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10.1576/toag.9.4.249.27355 www.rcog.org.uk/togonline
2007;9:249–255
Review
Review Management of cornual
(interstitial) pregnancy
Authors Radwan Faraj / Martin Steel
Key content:
• The Confidential Enquiry into Maternal and Child Health report for 2000–02 stated that
cornual pregnancy is a rare but dangerous type of ectopic pregnancy.
• Four out of the 11 deaths from ruptured ectopic pregnancy were due to ruptured cornual
pregnancy. In all four cases the diagnosis was made only after rupture.
• Haemorrhage can be severe because pregnancy is often more developed than extrauterine tubal
pregnancy and because of the large blood supply to the uterus.
• Clinicians should be aware of the difficulties with both clinical and ultrasound diagnosis.
• Many case reports have been written about sporadic cases of intact and ruptured cornual
pregnancy and several treatment modalities discussed. There are very few publications
collecting all management strategies, including both surgical and medical treatment, for this
dangerous type of ectopic pregnancy.
Learning objectives:
• To understand recent advances in diagnosis and conservative laparoscopic and medical
treatment.
• To review the most reputable case reports discussing all modalities of treatment, including
radical surgical and conservative laparoscopic methods and different types of medical
treatment, with critical appraisal of each approach.
Ethical issues:
• How should a couple be counselled regarding future pregnancy risks and the optimum mode
of delivery?
Keywords cornual pregnancy / cornuostomy /cornual excision / methotrexate
Please cite this article as: Faraj R, Steel M. Management of cornual (interstitial) pregnancy. The Obstetrician & Gynaecologist 2007;9:249–255.
Author details
Radwan Faraj MRCOG
Specialist Registrar
Department of Obstetrics and Gynaecology,
Blackpool Victoria Hospital, Whinny Heys
Road, Blackpool FY3 8NR, UK
Email: [email protected]
(corresponding author)
Martin Steel FRCOG
Consultant Obstetrician and
Gynaecologist/Clinical Director
Blackpool Victoria Hospital, UK
© 2007 Royal College of Obstetricians and Gynaecologists
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Introduction
Cornual gestation is one of the most hazardous
types of ectopic gestation. The diagnosis and
treatment are challenging and frequently constitute
a medical emergency. In general, the death rate
associated with ectopic pregnancy has not declined
since the Confidential Enquiry into Maternal and
Child Health (CEMACH) report for 2000–02 and is
increased on the rates for 1991–93. In the last
report1 there were 11 deaths from ruptured ectopic
pregnancy: 7 were located in the extrauterine tube
and 4 in the interstitial portion of the tube (cornual
pregnancy). Cornual pregnancy accounts for 2–4%
of ectopic pregnancies and is said to have a
mortality rate in the range of 2.0–2.5%.
Figure 1
Coronal endovaginal image of right
cornual region (complex cystic
mass with an echogenic rim
compatible with a gestational sac,
located close to the uterus. The
myometrium does not completely
surround the gestational sac).
Figure 2
Transverse image of a cornual
ectopic pregnancy. The uterus is
outlined by arrowheads and the
ectopic is outlined by arrows. There
is a small pseudogestational sac in
the endometrial cavity.
(Reproduced by permission of the
University of Florida.)
The interstitial part of the fallopian tube is the
proximal portion that lies within the muscular wall
of the uterus. It is 0.7 mm wide and approximately
1–2 cm long, with a slightly tortuous course,
extending obliquely upward and outward from the
uterine cavity. Pregnancies implanted in this site are
called interstitial (cornual) pregnancies.2 They pose
a significant diagnostic and therapeutic challenge
and carry a greater maternal mortality risk than
ampullary ectopic pregnancy. Because of
The Obstetrician & Gynaecologist
myometrial distensibility, they tend to present
relatively late, at 7–12 weeks of gestation.
Significant maternal haemorrhage leading to
hypovolaemia and shock can rapidly result from
cornual rupture.
Diagnosis
Clinically, risk factors are as for other types of
ectopic pregnancy: contralateral salpingectomy,
previous ectopic pregnancy and in vitro
fertilisation.2 Because of its location, early diagnosis
of cornual pregnancy has historically been difficult.
