Hysteroscopic management of cornual ectopic pregnancy

Abstract

A 32 year old woman attended the accident and emergency department with a two day complaint of vaginal bleeding and cramping lower abdominal pain, and a brown vaginal discharge since her last menstrual period which was 24 days prior to presentation. She had discontinued the combined oral contraceptive pill two months prior to her last menstrual period. Her urine pregnancy test (Guest Medical, UK) was positive. On abdominal examination, there was tenderness noted in the right iliac fossa. Vaginal examination revealed no cervical excitation but there was right adnexal tenderness. A transabdominal and transvaginal ultrasound scan (Diagnostic Sonar, multifrequency abdominal probe and 6.5 Hz transvaginal probe) revealed an empty uterus with an endometrial thickness of 11 mm. There was a right-sided ovarian cyst measuring 77 54 66 mm and a small amount of free fluid in the pouch of Douglas. Her serum h-hCG quantitative assay (Immulite 2000, immunoassay calibrated to WHO 3rd International Standard) at that point was 2830 IU/mL. A diagnostic laparoscopy was performed the following day to exclude an ectopic pregnancy. At laparoscopy, the finding of a right ovarian cyst was confirmed, with normal tubes, uterus and left ovary. A laparoscopic right ovarian cystectomy was performed as this was presumed to be the cause of her pain. A repeat h-hCG level the following day (48 hours after admission) was 3116 IU/mL. A repeat ultrasound scan two days later (four days after admission) showed what was presumed to be a viable intrauterine pregnancy, which was high within the uterine fundus. The possibility of a cornual pregnancy was raised. It was decided to rescan her in two weeks. A repeat ultrasound scan two weeks later revealed a left-sided cornual ectopic pregnancy, with a 25 mm gestational sac containing a 6 mm fetal pole. There was a large vascular signature from the surrounding decidual reaction, no fetal heart activity was seen and there was no free fluid in the pouch of Douglas. The serum h-hCG level at this stage was 15,208 IU/mL. Management options were discussed with the patient and she opted for surgical management. The following day, a laparoscopy and hysteroscopy were performed. The laparoscopy confirmed the diagnosis of a left-sided cornual ectopic pregnancy. A dilute solution of vasopressin (20 units in 20 mL of normal saline) was injected around the pregnancy. A hysteroscopy (5 mm, 30j forward angled scope) with normal saline showed a pregnancy beyond the left tubal ostium. The hysteroscope was advanced beyond the dilated left ostium and the sac was ruptured. The fetus was seen floating in the irrigation fluid. The hysteroscope was then withdrawn and a No. 6 flexible suction cannula (Rocket Medical, UK) inserted into the uterine cavity. Under transabdominal ultrasound guidance, the flexible suction cannula was advanced into the cornual gestation. Suction was then applied under direct laparoscopic control to ensure that the cannula did not perforate the uterine cornu. The suction evacuation yielded products of conception, which were sent for histology. There was minimal bleeding and the patient was kept in the hospital for observation. The serum h-hCG level fell to 1929 IU/mL by the third post-operative day. She recovered well and was discharged home. She was followed up in the Early Pregnancy Assessment Unit with weekly serum h-hCG levels, which fell gradually and became undetectable by five weeks following the operation. The histology confirmed products of conception.