9 weeks gestation. She presented with painless vaginal bleeding. Ultrasound showed unruptured cornual pregnancy with hCG level of 7456mIU/ml. A single dose of 75mg IM methorexate was given and she responded well with significant reduction of hCG level. The second case, a 26-year-old gravida 5 para 2+2, with 2 previous ectopic pregnancies and bilateral salpingectomy, conceived via in-vitro fertilization (IVF). She presented with acute abdomen and one episode of syncope at 8 weeks 4 days gestation. Laparotomy showed ruptured ectopic pregnancy at the left tubal stump requiring a left salpingectomy. The third case was a 26-year-old, gravida 5 para 2+2, with two previous vaginal deliveries and two previous first trimester miscarriages. Her menses was irregular since she took injectable progestin. She presented to the emergency department with sudden onset of lower abdomen pain. Urine pregnancy test was positive. Ultrasound showed empty uterus, no adnexal mass but there was significant free fluid in the cul-de-sac. During laparoscopy, a ruptured ovarian pregnancy was diagnosed and salpingo-oophorectomy performed. There was no significant risk factor contributing to ectopic pregnancy identified in the first and third case. In the second case, despite previous bilateral salpingectomy, the patient still had ectopic pregnancy in the left fallopian tube remnant.

Cornual Pregnancy: A Case Report.

Ectopic pregnancy is a condition where gestation sac is located outside the uterine cavity; it is a major life threatening situation in early pregnancy. A cornual pregnancy is an ectopic pregnancy that develops in the interstitial portion of the fallopian tube invading through the uterine wall. As myometrium is more distensible fallopian tube cornual pregnancies often rupture later than other tubal pregnancies. Cornual pregnancy is rare and carries grave consequences to both mother and fetus. Here a case report has been presented where the patient was admitted in Faridpur Medical College Hospital. The case was presented with intra-abdominal haemorrhage at second trimester. In this cases investigation missed the diagnosis, final diagnosis was only made after laparotomy. The need for clinical suspicion and role of ultrasonography, resuscitation and laparotomy is necessary to prevent catastrophe

Embarazo cornual: tratamiento médico con dosis única de metotrexato / Cornual pregnancy treated with single intramuscular methotrexate dose

Presentamos un caso de embarazo cornual o intersticial diagnosticado en forma precoz a través de ecografía transvaginal, tratado exitosamente, en forma conservadora, con dosis única sistémica de metotrexato.

We present a case of cornual or interstitial pregnancy diagnosed during early stage through transvaginal ultrasound, treated successfully with single systemic intramuscular methotrexate dose.

A case of ipsilateral ruptured cornual pregnancy after salpingectomy for tubal pregnancy: 2-port pelviscopic cornual resection using a multichannel port / 대한산부인과내시경학회지

Cornual pregnancy is a rare type of ectopic pregnancy. Its incidence is 2-4% of all tubal pregnancy. Cornual pregnancy is relatively rare in the woman who has the history of ipsilateral salpingectomy. The standard treatment of cornual pregnancy was cornual resection or hysterectomy through laparotomy. Recently, pelviscopic cornual resection has been performed with the advance of technique and instruments. We performed 2-port pelviscopy using a multichannel port in the case of ipsilateral ruptured cornual pregnancy after salpingectomy for tubal pregnancy. This method was relative safe and easy and offers the advantages in reduced surgical morbidity, less bleeding and less operation time. Therefore, we present a case of ipsilateral cornual pregnancy after salpingectomy that surgically treated under 2-port pelviscopy with a brief review of literature.

Interstitial heterotopic pregnancy by in vitro fertilization and embryo transfer after bilateral salpingectomy / 대한산부인과학회지

Although assisted reproductive technology is associated with higher rates of interstitial pregnancy and heterotopic pregnancy, heterotopic pregnancy after bilateral salpingectomy is still extremely rare. We report a case of heterotopic pregnancy after bilateral salpingectomy in an in vitro fertilization/embryo transfer patient, who underwent cornual resection by laparotomy due to ruptured cornual pregnancy. However, 3 days after surgery, the remaining intrauterine pregnancy miscarried, and a dilatation and curettage was performed.

Hysteroscopic management of cornual pregnancy / 대한산부인과학회지

OBJECTIVE: The purpose of this study introduces a safe, effective method for treating cornual pregnancy. METHODS: Between April 2005 and December 2008, seven patients with cornual pregnancy underwent hysteroscopic surgery at a minimally invasive surgery clinic. An 18F Foley catheter was inserted after dilating the cervix; then, the uterine cavity was irrigated with 300 mL of H2O2 solution to prevent excessive bleeding. The cornual gestation was removed by hysteroscopy without complications under ultrasonographic guidance. RESULTS: The serum beta-human chorionic gonadotropin levels were monitored postoperatively and decreased optimally in all patients. All tissues removed from the uterus were confirmed to be gestational products. The estimated blood loss was less than 30 mL. All patients were discharged on the first or second postoperative day. CONCLUSION: Hysteroscopic removal of a cornual pregnancy with H2O2 is very practical and safe.