The eccentric position of the gestational sac and
thinning of the myometrial mantle means that
differentiation between eccentric intrauterine and
cornual pregnancy is often difficult.3 The rate of
diagnosis can be improved, however, with
transabdominal or transvaginal ultrasound
(Figure 1), using three criteria:
1. an empty uterus;
2. a gestational sac seen separately and <1 cm from
the most lateral edge of the uterine cavity and;
3. a thin myometrial layer surrounding the sac.4
The gestational sac is usually in the lateral portion
of the uterus early in gestation but in advanced
cornual pregnancy it can be located above the
uterine fundus and can be confused with an
eccentric intrauterine pregnancy. This is referred to
as the ‘interstitial line’ sign.5 A thin echogenic line
extends directly up to the centre of the cornual
gestational sac: this represents either the
endometrial cavity or the interstitial portion of the
fallopian tube, depending on the size of the cornual
pregnancy (Figure 2).
Care must be exercised to avoid misinterpreting a
normal intrauterine pregnancy in an anomalous
(bicornuate or septate) uterus as a cornual
pregnancy. With 2-dimensional scanning in a
sagittal plane, the endometrial cavity will appear
shorter and then longer for a bicornuate uterus but
will remain the same length for cornual ectopic
pregnancy. It is also important to count the number
of corpora lutea. Heterotopic pregnancy is not
possible when there is a single corpus luteum.
Asymmetrically increased low-resistance flow in a
uterine cornu can also be a secondary sign of
cornual pregnancy.
Features that are helpful with the use of 3dimensional TVS include a live embryo in a
gestational sac, surrounded by myometrium below
the cornu lying outside the endometrium.6
One study7 has shown that early diagnosis of
cornual pregnancy with TVS allows for firsttrimester conservative management with
methotrexate. If the diagnosis is made later in
gestation, however, surgical treatment with
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cornual resection, or even hysterectomy, may be
required.
Tulandi et al.2 reviewed the management of 32
reported cases of cornual pregnancy. Ultrasound
revealed an ectopic cornual gestational sac in 40.6%
of the women and a hyperechoic mass in the
cornual region in another 25%. The diagnosis was
established in 71.4% of the 32 women. A sensitivity
of 80% and specificity of 99% have been reported.
Four-dimensional volume contrast imaging with
coronal-plane technology provides scan planes
inaccessible by conventional 2-dimensional
scanning, with enhanced tissue-contrast resolution
in the region of interest. This new ultrasound
technique, although not yet widely available, has
the potential to provide a more accurate image,
particularly when 2-dimensional TVS fails to
differentiate between cornual and angular
pregnancy.8 In angular pregnancy the embryo is
implanted in the lateral angle of the uterine cavity,
medial to the uterotubal junction and round
ligament. Angular pregnancy must be distinguished
from cornual pregnancy, in which the embryo is
implanted lateral to the round ligament.
Another diagnostic aid is laparoscopy, which has the
advantage of allowing both diagnosis and treatment.
Petersen et al.9 reported a case of uterine cornual
rupture following attempted mid-trimester
induced abortion for (presumed) intrauterine
pregnancy. They stated that physicians should
consider ectopic pregnancy when attempts at
induced abortion do not succeed. Similarly, the
CEMACH report (1994–96)10 supplied details of
maternal death from a ruptured cornual pregnancy
at 9 weeks of gestation. The woman underwent
suction curettage for termination of pregnancy
twice. With improved ultrasound facilities,
combined with clinical expertise, these cases of
missed or delayed diagnosis should become less
frequent.
Treatment
Traditionally, the treatment of cornual pregnancy
has been hysterectomy or cornual resection at
laparotomy. As all surgical management has been
associated with morbidity and unfavourable effects
on fertility, more conservative approaches have
been introduced into clinical practice. Medical
treatment (as with other types of tubal pregnancy)
has been introduced with generally satisfactory
results. See Box 1.
2007;9:249–255
Review
operations such as hysterectomy. Radical surgery is
necessary in cases where haemorrhage is lifethreatening.11 Surgical treatment involving
resection of the involved cornual region is
associated with decreased fertility rates and
increased rates of uterine rupture in future
pregnancies.12
Because of the abundant blood supply in the
cornual region from both uterine and ovarian
vessels, rupture occurring after 12 weeks of
gestation often leads to severe haemorrhage and
even death. Laparotomy used to be the preferred
approach for treatment of ruptured cornual
pregnancy, especially when it happens in advanced
gestation (Table 1).9,15,19–22 Khawaja et al.21 reported a
unique method of management for ruptured
cornual gestation, using uterine artery ligation to
conserve the uterus. The authors suggested that
ipsilateral uterine artery ligation should be
performed before attempting to repair a ruptured
uterine cornu. This will help to achieve haemostasis
and allow time to repair the cornu.
