Cornual heterotopic pregnancy: a case report

Bernardo Daniel Lawrencius

Abstract. The word heterotopic pregnancy is used to replace the old term of combine
pregnancy. Heterotopic pregnancy is a intra uterine pregnancy that coincides with a second
pregnancy with a location at extrauterine. Most heterotopic pregnancies are the pregnancy of
the fallopian tubes and uterus, but also can happen at cornu, ovaries, cervix, and others. The
incidence of heterotopic pregnancy is estimated about 1 in 30.000, but when associated with
Assisted Reproductive Techniques ( ART ), the incidence is increase to 1 in 7.000 and after
ovulation can reach to 0,5 % - 1 %. To ensure a clinical diagnosis suspected of ectopic
pregnancy, Transvaginal Sonography ( TVS ) and Transabdominal sonography are
irreplaceable. Direct visualization of uterine and pelvic tubes with laparoscopy offers a reliable
diagnosis for almost all cases of ectopic pregnancy suspected. The principles management of
heterotopic pregnancy are elimination of the ectopic pregnancy, conservation of the intrauterine
pregnancy and haemostasis.

1. Case report cervix, and others. The incidence of

A 33 years old female, gravida one para
zero abortion 0,come to our department with
abdominal pain, spotting (+) and nausea
(+). Previously she had done IVF and
confimed pregnant. Vaginal tuse
examination were found prominent cul de
sac and cervical pain movement. TVS
examination showed a well formed
intrauterine gestation with fetal pole (+),
fetal echo (+) and also seen echoic shadow
on the right tubes. Heterotopic pregnancy
was confirmed and followed by laparotomy
and cornual resection. The patients
received 2 units of packed RBCs
2. Introduction
Heterotopic pregnancy is a intra uterine
pregnancy that coincides with a second
pregnancy with a location at extrauterine.
Most heterotopic pregnancies are the
pregnancy of the fallopian tubes and uterus,
but also can happen at cornu, ovaries,
heterotopic pregnancy is estimated about 1
in 30.000, but when associated with
Assisted Reproductive Techniques ( ART ),
the incidence is increase to 1 in 7.000 and
after ovulation can reach to 0,5 % - 1 %.
Interstitial pregnancy is very rare,
accounting for between 1.1 % and 6.8% of
all ectopic pregnancy, with a maternal
mortality rate of approximately 2% to 2.5%.
Nowadays, by using USG especially TVS
( Transvaginal Sonograph ),have been
made much easier to diagnose heterotopic
pregnancy. With high resolution TVS with
color Doppler will help because Trophoblast
tissue in adnexa in the case of heterotopic
pregnancy will show an increase in blood
flow with a significantly decreased index of
resistance.
Reported gestational age at the diagnosis of
various heterotopic pregnancies of 5-20
weeks, more than 70% were diagnosed
between 5-8 weeks of pregnancy, 20% of
which were 9-10 weeks and only 10% after
week 11 with an average age of 8 weeks.
The principles management are
hysterectomy or cornu resection in
laparotomy. Since all surgical management
has been associated with morbidity and
unfavorable effects on fertility, a more
conservative approach has been introduced
into clinical practice.
3. The case
A 33 years old female, gravida one para
zero abortion 0,come to our department with
abdominal pain. Pain is felt continuously
and even worst. History spotting (+) ,nausea
(+). There is no history of flour albus, fever
and trauma. Previously she did IVF.
Physical examination revealed a stable
patient with mild lower abdominal pain.
Vaginal examination revealed a prominent
cul de sac and painful movement of cervix.
Her vital signs on presentation were blood
pressure (BP) 120/70 mmHg, pulse rate 100
(PR) beats/min,respiratory rate (RR) 24
times/min,and temperature 36.4C. Normal
breathing sound on both chest, no wheezing
or ronchi. A crystalloid IV fluid bolus was
started. Laboratory tests showed
hemoglobin (Hb) 12.0 g/dL , hematocrit (Ht)
37.5 %,leucocyte 349.000 /L, bleeding
time 2 mins , clotting time 7 mins 30 secs
and adrandom glucose 146 mg / dL. On
transvaginal sonograph (TVS), an
intrauterine pregnancy (IUP) with fetal pole
and fetal echo, crown rump length (CRL)
0.73cm,corresponding with a 6 weeks 4 day
gestational age. Also seen echoic shadow
on right tubes. Conclusion heterotopic
pregnancy and she was schedule for
laparotomy on the next day.
along 12 cm, by inserting an anatomical
tweezers underneath, the fascia is cut out
left and right and muscles slowly open until
peritoneum was seen. Peritoneum clamped
with clamps, lifted, then cut up and down.
Blood was seen fill the abdominal cavity and
evacuation of the blood was done and
aspirated 500 cc. Evaluation on tube and
right ovarium, were seen heterotopic
pregnancy on cornu. Decided to do cornual
resection ,bleeding control stable,and
peritoneum were clamped, then the
abdominal cavity is cleansed from a blood
clot. Peritoneum stitched with plain cat gut
no 00 and also abdominal wall mucles with
simple suture. The two ends of the fascia
are clamped with a kocher, then sewed in a
brazen locked with vicryl no.1. The subcutis
is sewn in a simple suture with chromic
catgut no.2 and cutis is sewn subcuticularly
with vicryl no.3 cutting. Surgical wound
covered with sterile gauze and betadine
solution. On the first day post operative,
patient was stable but second day post
operative,patients complaining fever and
gag / vomit more than 8 times, on
abdominal examination were found
distention and low peristaltic, defacate (-),
flatus (-). Given nasogastrictube (NGT) to
decompressing,spooling NGT . On the third
day post-op, patients showed a good
progress with no gag anymore, flatus (+),
and defecate (+). After 1 week, patients
were schedule for USG, the result are single
intrauterine pregnancy, fetal pole (+)
without heartbeat. Missed abortion was
confirmed and schedule for dilatation and
curette (D&C). Post currete patient stable.

