A case series on Cornual (Interstitial) Ectopic Pregnancy

1. Interstitial (Cornual) Pregnancy
A Case Series

2. 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

3. 
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

5. 
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 +

6. 
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

7. 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

8. 
Trans-Abdominal Sonography
− SIUGS, FCA+, CRL 7wk
− Eccentrically placed in fundus
− ?Septate uterus

Transvaginal Sonography
− SIUGS, FCA+, CRL 7 wk
− Rt cornual pregnancy

10. 
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

12. 
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

13. 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

14. 
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

16. 
G5A4 lady at 6w5d POG, Post IUI pregnancy Rt
Interstitial Pregnancy

Plan
− Fertility preservation
− Medical Management with Inj Methotrexate

17. 
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

18. 
USG done on Day 12:
− Rt cornual pregnancy
− Colour echoes absent
− Sac with GSD of 5w6d

Plan:
− Intrasac Methotrexate instillation

20. 
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

21. INTERSTITIAL (CORNUAL) PREGNANCY

22. 
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

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

24. 
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) 18:235-240
Rock J A, Jones H W “Telinde's Operative Gynaecolgy”, 10th
edn, Wolters Kluwer

25. 
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) 79:1044-49
B Rizk et al “Challenges in the diagnosis and management of interstitial and cornual
ectopic pregnancies”. J Mid East Fert Soc (2013) 18:235-240

27. 
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

28. 
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

30. 
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

31. 
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

32. THANK YOU