Laparoscopic techniques
In general, laparoscopic techniques involve cornual
resection, cornuostomy, salpingostomy or
salpingectomy. Even in women with ectopic
pregnancy with a significant haemoperitoneum,
laparoscopic surgery has been safely conducted by
experienced laparoscopists, with intraoperative
autologous blood transfusion if haemodynamic
stability is achieved by perioperative
management.11,23
Initial laparoscopic procedures involved loss of
tubal continuity by cornual excision. Hill et al.23
described a woman who presented at 10 weeks of
gestation with a large unruptured cornual
Surgical
Laparotomy
•
Hysterectomy
•
Cornual resection
•
Uterine artery ligation and repair of ruptured uterine cornu
Box 1
Treatment summary
Laparoscopic procedures
•
Cornual resection
•
Salpingostomy
•
Cornual resection and salpingectomy
•
Endoloop® and encircling suture25
Hysteroscopic procedures
•
Hysteroscopic endometrial resection under laparoscopic
control
•
Hysteroscopic cornual evacuation aided by polyp forceps
under ultrasound (USS) or laparoscopic guidance
Medical
Surgical treatment
Surgical treatment consists of conservative
techniques, such as laparoscopic cornual resection,
laparoscopic cornuostomy or hysteroscopic
removal of interstitial ectopic tissue, and radical
© 2007 Royal College of Obstetricians and Gynaecologists
Systemic methotrexate
USS guided methotrexate
Laparoscopic guided methotrexate/potassium chloride
Systemic methotrexate followed by selective uterine artery
embolisation46
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pregnancy. After placing an Endoloop® (Ethicon
Endosurgery, Edinburgh, UK) around the cornu,
the authors were able to evacuate the pregnancy
using unipolar current and blunt dissection. Both
Tulandi et al.24 and Reich et al.25 used laparoscopic
cornual excision to manage cornual pregnancy.
Cornual excision has also been useful for the
treatment of ruptured cornual pregnancy.13
Trends toward less extensive laparoscopic
procedures are evident in further case reports
using cornuostomy (Table 2).26,27 Most authors
agree that the size of cornual gestation determines
the best laparoscopic approach. Tulandi24
reported that salpingostomy is appropriate for
gestations of <3.5 cm, whereas cornual excision
was recommended by Grobman et al.29 for
gestations of >4 cm. In an uncontrolled
retrospective study, Moon et al.32 reported that
‘The endoloop method and the encircling suture
method are simple, safe, effective, and nearly
bloodless’. There were no uterine ruptures in the
pregnancies following these methods of
endoscopic management.
Table 1
Outcome of ruptured cornual
pregnancy
Study
Reich et al. (1990)13
Petersen et al. (1992)9
14
Idama et al. (1999)
Treatment
approach
18
Laparoscopy
Laparotomy
30
Laparotomy
15
30
Laparotomy
16
12
Laparoscopy
Hussain et al. (2003)
Sergent et al. (2003)
Gestation
(weeks)
17
Laparoscopy
17
Laparoscopy
Chan et al. (2003)
Chan et al. (2003)
18
Faraj (2004)
12
Laparotomy
7
Laparoscopy
Brewer et al. (2005)
Attia et al. (2005)20
28
17
Laparotomy
Laparotomy
Khawaja et al. (2005)21
Takeda et al. (2006)22
NA
Laparotomy
Laparoscopy
11
Grimbizis et al. (2004)
19
A laparoscopic approach should only be attempted
if the surgeon is skilled in laparoscopic techniques
and has the ability to convert the operation quickly
to a laparotomy.29 If these conditions are met,
laparoscopy provides several advantages over
laparotomy: fewer postoperative hospital days, a
faster return to normal activity and decreased
healthcare costs. In many centres laparoscopic
surgery alone is quicker than laparoscopy followed
by laparotomy. However, in general, laparoscopic
surgery requires more overall theatre time because
of the need to set up the equipment.
