Molar cornual ectopic pregnancy

Abstract

Few cases of ectopic molar pregnancies have been reported. We present a rare case of molar cornual pregnancy. A 40-year-old woman, para 3 with last delivery 7 years back attended the Out Patient Department with complaints of irregular and excessive vaginal bleeding and pain in the lower abdomen for 3 months. This was not preceded by any history of amenorrhea. General condition was fair, pallor +1, pulse 84/min, and blood pressure 122/84 mmHg. Abdomen was soft on palpation. On pelvic examination, uterus was asymmetrically enlarged toward the left side corresponding to 12 weeks size. Sonography revealed a hyperechoic mass in the posterolateral wall of uterus with anechoic channels showing flow on color Doppler. The appendages were normal. A dilatation and curettage showed endometrium in proliferative phase. The patient was started on cyclical progesterone for 3 months but her symptoms did not regress. With a provisional diagnosis of fibroid uterus, a hysterectomy was planned. At laparotomy, uterus was asymmetrically enlarged more toward the left cornua. The enlarged part appeared to be soft cystic in consistency with increased vascularity. Both adnexae were normal. A total abdominal hysterectomy was carried out. On the cut section of the specimen, uterine cavity was found to be normal but the left cornual protuberance extruded grape-like vesicles (Figure 1). There was no placenta or fetus. Cut section of specimen. Serum β-HCG in the immediate postoperative period was found to be 2905 mIU/ml. Histopathology revealed a hypertrophied myometrium lined by secretary endometrium and a mass of hydatidiform mole at one cornu. Postoperative period was uneventful. Serum β-HCG was performed weekly, which reached normal level within 3 weeks. The incidence of ectopic pregnancy is 20 per 1000 pregnancies 1. Hydatidiform moles occur in 1 per 1000 pregnancies 2. Thus, the two occurring together is very rare. An ectopic pregnancy located in the cornual portion of the uterus occurs in only 2–4% of all ectopic pregnancies 3. Given the incidence stated above, the probability of a molar cornual pregnancy would be 0.04 or approximately 1.5 cases in one million pregnancies 4. Only one case of cornual ectopic molar pregnancy could be traced in literature 4. Typically, hydatidiform molar pregnancy presents with amenorrhea, first-trimester bleeding, hyperemesis, and uterine size greater than dates or non-detectable fetal heart tones. Ultrasound findings of multiple echogenic area within the uterine cavity with or without fetus are reliable in making the diagnosis of molar pregnancy 3. However, classic appearance of molar pregnancy on ultrasonography can be seen in less than half of the cases only 5. This was a case with atypical presentation in a 40-year-old woman, which eluded the diagnosis. Had there been a further delay in establishing the diagnosis, the complications of molar pregnancy could have been missed with fatal consequences.