Ultrasound-guided local injection of potassium chloride (KCl) and methotrexate (MTX) in the treatment of cornual pregnancy / 대한산부인과학회지

OBJECTIVE: To evaluate efficacy and safety of local injection of potassium chloride (KCl) and methotrexate (MTX) in the treatment of cornual pregnancy. METHODS: We retrospectively reviewed all cases of cornual pregnancy treated conservatively from 2005 through August 2007. Eight cases were identified and two cases were heterotopic interstitial pregnancy. All cases were managed with local injection of KCl or methotrexate under ultrasound guidance and 2 cases were treated with intra-muscular injection of MTX in combination. After the procedure all cases with cardiac activity was confirmed to be aborted by ultrasound. Also serial follow-up sonographic examination and serum beta-hCG measurement were performed. RESULTS: The mean initial beta-hCG level was 53,331.6 mIU/mL and ranged from 14,332 mIU/mL to 125,721 mIU/mL. Mean gestational age was 48.3 days from 40 to 65 days. All cases were aborted successfully and follow up beta-hCG were declined abruptly. Two cases of heterotopic pregnancy resulted in successful deliveries at full term. CONCLUSION: Cornual resection or hysterectomy should no longer be the first line of treatment for hemodynamically stable patients with cornual pregnancy. They can be successfully treated through local injection of MTX or KCl by ultrasound guidance.

Clinical study of unusual ectopic pregnancies / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to evaluate the clinical characteristics and the management of the unusual ectopic pregnancies. METHODS: Sixty one patients who were diagnosed as unusual ectopic pregnancies in the Department of Obstetrics and Gynecology, Inje University Ilsan Paik Hospital from December 1999 to June 2006, were retrospectively analyzed. The chief complaints, past histories, time of diagnosis, serum beta-hCG concentrations and method of the management were reviewed. RESULTS: During the designated study period, the incidence rate of the ectopic pregnancy was 9.5% of the all deliveries and that of the unusual ectopic pregnancy was 18.8% of the total ectopic pregnancies. In twenty two cases, implantation sites were not found out exactly by sonography at initial diagnosis. Theses ectopic pregnancies were cornual pregnancy (3 cases), ovarian pregnancy (6 cases), abdominal pregnancy (3 cases), and unclassified unusual ectopic pregnancy (10 cases). Unusual ectopic pregnancies which were diagnosed before six weeks of gestation were eleven cases. These unusual ectopic pregnancies were 6 cases in cervical pregnancy, 1 case in abdominal pregnancy, and 4 cases in unclassified unusual ectopic pregnancy. Initial mean serum beta-hCG concentration was the highest in cornual pregnancies and the lowest in abdominal pregnancies. MTX (methotrexate) was administered in seven cases, operation was done in forty six cases, and expectant management was done in nine cases. All initial treatment was successful except one case with cornual pregnancy, which was MTX administered with alternative regimen. CONCLUSIONS: In our study the diagnostic accuracy of the unusual ectopic pregnancy was 63.9% and the successful treatment was done in 98.3% of them. There were significant statistical differences between the serum beta-hCG concentrations and the kinds of unusual ectopic pregnancies (p<0.001).

A Case of Cornual Curettage Under the High-resolution Ultrasound Guidance / 대한주산의학회잡지

Cornual or interstitial pregnancy is a rare form of ectopic pregnancy. In previous reports it accounted for 2~6% of all ectopic pregnancies. Because this unique anatomic location of the implantation site is a highly vascular area, potentially catastrophic hemorrhage from uterine rupture may occur in 15~20% of the cases, and early diagnosis is very important. As sensitive serum beta-hCGmeasurement and imaging techniques have evolved, it is possible to diagnose cornual pregnancies earlier than in the past. Traditional management is cornual wedge resection or hysterectomy by laparotomy. But this invasive treatment method may increase the morbidity and the risk of uterine rupture in subsequent pregnancies, medical treatment with methotrexate has been applied to treat cornual pregnancies, offering an alternative to surgery. Also there have been case reports of laparoscopic treatment of cornual pregnancy. We report a case of viable cornual pregnancy, which was treated successfully by curettage of the uterine cornus under the guidance of high-resolution ultrasound.

Analysis of clinical characteristics of cornual pregnancy / 대한산부인과학회지

OBJECTIVE: To determine the efficacy of ultrasonogram in the detection of cornual pregnancy and the factors that might be affected on early diagnosis. METHOD: We studied 26 cases which were diagnosed as a cornual pregnancy from Jan, 1, 2000 to Dec, 31, 2004 at department of Obstetrics and Gynecology, St. Vincent's Hospital, the Catholic University of Korea. We compared two groups about clinical characteristics and outcomes. One group (A group) was diagnosed as cornual pregnancy before beginning of treatment, another group (B group) was not diagnosed as cornual pregnancy until operation. RESULTS: A group was 8 cases (30.8%) and B group was 18 cases (69.2%). There were no significant differences in age (33.0+/-6.21 years : 31.0+/-5.82 years), duration of amenorrhea (7.32+/-1.07 weeks : 8.90+/-5.44 weeks), previous cesarian section history (25.0% : 27.8%), present myoma (12.5% : 11.1%) and abdominal pain (50% : 77.78%), vaginal bleeding (50% : 55.6%), shock (0% : 27.8%) between two groups. There were significant differences in parity (1.63+/-0.74 : 1.0+/-0.77, p=0.032), number of abortions (2.25+/-1.16 : 1.11+/-1.18, p=0.016), previous history of ectopic pregnancy (37.5% : 0%, p=0.022). Of the method of treatments, only cornual resection (50% : 94.4%) showed significant differences between two groups. CONCLUSION: 30.8% of cornual pregnancy was early diagnosed by ultrasonogram. The important early detective factors for cornual pregnancy might be parity, previous ectopic pregnancy history and abortion history. Therefore if the patient has the previous ectopic pregnancy and abortion history, she can visit early to the hospital and the doctors do pay attention to the possibility of cornual pregnancy.