Hysteroscopic management
The rationale behind this approach is to avoid
more extensive surgery. It can be particularly
suitable for women who are reluctant to undergo
medical treatment with methotrexate or in
whom this treatment fails or is unavailable.33
Minelli et al.34 stated that, in expert hands, resection
of the cornual endometrium, including the tubal
ostium, can be successfully performed without
perforation of the uterus. The authors concluded
Procedure
Comments
Cornual excision
Cornual resection
and salpingectomy
Cornual incision and
delivery of baby
Cornual resection and
uterine repair
Cornual excision with
automatic stapler
Cornuostomy and
removal of POC
Cornual resection and
uterine repair
Cornual resection and
uterine repair
Cornual resection and
salpingectomy
Hysterectomy
Cornual resection and
uterine repair
Uterine artery ligation
Cornual excision
Misdiagnosis/
induced abortion
Alive baby/
primigravida/no risk
Alive baby,
birthweight 1 kg
IVF, heterotopic,
alive twin
Alive baby
IVF = in vitro fertilisation; NA = not available; POC = products of conception
Table 2
Summary of reported cases of
laparoscopic treatment of cornual
pregnancy
Study
Reich et al. (1988)25
Hill et al. (1989)23
Reich et al. (1990)13
Tulandi et al. (1995)24
Pasic and Wolfe (1990)26
Gleicher et al. (1994)27
Pansky et al. (1995)28
Grobman et al. (1998)29
Takeda et al. (2006)22
Coric et al. (2004)30
Grimbizis et al. (2004)11
Bremner et al. (2000)31
Operation
Cornual excision
Cornual excision
Cornual excision
Salpingostomy
Cornual excision
Cornual excision
Cornual excision
Cornual excision
Cornual excision
Salpingotomy
Salpingostomy
Salpingostomy
Salpingostomy
Salpingostomy
Salpingotomy
Cornual excision
Cornual resection
Cornual resection and
salpingectomy
Salpingotomy
hCG
(mIU/ml)
Diameter
(cm)
Rupture
Estimated
GA in weeks
Vasopressin
NA
NA
NA
NA
16 300
6000
14 500
12 000
4700
8000
4400
7704
3000
2600
32 827
NA
NA
821
NA
NA
NA
NA
NA
3
4
5
5
4
2
0
NA
NA
4.5
NA
NA
2
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
14 (calcified)
NA
NA
10
NA
6
NA
10
6
6
6
NA
7
9
7
NA
NA
7 (50 days)
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
NA
6
No
14
No
GA = gestational age; NA = not available
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that operating interstitially was safe because the
resection was performed under laparoscopic control.
A search of the literature revealed three cases of
cornual pregnancy managed using a hysteroscopic
approach. In one case,35 the products of conception
were removed with forceps using an operating
hysteroscope under laparoscopic guidance. In the
second case,36 the sac was perforated under
hysteroscopic control and the products of
conception removed with polyp forceps under
sonographic guidance. This procedure was done
following the failure of systemic methotrexate. The
third case33 used a combination of all three
modalities of hysteroscopy, laparoscopy and
ultrasound. The management here consisted of
identifying and perforating the sac under
hysteroscopic control and injecting dilute
vasopressin solution into the uterine cornu around
the pregnancy through a laparoscopic accessory
port to reduce the risk of haemorrhage. To
minimise the possibility of leaving retained
products of conception in the cornu, a
laparoscopically controlled suction evacuation of
the pregnancy was performed. A flexible suction
cannula was inserted under ultrasound control and
the pregnancy aspirated under direct laparoscopic
vision to prevent perforation.
Medical treatment
See Box 2. Systemic methotrexate is a safe and highly
effective treatment for cornual pregnancy. Surgery
can be avoided in the majority of women. Early
recognition of the cornual pregnancy is essential.
In a prospective observational study7 at St George’s
Hospital Medical School in London, 17 out of 20
women with cornual pregnancy were treated with
single-dose intramuscular methotrexate, which was
administered on day 0. A second dose of
methotrexate was given if the human chorionic
gonadotrophin (hCG) levels had not fallen by 15%
between days 4 and 7. Sixteen (94%) were treated
successfully, including all of the 4 cases with fetal
heart activity present. A second methotrexate dose
was given to 6 women.
Many studies have focused on the use of local
injection of methotrexate into the interstitial
gestation, either transvaginally or laparoscopically,
and both provide highly effective methods of
administration. One of the arguments for the local
administration of methotrexate has been its
favourable side-effect profile. However, this has
been based on comparisons with multiple systemic
dose regimes. The effectiveness of single-dose
systemic methotrexate and, more importantly, its
side-effect profile, was demonstrated by Stovall and
Ling37 in the treatment of tubal gestations. Of
120 women receiving single-dose systemic
methotrexate, side effects were virtually eliminated,
© 2007 Royal College of Obstetricians and Gynaecologists
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•
Haemodynamic stability is an essential prerequisite for
medical management.
•
There should be no signs of rupture.
•
The woman should be well motivated to attend for regular
(perhaps prolonged) follow-up.
•
There should be no medical contraindications to
methotrexate.
•
The initial level of hCG may predict the need for a second
dose of methotrexate.
•
Single-dose methotrexate is not associated with toxicity
and folinic acid rescue is not needed.
