Managing And Treating Cornual Pregnancies, UK

Main Category: Pregnancy / Obstetrics
Also Included In: Women's Health / Gynecology
Article Date: 01 Nov 2007 - 1:00 PDT


A new paper to be published in The Obstetrician & Gynaecologist ( TOG ) discusses the treatment of women with cornual (interstitial) pregnancies.

A cornual pregnancy is a rare type of ectopic pregnancy which occurs when the fertilised egg implants in that part of the fallopian tube buried deep in the wall of the uterus. Pregnancies of this kind are difficult to diagnose as they appear to be in the uterus on scan and are more dangerous than other forms of ectopic pregnancy as they tend to rupture later and with potentially devastating haemorrhage.

Cornual pregnancies are regarded as a medical emergency as severe maternal haemorrhage and shock can result during a cornual rupture. In the last Confidential Enquiry into Maternal and Child Health report, Why Mothers Die 2000 - 02 , four out of 11 deaths from ectopic pregnancies were a result of cornual rupture.

Doctors believe that the use of new ultrasound technologies, such as 4D imaging, may help to identify cornual pregnancies since the enhanced images pinpoint where the embryo is located.

The traditional treatment of a cornual pregnancy is to offer surgical removal (resection) of the cornual ectopic tissue but, as this is a highly vascular area, haemorrhage at surgery may necessitate hysterectomy. However, even where the uterus is conserved, there is an increased risk of uterine rupture in a future pregnancy. Gynaecologists and surgeons are looking at other ways to treat the condition.

Traditionally surgery has been performed by opening the abdomen to gain entry. However, laparoscopic procedures are increasingly being used. A laparoscope (a small telescopic instrument) is inserted into the body through an incision at the umbilicus with 2-4 additional tiny incisions being made in the lower abdomen to allow access with the surgical instruments. Authors advise that this laparoscopic approach is employed only if the surgeon is skilled in laparoscopic techniques, including emergency surgery. Results have been encouraging and include fewer postoperative days in hospital, a faster return to normal activity and decreased healthcare costs.

Alternatively, a combined hysteroscopic and laparascoic route has been used followed by the medical administration of methotrexate. This method minimises haemorrhage occurring after a cornual rupture and preserves the uterus for future pregnancies. Authors suggest this form of treatment is suitable in a dedicated early pregnancy unit with clear guidelines on treatment.

The authors add that for the different types of treatment, appropriate individual counselling is needed regarding the risk of future pregnancy and mode of delivery.

Dr Radwan Faraj, from the Department of Obstetrics and Gynaecology at the Royal Bolton Hospital, who co-authored the paper, said " Ectopic pregnancy remains a significant cause of morbidity and maternal death in women of childbearing age, despite advances in both diagnosis and therapy.

"Specifically, a cornual pregnancy is one of the most hazardous types of ectopic pregnancy - as the pregnancy whilst technically in the uterus, is actually in the wall of the uterus where it will eventually rupture with devastating consequences.

"Cornual ectopic pregnancy poses a significant diagnostic and therapeutic challenge.

"Historically, radical surgical treatment including hysterectomy was the gold standard treatment mainly due to late presentation with rupture. Currently, more conservative laparoscopic treatment and even medical treatment can be accomplished with great success and less unfavourable effects on future fertility."

Professor Neil McClure, TOG editor-in-chief said, "Ectopic pregnancy remains a significant cause of death in young women through rupture. An ectopic pregnancy requires quick, decisive action.

"A cornual ectopic pregnancy presents late and the consequences of rupture of the uterus are even more devastating than the more common rupture of the tube.

"Better tests for the diagnosis of ectopic pregnancy have facilitated the introduction of the newer and less invasive laparoscopic and medical approaches to the treatment of such ectopic pregnancies thus helping to preserve a woman's ability to have babies after this condition."

The Obstetrician & Gynaecologist ( TOG ) is published quarterly and is the Royal College of Obstetricans and Gynaecologists' (RCOG) medical journal for continuing professional development. TOG is an editorially independent, peer reviewed journal aimed at providing health professions with updated information about scientific, medical and clinical developments in the specialty of obstetrics and gynaecology.

Reference

Faraj R, Steel M. Management of cornual (interstitial) pregnancy. The Obstetrician & Gynaecologist 2007: 9 :249-255.

http://www.rcog.org.uk

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