Interstitial (Cornual) Pregnancy

A Case Series

Case 1

33 yr old G4P1L1A1E1 at 7 wk POG Post LSCS pregnancy Case of secondary infertility, conceived post OI LMP 8/1/2010, Cycles regular h/o Rt ectopic pregnancy ruptured, partial

salpingectomy done OPD visit for booking of present pregnancy

O/E – Vitals stable P/A – soft, non-tender, NAD P/V – uterus 6 wk size, no fornyceal tenderness, no

adnexal mass TVS

SLIUF, FCA +, CRL – 7w Lt cornual pregnancy

Plan: Medical management with Inj Methotrexate Inj Methotrexate 50 mg on Day 1, 3, 5, 7 Inj Leucovorin 5 mg on Day 2, 4, 6, 8 TVS on Day 6:

SLIUF, FCA +

Plan: KCl instillation in fetal heart Under GA, Inj KCl administered inside Gest Sac Intra-op/Post-op uneventful Pt passed fleshy mass P/V on Day 10 Β-HCG – 7300 uIU/ml Pt discharged and on subsequent follow up showed

complete absorption of sac with resolution of HCG levels

Case 2

42 yr old G5P4L4 at 7 wk POG Willing for MTP + Lapster Offers no complaints LMP – 10/11/2010, Cycles Regular O/E – Vitals stable P/A – soft, non-tender, NAD P/V – uterus 8 wk size, No adnexal mass, no

fornyceal tenderness

Trans-Abdominal Sonography SIUGS, FCA+, CRL 7wk Eccentrically placed in fundus ?Septate uterus

Transvaginal Sonography SIUGS, FCA+, CRL 7 wk Rt cornual pregnancy

Plan: Conservative management with Inj KCl instillation in fetal heart

Under GA, TVS guided instillation of Inj KCl done Intra-op/Post-op – uneventful Repeat TVS

SIUGS with crenated margin, No FCA, No free fluid in POD

S. β-HCG – 56714 uIU/ml

Plan: Combined management with systemic Methotrexate

Started on Inj Methotrexate 60 mg: Day 1, 3, 5, 7 Inj Leucovorin 6 mg: Day 2, 4, 6, 8

S. β-HCG on Day 11 – 3713 uIU/ml Pt discharged and on subsequent follow up showed

resolution of sac and β-HCG values

Case 3

27 yr old G5A4 at 6 wk 5 d POG, Post IUI pregnancy LMP 11/5/2014, Cycles regular Admitted for safe confiment with USG finding of

Rt cornual pregnancy No c/o pain abdomen, bleeding P/V

On Examination: General Condition Fair PR 84/min normal volume, regular BP 134/80 mm HG No Pallor

Systemic Examination: RS/CVS: NAD P/A: Soft, nontender, no organomegaly P/S: No active bleeding

G5A4 lady at 6w5d POG, Post IUI pregnancy Rt Interstitial Pregnancy

Plan Fertility preservation Medical Management with Inj Methotrexate

Multi-dose regime Inj Methotrexate 1 mg/kg on Day 1, 3, 5, 7, 9 Inj Leucovorin 0.1 mg/kg on Day 2, 4, 6, 8, 10

S. β HCG levels: Day 5: 14641 uIU/ml Day 10: 10064 uIU/ml

USG done on Day 12: Rt cornual pregnancy Colour echoes absent Sac with GSD of 5w6d

Plan: Intrasac Methotrexate instillation

Day 13: Under TVS guidance, 50 mg of methotrexate instilled

in amniotic sac with aspiration of fluid Day 16:

S. β HCG: 3000 uIU/ml TVS: Thick ET, No IUGS seen

Pt asymptomatic and discharged

INTERSTITIAL (CORNUAL) PREGNANCY

Ectopic Pregnancy – first recognised by Busiere in 1693

One of the serious complications of pregnancy Leading cause of early pregnancy-related death Early diagnosis possible with advances in USG and

highly sensitive HCG assays Higher incidence of ectopic Decline in case fatality rate

Rock J A, Jones H W “Telinde's Operative Gynaecolgy”, 10th edn, Wolters Kluwer

Cunningham et al “William's Obstetrics”, 23rd edn, The McGraw Hill Companies

Interstitial vs Cornual pregnancy True interstitial pregnancy Pregnancy in one horn or septate uterus Angular pregnancy

Presenting symptoms Acute abdominal pain Low hematocrit Intraperitoneal bleed Positive serum or urine pregnancy test

B Rizk et al “Challenges in the diagnosis and management of interstitial and cornual ectopic pregnancies”. J Mid East Fert Soc (2013) 18:235-240Rock J A, Jones H W “Telinde's Operative Gynaecolgy”, 10th edn, Wolters Kluwer

Transvaginal sonographic criteria for diagnosis: Empty uterine cavity Chorionic sac seen >1cm from the most lateral edge of the

uterine cavity Thin myometrial layer surrounding the chorionic sac

“Interstitial line sign” Echogenic line extending from endometrial cavity to cornual

region, bordering the margins of the gestational sac 99% specificity, 80% sensitivity

Timor-Tritsch IE et al “Sonographic evaluation of cornual pregnancies treated without surgery” Obstet Gynsecol (1992) 79:1044-49B Rizk et al “Challenges in the diagnosis and management of interstitial and cornual ectopic pregnancies”. J Mid East Fert Soc (2013) 18:235-240

Delayed risk of rupture (>12 weeks) due to protective effect of myometrium? Rupture could happen at any time of pregnancy Profound hemorrhage and collapse

Cornu: anastomosis of uterine and ovarian vessels

Tulandi and Al-Jaroudi. Interstitial Pregnancy: Results generated from the Society of Reproductive Surgeon registry. Obstet Gynecol (2004) 103 (1): 47-50

Management Depends on:

Hemodynamic status of patient (ruptured or unruptured) Size of gestation

Modes of management Surgical Medical Expectant

Faraj R, Steel M. Management of cornual (interstitial) pregnancy. The Obstetrician & Gynaecologist 2007;9:249–255

Methotrexate first used for medical management of ectopic in 1982

Many reports of medical management of cornual pregnancy, but no consensus on best plan

Success rate of 83% Use of methotrexate

Systemic Local injection

Single dose vs multi-dose regime

J D Fisch et al. Medical Management of interstitial ectopic pregnancy: a case report and literature review. Hum Repr (13)7: 1981-86

RCOG recommendation: Patient selection

Hemodynamically stable No evidence of reupture HCG levels <3000

Single dose methotrexate Second dose depending on initial level of HCG (> 5000) Lecovorin rescue not needed

Our Recommendation

Faraj R, Steel M. Management of cornual (interstitial) pregnancy. The Obstetrician & Gynaecologist 2007;9:249–255

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