Review
Box 2
Key points for medical treatment
while the efficacy was equal to that of multiple
systemic dose regimes. The systemic route of
administration offers advantages over local
injection of the ectopic gestation in that it is less
invasive and not operator dependent. Follow-up
may need to be prolonged after medical treatment
of cornual pregnancy, as initial hCG values tend to
be higher than those encountered with tubal
ectopic pregnancy.
The Royal College of Obstetricians and
Gynaecologists recommends38 that the women with
tubal pregnancy who are most suitable for
methotrexate therapy are those with a serum hCG
level of <3000 iu/l and with minimal symptoms. In
the previously discussed series, all women with
cornual pregnancy presenting with initial hCG
values of <5000 iu/l were treated successfully with
single-dose methotrexate, but almost all women
with an initial hCG of >5000 iu/l required two
doses. These data help with counselling women
regarding the likelihood of needing a second dose
of methotrexate to achieve a successful outcome.
Alternatively, this latter group may benefit from
alternative dose strategies from the outset or from
local administration of methotrexate.
In those cases with higher hCG values there is
controversy over whether inpatient or outpatient
follow-up should be used. The latter is suitable in a
dedicated early pregnancy unit with clear guidelines
and open access for admission when indicated.
Methotrexate has been given by intramuscular
injection in most studies in the literature. However,
the intravenous route has also been used successfully.39
Medical treatment is not free of complications: it
can be associated with uterine rupture and
catastrophic haemorrhage. A large ectopic
pregnancy and the presence of a heartbeat are
relative contraindications to medical treatment.
Ultrasound- or laparoscopic-guided medical
treatment
The main advantages of local injection of
methotrexate include smaller drug dosage, fewer
systemic side effects and higher tissue
concentration. Many types of unruptured live
ectopic pregnancy can be successfully managed
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without surgical intervention through TVSguided local injection of potassium chloride or
methotrexate. In a series of consecutive cases (4 of
cornual pregnancy out of a total of 18 different
ectopic sites), Monteagudo et al.40 described
immediate cessation of fetal cardiac activity with
potassium chloride or methotrexate injection.
The mean initial hCG level was 33 412 iu/l. There
was no difference in time to resolution of the
ectopic pregnancies between those treated with
potassium chloride and those treated with
methotrexate. The same group reported a 100%
success rate. They used a TVS-guided route of
local methotrexate injection by traversing the
myometrium and approaching the gestational sac
from the medial aspect, a technique that may
enable the wider use of this treatment modality
by lowering the complication rate caused by
bleeding at the puncture site if the lateral
approach is used.41
Heterotopic pregnancy remains an indication for
local injection of potassium chloride.7 Both
transvaginal and transabdominal ultrasound can
be used for guided medical treatment. This ablates
the ectopic pregnancy, permitting normal
continuation of a concomitant intrauterine
pregnancy and preserving the uterus for
subsequent pregnancies.42
Many studies43,44 have reported the use of
laparoscopy for local methotrexate injection into a
cornual pregnancy. Onderoglu et al.44 reported the
successful management of a cornual pregnancy
with a single high-dose laparoscopic methotrexate
injection (100 mg). Considering the rarity of
cornual pregnancy, a comparative study between
systemic and laparoscopic methotrexate would be
difficult. The best medical treatment regimen,
therefore, remains unknown.
Further non-surgical interventions after medical
treatment have been advocated to abolish or
minimise any risk of bleeding or rupture. Selective
uterine artery embolisation associated with
methotrexate (or after methotrexate failure) can be
used successfully in treating selected cases of early
cornual pregnancy.45 This procedure, combined
with methotrexate, could reduce haemorrhagic risk.
Expectant management
Few reports in the literature contemplate this
approach, although Kok-Min Seow et al.46 reported
a case of cornual pregnancy followed up by serial
transvaginal colour power Doppler angiography
and serum beta-hCG levels.
In contrast with other types of ectopic pregnancy,
this management is out of favour with most
authorities. The high risk of complications, which
include uterine rupture and massive internal
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bleeding, make expectant management an unsafe
approach.
Future pregnancy
One of the concerns of future pregnancy is rupture of
the interstitial portion of the tube (uterine rupture).
The postulated mechanism is through a defective
area of uterine wall.47
Uterine rupture was described at 20 weeks of
gestation in a woman who had cornual pregnancy
treated by salpingectomy and at 24 weeks in
another after spontaneous resolution of the
interstitial pregnancy.48,49 Some authorities,
therefore, suggest suturing the uterine wall after
surgical management to reinforce the defective area
in the uterine wall. Term deliveries have, however,
been reported following laparoscopic treatment of
cornual pregnancy without reinforcing sutures.27,32
If myomectomy (open or laparoscopic) is
performed, suturing the uterine wound may not
prevent uterine rupture in subsequent pregnancy.50
There is general agreement that suturing the uterine
wall should be performed in cases where the cornual
pregnancy sac extends into the endometrial cavity.
