Case Report: Spontaneous cornual Pregnancy at 7 Weeks: A Gynecological challenge

Case

Herein, we describe the case of a 35-year-old Caucasian female who presented to the Department of Obstetrics and Gynecology with significant vaginal bleeding and severe pelvic pain, suggestive of a potential EP. Her medical history revealed 12 weeks of amenorrhea, no use of contraception, a gravidity status of G3 P2A0, and a uterus with a single cesarean section scar. Additionally, she had a history of appendectomy. The patient is a non-smoker, has no risk-taking behavior, and works as a school teacher. Clinical examination revealed hypotension with a blood pressure of 110/60 mmHg, tachycardia at 110 bpm, and marked hypogastric tenderness. Quantitative β-HCG levels were elevated at 17,000 IU/L, raising suspicion of an abnormal pregnancy.

Endovaginal ultrasound played a critical role in the diagnostic process, demonstrating an unoccupied uterine cavity and a gestational sac positioned laterally on the right side, harboring an embryo with a crown-rump length indicative of 7 weeks of gestation, but with no detectable cardiac activity. The sac was notably eccentrically positioned, surrounded by a myometrial rim, and separated by more than 1 cm from the empty uterine cavity. Ultrasound imaging identified each ovary. Further examination revealed a 3.5 cm unruptured right CP (Figure 1).

Figure 1. (A): An empty uterine cavity; (B): A gestational sac located laterally on the right side, containing an embryo (white arrow).

Given the size and location of the EP, surgical management was pursued. A mini-laparotomy revealed a 5 cm unruptured CP on the right side, a critical finding that determined the course of treatment (Figure 2).

Figure 2. A 5 cm unruptured pregnancy located in the right cornua.

A cornuostomy, along with a right salpingectomy, was performed, achieving a definitive resolution of the condition (Figure 3).

Figure 3. The operative sample.

Discussion

Cornual pregnancy, a rare type of ectopic pregnancy, constitutes approximately 2% to 4% of all EP.^1,2 Despite its low incidence, it carries significant clinical risks, particularly due to its potential for uterine rupture and severe maternal morbidity.⁴ This condition arises from implantation in the cornua, where the fallopian tube meets the uterus leading to distinct diagnostic and treatment challenges. Risk Factors such as spontaneous miscarriages, prior elective abortions, sexually transmitted infections, and smoking can disrupt the normal structure or function of the fallopian tubes and uterus, thereby increasing the likelihood of ectopic implantation.⁵

Detecting CP early is often difficult, which heightens the risk of serious complications such as bleeding.⁶ Our case highlights the difficulty of early diagnosis, particularly because CP often mimics normal intrauterine pregnancies in the early stages. Ultrasound remains the primary diagnostic tool, with key indicators being an eccentrically located gestational sac surrounded by a myometrial rim and separated from the uterine cavity by more than 1 cm.^7,8 These ultrasound findings were crucial in our case, guiding the timely and appropriate intervention.

Managing this emergency necessitates a tailored strategy that considers several factors, including the patient’s hemodynamic stability, the gestational age of the pregnancy, future reproductive goals, and the surgeon’s level of expertise.⁸ Treatment options include a spectrum of approaches ranging from methotrexate injections to surgery. Methotrexate, a systemic chemotherapeutic agent, is commonly used in non-surgical management due to its ability to resolve ectopic pregnancies without invasive procedures, at a dose of 1 mg/kg.⁹ However, in cases like ours, where the gestational sac exceeds 40 mm or where rupture is imminent, surgical intervention is necessary to prevent catastrophic outcomes.¹⁰ In our case, a cornuostomy combined with salpingectomy was performed, achieving a definitive resolution of the condition.

Even if it’s rare, the chance of recurrence in CP is still a major concern. Recurrence can lead to more ectopic pregnancies or rupture of the uterus in subsequent gestations, posing significant dangers to maternal safety. Long-term follow-up and patient counseling are essential to monitor for potential complications and to manage future pregnancies safely.¹¹

This case emphasizes the importance of early detection and personalized management in CP. Imaging advancements and a better understanding of risk factors have improved the prognosis for patients suffering from this uncommon condition. Ongoing research is crucial to refining management strategies and improving prognosis, particularly in the areas of preserving fertility and decreasing the risk of recurrence.

Conclusion

In conclusion, CP although rare, poses significant risks due to its potential for rupture and associated maternal morbidity. This case highlights the critical importance of early detection and intervention to prevent life-threatening complications. Tailored management strategies based on patient-specific factors, including gestational age and future fertility goals, are essential. The successful resolution of this case through surgical intervention demonstrates the importance of maintaining a high level of vigilance and taking decisive action when managing similar situations. additional research and advancements in diagnostic strategies will be vital in enhancing patient outcomes and preserving fertility.

Consent

Written informed consent was obtained from the patient for the publication of their clinical details and/or images.