Laparoscopic management of a cornual pregnancy following failed methotrexate treatment: case report and review of literature.

To describe a rare case of a singleton 8-week cornual pregnancy (CP), treated by laparoscopic incision of the uterine wall, the ectopic pregnancy was removed and the uterine site was sutured with interrupted sutures. A 21-year-old woman was admitted for suspected singleton CP at week 8. Clinical examination, b-hCG increase, and transvaginal ultrasonography (TU) were used to monitor the suspected diagnosis of an ectopic pregnancy. Following failure of methotrexate administration, surgeons performed a laparoscopy. The CP removal was performed by laparoscopic incision, enucleating the corneal mass and suturing the uterine site of the ectopic pregnancy with interrupted sutures. Intraoperative and postoperative complications and uterine integrity preservation were studied. Postoperative recovery period was normal, without intraprocedural or postprocedural complications.Uterine integrity was preserved. No further therapeutic interventions were needed in follow-up. This study confirmed the feasibility, safety and efficacy of performing a safe, minimally invasive, laparoscopic treatment of an early unruptured CP, without intraoperative and postoperative complications, with a normal postoperative recovery period and preservation of uterine integrity.

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)

[Multidose treatment of methotrexate in cornual ectopic pregnancy]. / Protocolo de tratamiento multidosis con metotrexato a pacientes con embarazo-ectópico cornual.

BACKROUND: Ectopic pregnancy represents a common entity when the differential diagnosis of first trimester pathologies is performed. Extratubal location, nonetheless, is an in unfrequent situation that delays and difficults the diagnoses. CASE REPORT: 41-year-old women who goes to clinic for a pregnancy test, which proved positive done. During normal ultrasonographic we observed attached with endometrial 8 mm thick, without gestational sac inside, no free liquid in the bottom of the pouch of Douglas. In the left cornual region had a suggestive image of ectopic pregnancy, of 2.8 cm, with embryo without cardiac activity, tested with Doppler color, according to 6 weeks of amenorrhea was observed. The level of ß-HCG was 17,656 mU/mL, which confirmed the diagnosis of corneal ectopic pregnancy. Multidose protocol of methotrexate and folinic acid was prescribed at a dose of 50 mg on days 1, 3, 5 and 7, and 5 mg in the days 2, 4, 6 and 8, respectively. After 14 days of treatment a new ß-HCG study control was made, which results was 2,519 mU/mL. From that time we take a weekly control studies of the ß-HCG until was negative (six months later). The multidose protocol of methotrexate and folinic acid is an effective treatment in patients with cornual ectopic pregnancy.

[Medical management of interstitiel pregnancy by in situ methotrexate]. / Prise en charge des grossesses interstitielles par traitement médical selon un protocole de méthotrexate in situ.

INTRODUCTION: Interstitial pregnancy accounts for 3 to 11% of ectopic pregnancy; these pregnancies are the more frequently non-tubal ectopic pregnancy. Medical treatment can be used in case of unruptured interstitial pregnancy and is used more and more frequently to avoid hemorrhagic risk and risk of conversion to radical surgery when a surgical management is decided. However, a larger use of methotrexate in interstitial pregnancy and conditions of use are not clearly defined. The aim of this study is to report a series of unruptured interstitial pregnancy managed by in situ injection of methotrexate. WOMEN AND METHODS: This retrospective observational study included women treated for an interstitial pregnancy between 2010 and 2013 in a teaching hospital. Medical management used was an in situ injection of methotrexate (1mg/kg) guided by vaginal sonography plus an intramuscular injection of methotrexate (1mg/kg) in the 48hours following in situ injection and 600mg of mifepristone when progesterone blood rate was more than 9ng/mL. A great decrease of serum hCG without surgery was considered a success. RESULTS: Fourteen women had an interstitial pregnancy during the study period. Six were managed surgically in 5 cases for suspicion of uterine rupture and one for pregnancy of unknown location. Eight women had a medical management and the success rate was 100%. Mean time for decrease of serum hCG until 2 UI/L was 54.4 days [34.0-74.8]. No uterine rupture or immediate complication was reported. Five women out of 8 had a spontaneous pregnancy after management of interstitial pregnancy. CONCLUSION: Medical management by in situ injection of methotrexate under sonographic guidance with an intramuscular injection within the 48hours following the in situ injection and mifepristone when ectopic pregnancy was active can be proposed in first-line therapy in case of unruptured interstitial pregnancy. This treatment has a great efficiency and low rate of complications.

[Cornual pregnancy: Management and subsequent fertility]. / Grossesse extra-utérine cornuale : prise en charge, fertilité ultérieure et devenir obstétrical.

OBJECTIVE: Cornual pregnancy is a rare entity, representing 2% of ectopic pregnancies. Its management is poorly codified and often guided by the clinical situation. The aim of our study was to describe the management of cornual pregnancies, subsequent fertility, and obstetric outcomes according to the management. METHODS: Observational retrospective unicentric study. Nineteen patients hospitalized for cornual pregnancy between 2006 and 2015 were included. The data was collected with medical records and a phone standardized questionnaire. Patients were managed according to hemodynamic status by either systemic or local methotrexate injection or surgical corneal resection. RESULTS: Among the 19 patients, 32% (6) were treated by systemic injection (one failure treated by surgical treatment) and 68% (13) underwent surgical treatment by cornual resection. The median HCG rate decrease was 33 days (16-62). Among the twelve patients with a desire for a new pregnancy, 7 (58%) became pregnant without assisted reproductive technology (2 following medical treatment and 5 following surgical resection). Histological analysis of uterine horn showed proximal fallopian tube lesions in 76.9% of case (chronic salpingitis, endosalpingiosis and adenomyosis). CONCLUSION: Cornual pregnancies are at high risk of hemorrhagic rupture. Ectopic recidive may occur. Fertility and obstetrical outcomes following cornual pregnancy are not affected whatever the initial treatment. Other studies are needed to aid clinical management according to HCG level and ultrasound features.

[Therapeutic methods and their effects on patients with cornual pregnancy].

OBJECTIVE: To evaluate the therapeutic methods and their effects on patients with cornual pregnancies.
 METHODS: A retrospective study was performed on 83 patients, who were diagnosed as cornual pregnancy at Drum Tower Hospital from June 2010 to April 2015. The patients were divided into 5 groups: a laparoscope group, angle resection and uterine repair guided by laparoscope (n=16); a surgery group, operated with angle resection and uterine repair (n=49); an abortion group, guided by ultrasound or laparoscope (n=6); a drug group, treated by methotrexate and mifepristone (n=8) and a pregnancy bursal puncture group (n=4). We compared the general conditions, surgery circumstances and average days in hospital among the laparoscope group, the surgery group, and the abortion group. Moreover, we also investigated the outcomes of the drug group and pregnancy bursal puncture group.
 RESULTS: Compared with the surgery group, the intraoperative blood loss in the laparoscope group and abortion group was less (P<0.05). The length of procedure and average days in hospital between the surgery group and the laparoscope group were not statistically significant (P>0.05). The length of procedure in the abortion group was less than that in the laparoscope group or the surgery group (P<0.05). The cure rate was 100%.
 CONCLUSION: The therapeutic methods based on patient's condition can improve the curative effect and prognosis in cornual pregnancy, which can keep the integrity of generative organs with less injury. The laparoscope might be a main therapeutic method for cornual pregnancy due to its safety, effectiveness, and minimal invasion.