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Cornual ectopic case series

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A case series on Cornual (Interstitial) Ectopic Pregnancy

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Cornual ectopic case series

  1. 1. Interstitial (Cornual) Pregnancy A Case Series
  2. 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. 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
  4. 4.  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 +
  5. 5.  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
  6. 6. 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
  7. 7.  Trans-Abdominal Sonography − SIUGS, FCA+, CRL 7wk − Eccentrically placed in fundus − ?Septate uterus  Transvaginal Sonography − SIUGS, FCA+, CRL 7 wk − Rt cornual pregnancy
  8. 8.  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
  9. 9.  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
  10. 10. 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
  11. 11.  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
  12. 12.  G5A4 lady at 6w5d POG, Post IUI pregnancy Rt Interstitial Pregnancy  Plan − Fertility preservation − Medical Management with Inj Methotrexate
  13. 13.  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
  14. 14.  USG done on Day 12: − Rt cornual pregnancy − Colour echoes absent − Sac with GSD of 5w6d  Plan: − Intrasac Methotrexate instillation
  15. 15.  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
  16. 16. INTERSTITIAL (CORNUAL) PREGNANCY
  17. 17.  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
  18. 18. Cunningham et al “William's Obstetrics”, 23rd edn, The McGraw Hill Companies
  19. 19.  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
  20. 20.  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
  21. 21.  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
  22. 22.  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
  23. 23.  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
  24. 24.  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
  25. 25. THANK YOU

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