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.
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.
5.
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 +
6.
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
7. 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
10.
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
11.
12.
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
13. 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
14.
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
15.
16.
G5A4 lady at 6w5d POG, Post IUI pregnancy Rt
Interstitial Pregnancy
Plan
− Fertility preservation
− Medical Management with Inj Methotrexate
17.
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
18.
USG done on Day 12:
− Rt cornual pregnancy
− Colour echoes absent
− Sac with GSD of 5w6d
Plan:
− Intrasac Methotrexate instillation
19.
20.
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
22.
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
23. Cunningham et al “William's Obstetrics”, 23rd
edn, The McGraw Hill Companies
24.
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
25.
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
26.
27.
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
28.
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
29.
30.
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
31.
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