Local MTX and KCl treatment using a transvaginal needle together with D&C can avoid unnecessary laparotomy, and helps to preserve the fertility of most women with a caesarean scar pregnancy.
History:We present the case of a 21 year old woman attended our emergency room at 8 weeks gestation with a history of pv bleeding and abdominal pain. She had no relevant past medical history. She was para 1 with a previous vaginal delivery. Ultrasound examination showed an empty uterus with dilatation near the cornua. Initial serum hcg was 8620iu/l rising to 9680iu/l after 48 hours. The following day serum hcg was 12300iu/l and a cornual ectopic pregnancy was diagnosed on transvaginal ultrasound which measured 3x4.6cm. She was treated with methotrexate. One month after diagnosis the patient was readmitted with abdominal pain; serum hcg was 276iu/l, an ultrasound examination showed no change in the size of the ectopic and no signs of rupture. A second dose of methotrexate was given and at a follow up clinic visit serum hcg was < 0.1iu/l. Discussion: Cornual ectopic pregnancy is a rare and potentially life threatening condition. Cornual pregnancies represent 2 to 4% of ectopic pregnancy and it has a mortality of 2 to 2.5%. The CEMACH 2000-2002 showed 11 deaths from ruptured ectopic pregnancy, 4 of these were cornual pregnancies. Presentation is often later than for other ectopic pregnancies as the interstitial area distends more than other parts the fallopian tube. Presentation is with vaginal bleeding, pain or signs of rupture. Diagnosis is made with ultrasound and measurement of serum hcg. Ultrasound will detect 70% of corneal pregnancies and early diagnosis allows for more conservative management including methotrexate and laparoscopic cornual resection or cornuostomy. Macrae et al reviewed 11 patients with cornual ectopic pregnancy, ultrasound diagnosis occurred in 90% of cases and laparoscopic management was used in 91% of cases. The risks of cornual ectopic pregnancy include requiring blood transfusion, hysterectomy and death. The uterine wall defect (pouch) in correspondence of the Cesarean scar on the low segment was associated with several gynaecologic and obstetric complications: intermenstrual bleeding, uterine rupture during pregnancy or labour, placenta percreta, accreta, previa and ectopic pregnancy within the scar. The last complication was rare, but it was associated with a significant maternal morbility and loss of future fertility. Risk factors for obstetric complications are previous ectopic pregnancy and placental pathologies, IVF; risk factors for the pouch are previous uterine surgery (curettage, myomectomy, metroplasty and manual removal of the placenta), number of Cesarean deliveries, retroverse uterus and suturing technique. We here report the case of a patient who had 1 previous Cesarean delivery and 2 spontaneous abortions, came to our Department for voluntary interruption of pregnancy at 6 weeks of amenorrhea, because of a diagnosis of colic cancer. Transvaginal US revealed a gestational sac with a yolk sac and an embryonic pole located in the pouch of Cesarean scar and the color Doppler demonstrated a diffuse trophoblastic vascularization into the myometrium beneath. We performed first...
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