Long-term follow-up studies of women without
endometrial cavity involvement treated by
laparoscopic surgery may reveal the optimum way to
manage the uterine wound after cornual resection and
cornuostomy. Most authors are agreed that caesarean
section should be the optimum mode of delivery for
all pregnancies following cornual pregnancy.11
The second concern after conservative
management of cornual pregnancy is recurrence of
ectopic pregnancy, particularly cornual pregnancy
on the same side. This risk continues even after a
good anatomical result (whether assessed by
hysterosalpingography or direct laparoscopic
visualisation) following laparoscopic conservative
surgery.27
Tubal pathology is often the primary factor blamed
for recurrence. Weiden and Karsdorp51 reported a
case of recurrence after previous heterotopic
pregnancy in which the cornual pregnancy was
treated by selective feticide. Tubal pathology,
together with assisted conception and non-invasive
management of cornual pregnancy, have been
shown to contribute to a higher risk of recurrence
of cornual pregnancy.51 Wittich52 reported an
association of recurrent ectopic pregnancy with
uterine fibroids. In general, the available literature
provides conflicting guidance as to appropriate
counselling regarding future pregnancy risks and
optimum mode of delivery.
Conclusion
Cornual pregnancy poses a significant diagnostic
and therapeutic challenge and carries a greater
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maternal mortality risk than tubal pregnancy.
Transvaginal sonography can be helpful but often is
not conclusive. Early clinical diagnosis aided by
ultrasound or laparoscopy may help to contribute
towards effective conservative management. The
serious consequences of cornual pregnancy are
caused mainly by rupture after 12 weeks of
pregnancy, leading to catastrophic haemorrhage
and even death. Cornual excision or hysterectomy
used to be the traditional treatment for such cases.
Conservative management has, however, been
increasingly practised successfully. This includes
laparoscopic conservative treatment and medical
treatment with systemic methotrexate.
Sonographically guided, minimally invasive
treatment can be a safe and effective alternative to
surgical and systemic medical therapy. Appropriate
individual counselling is needed regarding risks of
future pregnancy and mode of delivery.
References
1 Confidential Enquiry into Maternal and Child Health. Why Mothers Die
2000–2002. The Sixth Report of the Confidential Enquiries into Maternal
Deaths in the United Kingdom. London: RCOG Press; 2004.
2 Tulandi T, Al-Jaroudi D. Interstitial pregnancy: results generated from the
Society of Reproductive Surgeons Registry. Obstet Gynecol
2004;103:47–50.
3 Auslender R, Arodi J, Pascal B, Abramovici H. Interstitial pregnancy: early
diagnosis by ultrasonography. Am J Obstet Gynecol 1983;146:717–8.
[PubMed 6683469]
4 Timor-Tritsch IE, Monteagudo A, Matera C, Veit CR. Sonographic evolution
of cornual pregnancies treated without surgery. Obstet Gynecol
1992;79:1044–9. [PubMed 1579304]
5 Johnson PT, Shah C. Ectopic pregnancy — role of ultrasound.
[www.sonoworld.com/Article/ShowArticleDetails.aspx?aid=28].
6 Lee GS, Hur SY, Kown I, Shin JC, Kim SP, Kim SJ. Diagnosis of early
intramural ectopic pregnancy. J Clin Ultrasound 2005;33:190–2.
doi:10.1002/jcu.20107
7 Jermy K, Thomas J, Doo A, Bourne T. The conservative management of
interstitial pregnancy. BJOG 2004;111:1283–8.
doi:10.1111/j.1471-0528.2004.00442.x
8 Chou MM, Tseng JJ, Yi YC, Chen WC, Ho ES. Diagnosis of an interstitial
pregnancy with 4-dimensional volume contrast imaging. Am J Obstet
Gynecol 2005;193:1551–3. doi:10.1016/j.ajog.2005.02.088
9 Petersen KR, Larsen GK, Nørring K, Jensen FR. Misdiagnosis of interstitial
pregnancy followed by uterine cornual rupture during induced
midtrimester abortion. Acta Obstet Gynecol Scand 1992;71:316–8.
10 Department of Health. Report on Confidential Enquiries into Maternal
Deaths in the United Kingdom, 1994–1996. London: The Stationery
Office; 1998.
