cornual ectopic case series
TRANSCRIPT
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Interstitial (Cornual) Pregnancy
A Case Series
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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
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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
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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 +
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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
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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
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Trans-Abdominal Sonography SIUGS, FCA+, CRL 7wk Eccentrically placed in fundus ?Septate uterus
Transvaginal Sonography SIUGS, FCA+, CRL 7 wk Rt cornual pregnancy
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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
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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
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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
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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
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G5A4 lady at 6w5d POG, Post IUI pregnancy Rt Interstitial Pregnancy
Plan Fertility preservation Medical Management with Inj Methotrexate
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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
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USG done on Day 12: Rt cornual pregnancy Colour echoes absent Sac with GSD of 5w6d
Plan: Intrasac Methotrexate instillation
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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
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INTERSTITIAL (CORNUAL) PREGNANCY
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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
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Cunningham et al “William's Obstetrics”, 23rd edn, The McGraw Hill Companies
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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
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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
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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
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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
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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
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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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THANK YOU