Final interesting case protocol

A Fragile Hope, A Second Chance: A case report of cornual pregnancy following a same site previously ruptured tubal pregnancy By Sittie Johara S. Musor, MD Department of Obstetrics and Gynecology Amai Pakpak Medical Center, Marawi City Abstract This case report describes a 22-year-old female, G2P0 (0010), presenting with abdominal pain who was diagnosed with a cornual pregnancy. This rare type of ectopic pregnancy, accounting for 2-4% of all ectopic pregnancies, carries a high mortality rate of 2.0-2.5% due to the risk of uterine rupture and hemorrhage. The patient’s history of a previously ruptured tubal pregnancy further emphasized the potential for severe complications. The patient underwent exploratory laparotomy, wedge resection of the cornual pregnancy with ipsilateral salpingectomy, and chromopertubation. The patient showed improvement after four days of hospitalization. This case highlights the importance of early diagnosis and prompt surgical intervention in managing cornual pregnancies to minimize the risk of life-threatening complications. Keywords: Ectopic pregnancy, cornual pregnancy Objectives: To discuss a case of cornual ectopic pregnancy. To discuss the management done to the index patient. Introduction Ectopic pregnancy, a condition where a fertilized egg implants outside the uterine cavity, poses a significant threat to maternal health, contributing to maternal mortality, morbidity and early fetal loss during the first trimester of pregnancy. While various types of ectopic pregnancies exist, cornual pregnancy, characterized by implantation in the cornua of the uterus, presents unique challenges due to its location in a highly vascularized region. This case report presents a clinical scenario of a 22-year-old female with a cornual pregnancy, emphasizing the critical role of early diagnosis and prompt intervention in ensuring patient safety and well-being. This case underscores the importance of heightened awareness among healthcare providers regarding the presentation and management of cornual pregnancies to facilitate timely diagnosis and appropriate treatment strategies..

Case Report A 22-year-old, G2P0 (0010), married, housewife, residing at Bandingun, Bayang, Lanao del Sur, who presented to the emergency department with right lower quadrant pain. The pain, which began three days prior to admission, was characterized by sudden onset, sharp, intermittent and non-radiating in character with a pain score of 5/10 and episodes lasting 1-2 hours. Notably, the patient did not report any associated symptoms such as fever, anorexia, nausea, vomiting, chronic cough, weight loss, dysuria, vaginal spotting or bleeding. Prior to presenting to the emergency department, the patient had consulted a private obstetrician. An ultrasound revealed a right complex mass bulging out from the cornual area measuring 5.2 x 5.1 x 5.1 cms with yolk sac (0.39 cm) and live embryo within (2.03 cm, corresponding to 8 weeks and 4 days of gestation), suggestive of a cornual pregnancy. The obstetrician recommended surgical intervention, however the patient declined due to financial constraints. Despite the initial refusal of surgery, the patient’s pain worsened, becoming severe and persistent, prompting her to seek medical attention at our institution few hours prior to admission. The patient reported no pre-existing medical conditions. She had previously been hospitalized and underwent pelvic laparotomy with right salpingectomy for an ectopic pregnancy last November 2022 at the same institution. She had no known allergies to food or medications. Her family history revealed a strong predisposition to hypertension on both maternal and paternal sides. No other heredofamilial diseases, such as diabetes mellitus, bronchial asthma or malignancy, were reported. Moreover, there was no history of exposure to tuberculosis or sexually transmitted diseases noted. The patient completed elementary education and is currently a housewife, married to a 25-year- old farmer for three years. She is a second-hand smoker, does not consume alcoholic beverages, and has no history of illicit drug use or maintenance medications. Her menstrual history indicates menarche at 14 years old, with regular cycles lasting about 4-5 days, using 2 pads per day that are moderately soaked, without associated dysmenorrhea. She became sexually active at 19 years old with only one partner. She never had a pap smear or history of contraceptives used. She has not received any prenatal checkups. Upon admission, the patient was hemodynamically stable, awake, conscious, in severe pain but not in respiratory distress. Relevant physical examination findings included a soft abdomen with direct tenderness in the right lower quadrant. Tests for Murphy’s sign and psoas or obturator sign were negative. During the bimanual pelvic examination, the external genitalia appeared normal, the cervix was closed and anteriorly oriented with cervical motion tenderness. The uterus was of normal size, symmetrical and non-tender. A right adnexal mass measuring approximately 5 x 5cm was palpable with tenderness and no vaginal discharges observed per examining fingers. A rectovaginal exam showed good anal sphincter tone, fixed parametria, no intraluminal masses, no hemorrhoids, an intact rectal vault and no blood upon digital examination. The patient underwent a surgical procedure called an exploratory laparotomy, where the right uterine horn was removed (wedge resection) along with right fallopian tube (salpingectomy). A dye test (chromopertubation) was also performed to check the patency of the fallopian tubes. This procedure was done under spinal anesthesia. During the procedure, no bleeding in the abdominal cavity (hemoperitoneum) was observed. The right uterine horn was connected to a 5cm x 6cm x 5cm, circular, intact mass. On cut section, the mass contained an embryo and placental-like.

