Case reportA 36 year old Italian woman, gravida 3, para 0, was admitted seven weeks after her last menstrual period because a transvaginal ultrasound examination had showed a gestation sac with yolk sac and fetal pole lateral to the endometrial stripe, raising suspicion of a right cornual pregnancy ( Fig. 1). Both ovaries appeared normal and there were no adnexal masses or free fluid in the cul de sac. The plasma h-hCG level was 9237 mIU/mL and general physical examination was normal. She had previously suffered two ectopic pregnancies in the right fallopian tube, which had both been treated by intravenous methotrexate. A subsequent diagnostic laparoscopy and hysteroscopy had documented a normal uterus and adnexa, and a hysterosalpingogram had confirmed bilateral tubal patency.After three days of expectant management, the plasma h-hCG level was 14,934 mIU/mL and fetal cardiac activity was detected by sonography. By day 10 from admission, the plasma h-hCG level had risen to 48,944 mIU/mL, with normal vital signs and an unremarkable physical examination. A transvaginal sonogram revealed a 2.7 mm thick myometrium surrounding the gestational sac. At this point, in the eighth week of pregnancy, the treatment options were reviewed and active surgical treatment was tried.Under general anaesthesia, diagnostic hysteroscopy confirmed the diagnosis (Fig. 2). A single-toothed Braun volsellum was applied to the cervix and gentle traction was exerted to align the uterus. The cervix was dilated by Hegar dilators and the pregnancy was removed via a vacuum curette rotated carefully within the cavity in a downward spiral motion. Remaining gestational debris was removed using the Stortz hysteroscopic resectoscope under laparoscopic and ultrasound control (Fig. 3). Sorbitol/ mannitol solution was used as distention medium, using a pressure cuff inflated to 100 mmHg. During the 20-minute procedure, total fluid input was 2500 mL and output was 2400 mL. The Erbe electrosurgical generator (ICC 350 E, Erbe Elektromedizin, Tubingen, Germany) was used on a setting of 90 W cut and 70 W coagulation. The entire right cornual endometrium was resected. Bleeding vessels were coagulated with the rollerball. Vaginal bleeding was minimal at the end of the procedure. Laparoscopy showed an enlarged, mobile uterus with a distorted right cornual region. Both tubes and ovaries appeared normal and no blood was present in the pouch of Douglas. Given the normal aspect of the left tube and her obstetric history, a right laparoscopic salpingectomy was performed to prevent further ectopic pregnancies. The estimated blood loss was less than 100 cc. The patient had an unremarkable post-operative course and was discharged after two days when transvaginal ultrasound showed a normal uterine cavity and the plasma h-hCG level had dropped to 7427 mIU/mL. The pathology report confirmed a cornual pregnancy. At both one and three month visits, the patient was well and no signs of the previous cornual pregnancy were detectable both by sonography and by hysteroscopy.
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