11 Grimbizis GF, Tsalikis T, Mikos T, Zepiridis L, Athanasiadis A, Tarlatzis BC,
Bontis JN. Case report: laparoscopic treatment of a ruptured interstitial
pregnancy. Reprod Biomed Online 2004;9:447–51. [PubMed 15511347]
12 Ross R, Lindheim SR, Olive DL, Pritts EA. Cornual gestation: a systematic
literature review and two case reports of a novel treatment regimen. J
Minim Invasive Gynecol 2006;13:74–8. doi:10.1016/j.jmig.2005.11.005
13 Reich H, McGlynn F, Budin R, et al. Laparoscopic treatment of ruptured
interstitial pregnancy. J Gynecol Surg 1990;6:135–8.
14 Idama TO, Tuck CS, Ivory C, Ellerington MC, Travis S. Survival of cornual
(interstitial) pregnancy. Eur J Obstet Gynecol Reprod Biol 1999;84:103–5.
15 Hussain M, Yasmeen H, Noorani K. Ruptured cornual pregnancy. J Coll
Phys Surg Pak 2003;13:665–6.
16 Sergent F, Le Cornec JB, Meilhaud MF, Marpeau L. [Laparoscopic cornual
excision with an automatic stapler for ruptured interstitial pregnancies.]
[Article in French.] J Gynecol Obstet Biol Reprod (Paris)
2003;32:426–30. [Pubmed 13130245]
17 Chan LY, Yuen PM. Successful treatment of ruptured interstitial pregnancy
with laparoscopic surgery. A report of 2 cases. J Reprod Med
2003;48:569–71. [PubMed 12953336]
18 Bhat SM, Hamdi IM, Faraj RA. Twin intrauterine and cornual gestation in a
case of triplet pregnancy. Saudi Med J 2004;25:1704–6.
[PubMed 15573207]
19 Brewer H, Gefroh S, Munkarah A, Hawkins R, Redman ME. Asymptomatic
uterine rupture of a cornual pregnancy in the third trimester: a case report.
J Reprod Med 2005;50:715–8. [PubMed 16363761]
20 Attia M, Karuppaswamy J, Griffith H. Management of interstitial (cornual)
pregnancy at 17 weeks’ gestation: conservation of a ruptured uterus. J
Obstet Gynaecol 2005;25:722–3. doi:10.1080/01443610500307391
21 Khawaja N, Walsh T, Gill B. Uterine artery ligation for the management of
ruptured cornual ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol
2005;118:269.
© 2007 Royal College of Obstetricians and Gynaecologists
2007;9:249–255
Review
22 Takeda A, Manabe S, Mitsui T, Nakamura H. Management of patients with
ectopic pregnancy with massive hemoperitoneum by laparoscopic
surgery with intraoperative autologous blood transfusion. J Minim
Invasive Gynecol 2006;13:43–8. doi:10.1016/j.jmig.2005.09.100
23 Hill GA, Segars JH, Herbert CA. Laparoscopic management of interstitial
pregnancy. J Gynecol Surg 1989;5:209–12.
24 Tulandi T, Vilos G, Gomel V. Laparoscopic treatment of interstitial
pregnancy. Obstet Gynecol 1995;85:465–7.
25 Reich H, Johns DA, DeCaprio J, et al. Laparoscopic treatment of one
hundred and nine consecutive ectopic pregnancies. J Reprod Med
1988;33:885–90.
26 Pasic R, Wolfe WM. Laparoscopic diagnosis and treatment of interstitial
ectopic pregnancy: a case report. Am J Obstet Gynecol
1990;163:587–8. [PubMed 2143628]
27 Gleicher N, Karande V, Rabin D, et al. Laparoscopic removal of twin
cornual pregnancy after in vitro fertilization. Fertil Steril 1994;61:1161–2.
[PubMed 8194635]
28 Pansky M, Bukovsky I, Golan A, Raziel A, Caspi E. Conservative
management of interstitial pregnancy using operative laparoscopy. Surg
Endosc 1995;9:515–6. doi:10.1007/BF00206839
29 Grobman WA, MP Milad. Conservative laparoscopic management of a
large cornual ectopic pregnancy. Hum Reprod 1998;13:2002–4.
30 Corić M, Barisić D, Strelec M. Laparoscopic approach to interstitial
pregnancy. Arch Gynecol Obstet 2004;270:287–9.
31 BremnerT, Cela V, Luciano AA. Surgical management of interstitial
pregnancy. J Am Assoc Gynecol Laparosc 2000;7:387–9.
32 Moon HS, Choi YJ, Park YH, Kim SG. New simple endoscopic operations
for interstitial pregnancies. Am J Obstet Gynecol 2000;182:114–21.
