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.

Ruptura uterina secundaria a embarazo ectópico cornual del segundo trimestre / Uterine rupture secondary to ectopic pregnancy in the second trimester

Resumen ANTECEDENTES: El embarazo ectópico cornual es poco común. La prevalencia estimada es de 2% y debido a su ubicación cercana a las arterias uterinas, el índice de mortalidad materna es de 10%. CASO CLINICO: Paciente de 42 años, con embarazo de 20.2 semanas, quien acudió al servicio de Urgencias por dolor pélvico opresivo, intenso, de 24 horas de evolución. A la exploración física se encontraron: tensión arterial 80-70 mmHg, frecuencia cardiaca de 112 latidos por minuto y signo de Murphy positivo. La biometría hemática reportó leucocitosis de 22.4/mL y hemoglobina de 10.7 g/dL. El ultrasonido evidenció un feto vivo de 21 semanas, con frecuencia cardiaca de 152 latidos por minuto, placenta grado 0-1, líquido amniótico normal, con abundante líquido libre en el espacio retroperitoneal. Los estudios de control de hemoglobina mostraron descenso a 5.38 g/dL, por lo que se decidió efectuar una laparotomía exploradora, en la que se encontró un embarazo ectópico cornual izquierdo; se extrajo el feto. Se practicó histerectomía subtotal, se trasladó a la paciente a la unidad de cuidados intensivos, donde su evolución fue satisfactoria. CONCLUSION: El diagnóstico de embarazo ectópico cornual sigue siendo difícil de establecer, su cuadro clínico puede simular otras alteraciones, con posibilidad de falla en 50-90% de los casos, dependiendo de la destreza del médico ultrasonografista y la sospecha clínica.

Abstract BACKGROUND: The cornual ectopic pregnancy has an unusual location representing 2% of the prevalence and because of its location close to the uterine arteries it has a maternal mortality of 10%. CLINICAL CASE: A 42-year-old patient with a pregnancy of 20.2 weeks of gestation attended the emergency department for oppressive, intense pelvic pain of 24 hours of evolution; physical examination: blood pressure of 80/70 mmHg and heart rate 112 beats per minute in addition to Murphy positive, laboratory studies were collected with blood count that reported leukocytes: 22.4/mL) and hemoglobin of 10.7 g/dL. An ultrasonographic scan was performed, finding a single 21-week live product with a heart rate of 152 beats per minute, placental grade 0-1, normal amniotic fluid, with abundant free fluid in the retroperitoneal space. Control of hemoglobin was requested with decrease to 5.38 g/dL, so it was decided to go to exploratory laparotomy, finding broken left cornual ectopic pregnancy, which was extracted product of conception and subtotal hysterectomy was performed and subsequently moved to the Intensive Care Unit achieving an adequate evolution. CONCLUSION: The diagnosis of cornual ectopic pregnancy continues to be difficult to perform among medical entities, its clinical picture can simulate other entities with possibility of failure in the diagnosis by 50-90% depending on the skill of the ultrasonographer and clinical suspicion.

Embarazo ectópico cornual recurrente: caso clínico y revisión de la literatura / Recurrent cornual ectopic pregnancy: clinical case and literature review

OBJETIVO: Reportar un caso de embarazo ectópico cornual recurrente, al que se le realizó manejo por laparoscopia. Realizar una revisión de la literatura sobre este tema. CASO CLÍNICO: Se presenta el caso de una paciente de 34 años, con embarazo cornual recurrente a quien se le realizó manejo exitoso por laparoscopia. MÉTODO: Se realizó una búsqueda bibliográfica en las bases de datos con las palabras clave: pregnancy, intersticial y cornual ectopic en Medline, PubMed, Embase, Cochrane Data base, Ovid, Hinari, Scielo y Bireme. Resultados: La búsqueda inicial arrojó 311 artículos, de los cuales se seleccionaron 116 y posteriormente 74 artículos, que estaban relacionados con el tema a revisar, finalmente se escogieron 38 artículos con texto completo. CONCLUSIÓN: El embarazo ectópico cornual o intersticial tienen los mismos factores de riesgo que el embarazo tubárico. El avance en ecografía y los niveles de ßHCG han permitido un diagnóstico precoz, lo que permite realizar tratamientos médico o quirúrgico más conservadores, donde la laparoscopia ha empezado a tener un papel muy importante.

