Diagnosis and Management of 'Cornual' Pregnancies from 2002 to 2015 at a Tertiary Referral Centre in South India: Insights from Introspection

Successful delivery in a cornual pregnancy after expectant management with traditional Chinese medicine and low-molecular-weight heparin: A case report

RATIONALE

Horn pregnancy is a rare subtype of ectopic pregnancy that presents a diagnosis and treatment challenge due to its nonspecific symptoms and high risk of rupture.

PATIENT CONCERNS

A 32-year-old woman without vaginal pregnancy with history of right corner who presented with painless vaginal bleeding.

DIAGNOSES

A transvaginal ultrasound revealed a pregnancy sac implanted in the left corner of the uterus, confirming the diagnosis of a cornual pregnancy.

INTERVENTIONS

Treatment options include pharmacological or surgical interventions, and anticipatory treatment is rarely recommended. Conservative treatment was chosen after extensive consultation, and the patient was treated with low molecular weight heparin and traditional Chinese medicine.

OUTCOMES

Subsequent ultrasound tests showed stable fetal development and a successful cesarean section.

LESSONS

This case highlights the success of combining low molecular weight heparin with traditional Chinese medicine in the treatment of cornual pregnancy. Factors affecting horn pregnancy, diagnostic challenges, and treatment considerations are discussed. Further research is necessary to determine the best management strategy and to ensure safe delivery for patients with impaired fertility but a strong desire to conceive.

Spontaneous angular dichorionic diamniotic twin pregnancy: a case report

OBJECTIVE

To report a peculiar case of ultrasound diagnosis of spontaneous angular twin pregnancy. In literature, the terms "angular," "interstitial," and "cornual" pregnancies are often used inappropriately. Confusion in terminology may have contributed to difficulties in developing diagnostic ultrasound criteria to differentiate these ectopic pregnancies.

DESIGN

Case report.

SETTING

Obstetrics and Gynecology, Community Hospital "S. Maria delle Croci."

PATIENT

A 28-year-old patient with a previous cesarean delivery was admitted to our hospital for management of a presumed angular ectopic pregnancy. Transvaginal ultrasound confirmed an ectopic dichorionic diamniotic twin pregnancy eccentrically located in the right superior angle of the uterine cavity: the first gestational sac appeared to have right angular implantation, whereas the second gestational sac seemed to deepen inside the myometrium, with a thin myometrial margin of only 3 mm.

INTERVENTIONS

After discussing the risks, the patient requested to proceed with termination. A single intramuscular injection of 75 mg of methotrexate was administered, followed by ultrasound-guided hysterosuction after 19 days due to severe vaginal bleeding.

MAIN OUTCOME MEASURES

An early and accurate ultrasound diagnosis of a high-risk condition allowed for conservative medical treatment.

RESULTS

The serum beta-human chorionic gonadotropin levels progressively decreased. After 1 month, a clinical and ultrasound examination showed a regular endometrial line with a regular reappearance of menstrual bleeding.

CONCLUSIONS

Although there are remarkable advances in ultrasound techniques, angular pregnancy remains a condition of difficult diagnosis and management; it is potentially dangerous and may lead to severe complications. An early and accurate diagnosis of this condition is necessary to avoid complications and individualize the subsequent management.

Cornual Pregnancy After Ipsilateral Salpingectomy

Ectopic pregnancy is a serious diagnosis occurring in 1-2% of all pregnancies, causing significant morbidity and mortality if unrecognized. Management of ruptured ectopic pregnancy typically includes salpingectomy, which decreases the risk for repeat ectopic pregnancies. In rare cases after salpingectomy, non-viable implantation may occur on the ipsilateral side of prior surgery. We present a patient with a cornual pregnancy on the ipsilateral side of her prior ectopic pregnancy and salpingectomy.