tissues. The right ovary appeared normal. The left fallopian tube and ovary were also visually normal. All other pelvic and abdominal organs appeared grossly normal. Following the surgery, the patient was counseled about the importance of contraception and offered oral contraceptives. The potential for future ectopic pregnancies was explained. The final surgical pathology report confirmed the diagnosis of an interstitial ectopic pregnancy in the right fallopian tube. However, there was no evidence of genital tuberculosis was found. Discussion Cornual pregnancy (CP) is a type of ectopic pregnancy where the fertilized egg implants in the interstitial part of the fallopian tube, specifically in the upper and lateral areas of the uterus near the tubal recesses. This section of the fallopian tube is around 1-2 cm long and 0.7 cm wide, supplied by Sampson’s artery and connected to both the ovarian and uterine arteries. Because of the flexibility of the myometrium, the tubal section within the muscle wall can expand significantly before rupturing, leading to cornual pregnancies often being detected later in the pregnancy and remaining symptom-free until around 7 to 12 weeks of gestation. The risk factors for a recurrent ectopic pregnancy on the same side are similar to those for the initial ectopic pregnancy. A prior ectopic pregnancy significantly raises the likelihood of a subsequent ectopic pregnancy with each occurrence. After experiencing one ectopic pregnancy and undergoing salpingectomy, there is a 15% to 20% chance of recurrence. If there have been two ectopic pregnancies, the risk of recurrence increases to 32%. Additionally, advanced age, smoking, exposure to diethylstilbestrol, assisted reproductive technologies, a history of previous tubal or pelvic surgery, pelvic inflammatory disease and sexually transmitted infections significantly elevate the risk of a repeat ectopic pregnancy as they can lead to changes in tubal anatomy and disrupt the embryo’s physiological implantation process. Research has also shown that damaged tubes are more common sites for proximal ectopic pregnancies, including cornual pregnancies. Currently, the precise cause of a repeat ectopic pregnancy on the same side is not fully understood. However, there are several theories that have been proposed. One theory suggests that sperm travel through the open tube into the pouch of Douglas, where they fertilize an egg on the side of the affected tube. The fertilized egg then implants at the site of the previous ectopic pregnancy. Another theory involves the concept of transperitoneal migration, where the fertilized egg from the normal tube migrates and implants on the remaining portion of the fallopian tube. A third theory suggests that despite ligation, the lumens of the interstitial and distal parts of the fallopian tube may remain intact. Typically, the tube is ligated after salpingectomy, but there may still be some residual patency or the possibility of recanalization. This residual opening can allow for communication between the endometrial and peritoneal cavities, enabling the migration of fertilized eggs or sperm from the endometrial cavity to the distal part of the fallopian tube. The symptoms of a cornual pregnancy (CP) can vary depending on where the fertilized egg implants. However, these symptoms are generally similar to those of other types of ectopic pregnancies. If the fallopian tube ruptures and bleeding occurs in the abdominal cavity (hemoperitoneum), the patient will experience sudden and severe abdominal pain and tenderness. If significant blood loss occurs, the patient’s blood pressure and heart rate may be affected, leading to instability..