3.1. Management

Under general anesthesia in operative

theater, midline incision of cutis - subcutis

4. Discussion
Cornual heterotopic pregnancy is very rare,
although its prevalence has probably
increased due to the emergence of Assisted
Reproductive Technologies (ART). Thirty-
two cases have been published since
1990,whereas only nine cases were
reported before the last decade.
The preoperative diagnosis of a heterotopic
cornual pregnancy is difficult. Identification
of an intrauterine pregnancy can divert
attention from the possibility of a concurrent
ectopic pregnancy. In the case of an
intrauterine pregnancy with acute lower
abdominal pain,the possibility of a
heterotopic pregnancy should be
considered. This condition is very rare in a
natural cycle.
The ultrasound diagnosis of a cornual
heterotopic pregnancy is made on three
sonographic criteria.
Ultrasound criteria for the diagnosis of
cornual pregnancy
1.The presence of an eccentric gestational
sac
2.Thinning of surrounding superficial
myometrium
3.The interstitial line sign representing
either the interstitial portion of the tube or
the endometrial canal extending from the
cornu to the midportion of the interstitial
mass
The traditional treatment for interstitial
pregnancy has been cornual resection by
laparotomy or hysterectomy. Early diagnosis
allows a more conservative approach to
management. When interstitial pregnancy is
detected early and unruptured, treatment
options include expectant management with
aspiration and installation of potassium
chloride or prostaglandin into the gestational
sac. Systemic methotrexate (MTX) or local
injection MTX cannot be used in a
heterotopic pregnancy owing to its toxicity,
although some authors have used
installation of a small dose. Local
administration incldes injection under
ultrasound guidance or under direct vision
via laparoscopy or hysteroscopy. This is not
without risk,because puncturing a large
interstitial pregnancy may precipitate
hemorrhage or even cornual rupture .
Surgical intervention by hysteroscopic
removal or cornual excision/ cornuostomy
via laparotomy can be used in the case of
failed medical management of advantage
pregnancy, but no in heterotopic pregnancy.
REFERENCES
1.Cunningham, et al.2010.Obstetry Williams.
Edition 23 volume 1.Chapter 10:Ectopic
pregnancy.Jakarta:EGC
2. Poujade,Olivier. Ducarme,Guillaume.
Luton,Dominique.2009. Cornual heterotopic
pregnancy: a case report.France:Journal of
Medical Case Reports
3. Tufan, Cicerone, Et al. 2015. Cornual
Heterotopic Pregnancy- a rare cause for
haemorrhagic Shock.Romania:Maedica-a
journal of Clinical Medicine 2015;10(4): 357-360.
4. Kallitsaris M.D,Athanasios,et al. 2008.Fertility
and Sterility Vol.90,No.4. Ruptured heterotopic
interstitial pregnancy: rare case of acute
abdomen in a Jehovahs Witness
patient.Canada:Department of Obstetrics and
Gynecology, Memorial University of
Newfoundland, St.Johns. Elsevier Inc

5.Birge M.D,Ozer. Et al. 2015. Ruptured cornual

ectopic pregnancy: case
report.Turkey:Department of Obstetrics and
Gynecology,Nyala Sudan-Turkish Training and
Research Hospital, Wes Allessa District.

6.Utari,Dewi. 2017. Kehamilan Heterotopik di

Uterus dan Kornu. Medan: Departemen Obstetri
dan Ginekologi Fakultas Kedokteran Universitas
Sumatera Utara RSUP. H. Adam Malik.