Cultivating the Apprentice-Mentor Model for Minimally Invasive Gynaecology in the Era of Surgically Scarce Training: A Case Report of Laparoscopic Cornuostomy for Interstitial Ectopic Pregnancy by a Trainee

Over the last few years, there is an apparent growing concern amongst O&G trainees of the inadequacy in exposure to minimally invasive gynaecology surgical training, which has been inadvertently compounded by the more stringent working hour regulations and disproportionately increasing number of trainees relative to surgical volume. Therefore, it is vitally important for trainees to maximise opportunities in the operating theatre and develop autonomy in carrying out more complex surgical procedures. This case report outlines the step-by-step approach of laparoscopic excision of a cornual ectopic pregnancy performed by a trainee under the supervision of a surgical mentor. This manuscript highlights key characteristic traits of a trainee that serve to foster surgical trust and simple but effective steps to foster surgical preparedness.

Refining Angular Pregnancy Diagnosis in the First Trimester: A Case Series of Expectant Management

OBJECTIVE

To describe the natural history and outcomes of a large cohort of expectantly managed angular pregnancies diagnosed in the first trimester by specific ultrasound criteria.

METHODS

We conducted a prospective case series of women with prenatally diagnosed angular pregnancy at a single academic tertiary care center from March 2017 to February 2019. Participants were identified at first-trimester ultrasound scan using specifically proposed diagnostic criteria for angular pregnancy and followed prospectively. Maternal and fetal data were gathered from the medical record.

RESULTS

Forty-two cases of angular pregnancy were identified at first-trimester ultrasound scan. At presentation, 33 patients (79%) were asymptomatic, eight (19%) had vaginal bleeding, and two (5%) had pain. The mean gestational age at diagnosis was 7.4±1.0 weeks; the mean myometrial thickness was 5.1±1.6 mm (95% CI 4.6-5.6). At initial follow-up about 2 weeks later, 23 patients (55%) had ultrasound scans that normalized, 13 (31%) cases persisted as angular pregnancies, and six (14%) resulted in early pregnancy loss. After each gestation had been followed until completion, 33 (80%) pregnancies resulted in live birth and eight (20%) in early pregnancy loss. One patient was lost to follow-up. Of the 33 live births, 24 (73%) were vaginal deliveries, nine (27%) were cesarean deliveries, 27 (82%) were term deliveries, and six (18%) were preterm deliveries. There were no cases of uterine rupture, maternal death, abnormal placentation, or hysterectomy.

CONCLUSIONS

In 42 cases of angular pregnancy diagnosed by first-trimester ultrasound examination, outcomes were largely positive, with an 80% live-birth rate and a 20% early pregnancy loss rate. Early diagnosis of angular pregnancy using the described criteria may represent an entity that more closely resembles a normal, noneccentric intrauterine pregnancy rather than an ectopic pregnancy. Therefore, most cases can be closely observed and efforts made to expectantly manage pregnancies while awaiting viability.

Angular vs. interstitial pregnancy: A case report highlighting diagnostic nuances with stark management differences

Background

In the literature, the terms "angular", "interstitial" and "cornual" have often been inappropriately interchanged. The consequence is under-recognition of their differences as well as inaccurate imaging guidelines which do not reliably distinguish them as distinct entities. Angular pregnancies should be considered viable and may be managed to term.

Case

A woman at 7w5d was transferred for surgical management of a presumed interstitial ectopic pregnancy. Sonography and MRI confirmed an eccentric fundal pregnancy with a thin myometrial mantle of 2-5 mm; the diagnosis of interstitial pregnancy was favored. Upon laparoscopy, the round ligament was displaced lateral to the pregnancy bulge and the diagnosis of angular pregnancy was thus apparent. The pregnancy was continued to term and delivered via repeat cesarean section without incident.

Conclusion

Angular and interstitial pregnancies are different entities which cannot always be reliably distinguished via imaging alone. Diagnostic laparoscopy may be a final step in determining pregnancy location. Angular pregnancies should be considered potentially viable and may be managed to term.