SONOWORLD : Cornual (interstitial) ectopic pregnancy

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Obstetrics » Obstetrics 1st Trimester

Cornual (interstitial) ectopic pregnancy

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Author(s) :

Sheila Sheth, MD

Presentation A young woman presented with a 2 day history of right lower quadrant pain. Her last menstrual period was 3 months ago. She had no vaginal bleeding. Her urine HCG was positive.

Caption: Sagittal endovaginal image of the uterus.

Description:

Caption: Sagittal endovaginal image of right ovary.

Description: There is a small corpus luteum.

Caption: Coronal endovaginal image of right cornual region.

Description: There is a complex cystic mass with an echogenic rim compatible with a gestational sac intimately related to the uterus. Note myometrium does not completely surround the gestational sac.

Caption: Transverse endovaginal image of right cornual region.

Differential Diagnosis Tubal ectopic pregnancy
Eccentrically located intrauterine pregnancy
Intrauterine pregnancy in a bicornuate uterus.

Final Diagnosis Right cornual (interstitial) ectopic pregancy

Discussion The overwhelming majority of extrauterine gestations occur in the ampullary portion of the fallopian tube. Ectopic pregnancies that implant in the interstitial (cornual) portion of the fallopian tube represent only 2 to 4.7% of all ectopic gestations. Risk factors include previous salpingectomy and assisted reproduction. Despite their rarity, they pose a significant diagnostic and therapeutic challenge and carry a greater maternal mortality risk (up to 2.2%) then ampullary ectopic pregnancies. Because of myometrial distensibility, cornual pregnancy tend to present relatively late, at 7 to 12 weeks gestation. Significant maternal hemorrhage leading to hypovolemia and shock can result from cornual rupture.

Evaluation with endovaginal sonography allows accurate diagnosis which is critical for management. One study has shown that early diagnosis of cornual pregnancy with EVS allows for first trimester conservative management with methotrexate. If the diagnosis is made later in gestation, however, surgical treatment with cornual resection or even hysterectomy may be required.

The sonographic findings of cornual pregnancy include:
· Absence of a normally positioned intrauterine pregnancy
· Heterogeneous mass in the cornua
· Eccentrically placed gestational sac with myometrial mantle surrounding only portion of the gestational sac. The gestational sac is usually in the lateral portion of the uterus early in gestation but in advanced cornual pregnancies, the gestational sac may be located above the uterine fundus and may be confused with an eccentric intrauterine pregnancy.
· “Interstitial line" sign

Case References 1. Ackerman, TE, CS Levi, SM Dashefsky, SC Holt and DJ Lindsay: Interstitial line: sonographic finding in interstitial (cornual) ectopic pregnancy. Radiology, 1993. 189(1): p. 83-7.
2. Benifla, JL, H Fernandez, E Sebban, E Darai, R Frydman, and P Madelenat: Alternative to surgery of treatment of unruptured interstitial pregnancy: 15 cases of medical treatment. Eur J Obstet Gynecol Reprod Biol, 1996. 70(2): p. 151-6.
3. Bouyer, J, J Coste, H Fernandez, JL Pouly and N Job-Spira: Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod, 2002. 17(12): p. 3224-30.
4. Chen, GD, MT Lin and MS Lee, Diagnosis of interstitial pregnancy with sonography. J Clin Ultrasound, 1994. 22(7): p. 439-42.
5. Jafri, SZ, SJ Loginsky, JA Bouffard and JE Selis: Sonographic detection of interstitial pregnancy. J Clin Ultrasound, 1987. 15(4): p. 253-7.
6. Lemus, JF: Ectopic pregnancy: an update. Curr Opin Obstet Gynecol, 2000. 12(5): p. 36

Follow Up The patient underwent laparotomy with removal of the pregnancy and wedge resection of the right cornua.

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