[PubMed 10649165]
33 Pal B, Akinfenwa O, Kevin H. Hysteroscopic management of cornual
ectopic pregnancy. BJOG 2003;110:879–80.
34 Minelli L, Landi S, Trivella G, Fiaccavento A, Barbieri F. Cornual pregnancy
successfully treated by suction curettage and operative hysteroscopy.
BJOG 2003;110:1132–4. doi:10.1111/j.1471-0528.2003.03088.x
35 Meyer WR, Mitchell DE. Hysteroscopic removal of an interstitial ectopic
gestation. A case report. J Reprod Med 1989;34:928–9.
[PubMed 2685291]
36 Sanz LE, Verosko J. Hysteroscopic management of cornual ectopic
pregnancy. Obstet Gynecol 2002;99:941–4. [PubMed 11975968]
37 Stovall TG, Ling FW. Single dose methotrexate: an expanded clinical trial.
Am J Obstet Gynecol 1993;168:1759–65. [PubMed 8317518]
38 Royal College of Obstetricians and Gynaecologists. The Management of
Tubal Pregnancy. Green Top Guideline No. 21. London: RCOG; May
2004 [www.rcog.org.uk/index.asp?PageID=537].
39 Al-Khan A, Jones R, Fricchione D, Apuzzio J. Intravenous methotrexate for
treatment of interstitial pregnancy: a case report. J Reprod Med
2004;49:121–2. [PubMed 15018441]
40 Monteagudo A, MiniorVK, Stephenson C, Monda S, Timor-Tritsch IE. Nonsurgical management of live ectopic pregnancy with ultrasound-guided
local injection: a case series. Ultrasound Obstet Gynecol
2005;25:282–8. doi:10.1002/uog.1822
41 Timor-Tritsch IE. Monteagudo A, Lerner JP. A ‘potentially safer’ route for
puncture and injection of cornual ectopic pregnancies. Ultrasound
Obstet Gynecol 1997;7:353–5. doi:10.1046/j.14690705.1996.07050353.x
42 Doubilet PM, Benson CB, Frates MC, Ginsburg E. Sonographically guided
minimally invasive treatment of unusual ectopic pregnancies. J
Ultrasound Med 2004;23:359–70. [PubMed 15055783]
43 Benifla JL, Fernandez H, Sebban E, Darai E, Frydman R, Madelenat P.
Alternative to surgery of treatment of unruptured interstitial pregnancy:
15 cases of medical treatment. Eur J Obstet Gynecol Reprod Biol
1996;70:151–6.
44 Onderoglu LS, Salman MC, Ozyuncu O, Bozdag G. Successful
management of a cornual pregnancy with a single high-dose
laparoscopic methotrexate injection. Gynecol Surg 2006;3:31–3.
doi:10.1007/s10397-005-0159-8
45 Deruelle P, Lucot JP, Lions C, Robert Y. Management of interstitial
pregnancy using selective uterine artery embolization. Obstet Gynecol
2006;107:427–8.
46 Kok-Min S, Bin-Chwen Hsieh YL-A, Tsai L-W, Huang L-W, Hwang J-L.
Expectant management of a cornual pregnancy followed up by serial
transvaginal color power Doppler angiography and serum beta human
chorionic gonadotropin levels. Acta Obstet Gynecol Scand
2004;83:1221. doi:10.1111/j.0001-6349.2004.0133c.x
47 Lau S, Tulandi T. Conservative medical and surgical management of
interstitial ectopic pregnancy. Fertil Steril 1999;72:207–15.
[PubMed 10438980]
48 Weissman A, Fishman A. Uterine rupture following conservative surgery
for interstitial pregnancy. Eur J Obstet Gynecol Reprod Biol 1992;44:
237–9.
49 Downey GP, Tuck S. Spontaneous uterine rupture during subsequent
pregnancy following non-excision of an interstitial ectopic gestation.
Br J Obstet Gynaecol 1994;101:162–3. [PubMed 7864910]
50 Dubuisso JB, Fauconnier A, Babaki-Fard K, Chapron C. Laparoscopic
myomectomy: a current view. Hum Reprod Update 2000;6:588–94.
[PubMed 11129692]
51 van der Weiden RM, Karsdorp VH. Recurrent cornual pregnancy after
heterotopic cornual pregnancy successfully treated with systemic
methotrexate. Arch Gynecol Obstet 2005;273:180–1.
52 Wittich AC. Recurrent cornual ectopic pregnancy in a patient with
leiomyomata uteri. J Am Osteopath Assoc 1998;98:332–3.
255