When diagnosing an ectopic pregnancy, a blood test to measure the level of beta-hCG is used for both initial diagnosis and monitoring. In a normal pregnancy, beta-hCG levels rise steadily. For hemodynamically stable patients, less invasive treatment options may be considered, such as medical intervention or laparoscopic procedures. These procedures include laparoscopic cornual resection, laparoscopic cornuostomy, or hysteroscopic removal of the ectopic tissue. Patients who are in critical condition due to unstable vital signs or severe bleeding require immediate surgical intervention. Surgical options include removal of the fallopian tube (salpingectomy) or creating of an opening in the tube (salpingostomy), which can be performed laparoscopically (minimally invasive surgery) or through an open abdominal incision (laparotomy). Laparotomy is reserved for cases with extensive internal bleeding, compromised blood circulation, or poor visibility during laparoscopy. For patients who desire to preserve their fertility, salpingostomy is generally preferred. However, salpingostomy may not completely remove all pregnancy tissue, potentially leading to recurring symptoms. Therefore, after salpingostomy, regular weekly blood tests to monitor beta-hCG levels are crucial to ensure they return to zero. Conclusion This case report underscores the ongoing challenges associated with diagnosis and management of cornual ectopic pregnancies, a rare and potentially life-threatening condition. While surgical intervention remains the primary treatment modality, the importance of early clinical diagnosis supported by ultrasonography cannot be overstated. Early detection may facilitate conservative management options, potentially reducing the risk of mortality and preserving reproductive potential. This case highlights the need for continued research and development of more effective diagnostic and therapeutic strategies for cornual ectopic pregnancies, ultimately improving patient outcomes and minimizing the risk of life-threatening complications. References 1 Boykin, T. (2016). Ipsilateral recurrent tubal ectopic pregnancy following a salpingectomy. Journal of Diagnostic Medical Sonography, 33 (2), 114-119. https://doi.org/10.1177/8756479316670712 2 Faraj, R., & Steel, M. (2008). Can we reduce the recurrence of cornual pregnancy? A case report. Gynecological Surgery $BPrint/Gynecological Surgery, 6(1), 57-59. https://doi.org/10.1007/s10397-008-0385-y 3 Hoang, B.T., & Whitaker, D. W. (2023). Ruptured left cornual ectopic pregnancy: a case report. Curēus. https://doi.org/10.7759/cureus.41449 4 M, S. S., T, C., N, N. S., N, B. S., & S, N. T. (2013). A ruptured left cornual pregnancy: a case report. Journal of Clinical and Diagnostic Research. https://doi.org/10.7860/jcdr/2013/5644.3154 5 Mraihi, F., Buzzaccarini, G., D’ Amato, A., Laganà, A. S., Basly, J., Mejri, C., Hafsi, M., Chelli, D., Ghali, Z., Bianco, B., Barra, F., & Etrusco, A. (2024). Cornual Pregnancy: Results of a.

Single-Center retrospective experience and Systematic review on reproductive outcomes. Medicina, 60 (1), 186. https://doi.org/10.3390/medicina60010186 6 Sharma, C., & Patel, H. (2023). Ruptured cornual ectopic pregnancy: a rare and challenging obstetric emergency. Curēus. https://doi.org/10.7759/cureus.47842 7 Tulandi, T. (2017). Angular pregnancy, interstitial pregnancy, caesarean scar pregnancy and multidose methotrexate. JOGC/Journal of Obstetrics and Gynecology Canada, 39 (8), 611-612. https://doi.org/10.1016/j.jogc.2017.03.105 8 Yadav, A., Gupta, V., & Patel, S. (2015). Recurrent ectopic pregnancy after ipsilateral salpingectomy: a rare case report. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 1615-1617. https://doi.org/10.18203/2320-1770.ijrcog20150761.