OBJECTIVE: To report a recurrent cornual ectopic pregnancy who underwent laparoscopic management and review the literature on this topic. CASE REPORT: 34 year-old patient with a recurrent cornual ectopic pregnancy who underwent successful laparoscopic management. METHOD: A literature search was performed in databases Medline, PubMed, Embase, Cochrane Data Base, Ovid, Hinari, Scielo and Bireme, with the keywords: pregnancy, interstitial and cornual ectopic pregnancy. Results: The initial search yielded 311 articles of which 116 were selected and then 74 who were related to the subject to review, finally 38 full text articles were selected. CONCLUSION: Cornual or interstitial ectopic pregnancy has the same risk factors that tubal pregnancy. Advances in ultrasound and ßHCG levels have allowed earlier diagnosis allowing more conservative treatments either medical or surgical treatment where laparoscopy has begun to play an important role.

Pregnancy in rudimentary horn of uterus.

A 20-year-old primigravida with 3 months amenorrhea presented with complaints of acute abdominal pain. Her vital systemic parameters were stable. On vaginal examination, the patient was provisionally diagnosed of right cornual ectopic pregnancy, which was confirmed sonographically, and taken up for surgery. There was moderate hemoperitoneum and rupture of right horn of uterus with products protruding. The rudimentary horn was excised. The patient was discharged and advised contraception and follow-up.

Embarazo Ectópico Cornual: Reporte de un Caso / Ectopic Pregnancy: a Case Report

En el embarazo ectópico cornual el saco gestacional se implanta en el cuerno uterino. Son factores de riesgo: infecciones genitales, tabaquismo, cirugía abdomino-pélvica previa, embarazo ectópico previo, tratamientos de esterilidad, técnicas de reproducción, fármacos, endometriosis, edad materna y la enfermedad inflamatoria pélvica. Se diagnostica por: anamnesis clínica, exploración física, marcadores plasmáticos placentarios, ecografía transvaginal y punción saco de Douglas. En el tratamiento médico se recomienda administrar metotrexate, si se acompaña de hemorragia se realiza laparotomía con resección cornual o histerectomía. Les presentamos un caso clínico de una paciente de sexo femenino de 28 años, con diagnóstico de embarazo cornual de 16 semanas de gestación, con antecedentes de presentar dos abortos y un embarazo ectópico previo. Presentaba: taquicardia, taquipnea e hipotensión. Al examen físico se evidencia sangrado transvaginal. La paciente fue sometida a cirugía, donde se interrumpió la gestación y se procedió a regularizar bordes y tejido desvitalizado.

In the cornual pregnancy the gestational sac is implanted in the uterine horn. Risk factors for the existence of ectopic pregnancy include: genital infections, smoking, previous abdomino-pelvic surgery, contraceptive use, previous ectopic pregnancy, infertility treatment and reproductive techniques, drug administration, luteal insufficiency, endometriosis, maternal age and pelvic inflammatory disease. Cornual pregnancy is diagnosed by anamnesis, clinical examination, placental plasma markers, transvaginal ultrasound and Douglas sac puncture. The medical treatment recommended for interstitial pregnancy is the administration of methotrexate. In case of bleeding caused by the cornual pregnancy is recommended laparotomy surgery whit cornual resection or hysterectomy. We present the case of 28 years old female patient diagnosed with a 16 weeks cornual ectopic pregnancy. With a history of four pregnancies; two of them end in abortion and one in a previous ectopic pregnancy.The review of vital sign showed tachycardia, tachypnea and hypotension. Physical examination evidence transvaginal bleeding. The patient was submitted to surgery where the ectopic pregnancy was interrupted and proceeded to regularize the edges and devitalized tissue.

Unruptured Left Cornual Pregnancy with a High Serum β-hCG: A Case Report

Ectopic pregnancy in the interstitial part of the fallopian tube (cornual pregnancy) is a rare condition but can be fatal. Traditionally, the treatment had been cornual resection or hysterectomy. More conservative approaches had been advocated recently. There is no consensus on the dose or number of methotrexate injections that should be used in the treatment of interstitial pregnancies. Single dose intramuscular methotrexate is one of the treatment options. However, the failure rate is higher if the serum β-hCG (beta-human chorionic gonadotrophin) level is more than 5000 IU/L. We report a case of cornual ectopic pregnancy with high initial serum β-hCG level being successfully treated with multiple doses of systemic methotrexate. MRI was used to assess clinical resolution of cornual ectopic pregnancy.

A cornual ectopic pregnancy case: diagnosis, etiology and its management.

This is a report of a case of cornual ectopic pregnancy, with transvaginal ultrasonography done for early detection, screening, β-hCG measuring, also discussed was the role of methotrexate therapy prior to operative procedure with conservative management. Multiple intramural myomas (22 myomas) in this case were strongly believed as the etiology of the cornual pregnancy.