|Year : 2022 | Volume
| Issue : 2 | Page : 118-121
Assistant Professor, Department of Community Health Nursing, College of Nursing, CMC, Vellore, Tamil Nadu, India
|Date of Submission||20-Jul-2021|
|Date of Decision||01-Dec-2022|
|Date of Acceptance||14-Dec-2022|
|Date of Web Publication||31-Dec-2022|
Mrs. Irene Dorathy
No. 21/5 Gandhi Street, Chenguttai, Katpadi, Vellore - 632 006, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Ectopic pregnancy is one of the major causes of maternal morbidity and mortality. Most ectopic pregnancies are diagnosed very late when mothers present with symptoms of rupture, and it can be fatal. Cornual pregnancy is a rare type of ectopic pregnancy where the gestational sac is implanted in the cornua of the uterus. It is more dangerous than other ectopic pregnancies, contributing to significant maternal mortality and morbidity. It is most often misdiagnosed or diagnosed late. Here is a case report of a patient who presented with recurrent cornual pregnancy and was managed appropriately and effectively at a tertiary hospital.
Keywords: Pregnancy, cornual pregnancy, ectopic pregnancy
|How to cite this article:|
Dorathy I. Cornual pregnancy. Indian J Cont Nsg Edn 2022;23:118-21
| Introduction|| |
An ectopic pregnancy is one outside the uterine cavity. The common site for ectopic pregnancy is the fallopian tubes. However, it is also found in other sites such as uterine Cornu, ovary, cervix, abdominal cavity and broad ligament. Although the incidence of ectopic pregnancy is only 4.62% of all pregnancies, it contributes to the increased morbidity and mortality.
The cornual pregnancy is 2%–4% of all ectopic pregnancies., It is more dangerous and life-threatening than the other types of ectopic pregnancy, causing increased mortality. The mortality rate due to cornual pregnancies is 2–5 times higher than other ectopic pregnancies. It is often misdiagnosed as it is difficult to differentiate from interstitial pregnancies.
| Case Report|| |
A 37-year-old woman married for 7 years presented with recurrent cornual pregnancies. Her menstrual cycles were regular. She had a bad obstetrical history with six spontaneous abortions treated with injection methotrexate and manual vacuum aspiration once.
The first time she was diagnosed with cornual pregnancy was when she presented with a history of spotting for 1 week at 8 + 4 weeks. She was managed conservatively with transvaginal ultrasound-guided aspiration of the gestational sac. Later after 2 years, she conceived spontaneously and had the scan done at 6 + 4 weeks which suggested a non-viable cornual pregnancy again at right Cornu. She underwent laparoscopic right cornual pregnancy excision and right salpingectomy, which was uneventful.
| Discussion|| |
Early diagnosis of ectopic pregnancy is crucial before it ruptures. Cornual pregnancy, a rare form of ectopic pregnancy, is tough to diagnose in the early weeks as it is mainly misdiagnosed and not seen clearly through ultrasonography.
In 1952, Johnston and Moir coined the term 'cornual pregnancy'. Cornual pregnancy is defined as the pregnancies located 'in one horn of a bicornuate uterus, or, by extension of meaning, in one lateral half of a uterus of bifid tendency'. Later, it was redefined as when the sac is present in a rudimentary uterine horn, a unicornuate uterus, the cornual region of a septate uterus, a bicornuate uterus, or a uterus didelphys. The ultra-sonographers and the gynecologist define cornual pregnancy differently. Williams's most current version of the definition is that the cornual pregnancy is 'a conception that develops in the rudimentary horn of a uterus with a Mullerian anomaly'.
The risk factors for cornual ectopic pregnancies are similar to the risk factors for tubal pregnancies. The previous history of ectopic pregnancy, pelvic inflammatory disease, united or bilateral salpingectomy, sexually transmitted infection, pregnancy through in vitro fertilization (IVF), and maternal smoking are some of the risk factors., There is an increase in the risk of cornual pregnancy after the use of assisted reproductive technology. The studies have found that the cornual heterotopic pregnancy is as high as 1:3600 IVF pregnancies.
Cornual pregnancies are usually diagnosed late, with 10% being diagnosed only after surgical intervention., Ultrasonography is the most commonly used diagnostic tool with 80% sensitivity and 98% specificity. The rate of detection of cornual ectopic pregnancy by ultrasonography is 71%.
The diagnostic criteria include:
- Absence of gestational sac in the uterine cavity
- The gestational sac is seen independently and <1 cm from the lateral edge of the uterine cavity
- A thin layer of myometrium around the gestational sac
- Interstitial line sign (echogenic line extending to the gestational sac).
In the early stage of cornual gestation, the sac is in the lateral part of the uterus. Later stage, the gestational sac moves above the uterine fundus. It appears as an abnormal uterine pregnancy when it is detected late. Transvaginal-Sonography (TVS) is much better in the diagnosis of cornual pregnancy than transabdominal sonography. The early diagnosis of cornual pregnancy with TVS allows for conservative management with Methotrexate during the first trimester. However, magnetic resonance imaging is an essential tool to reveal the eccentric location of the gestational sac to the junctional zone, but it is more expensive than ultrasonography.
The treatment of cornual pregnancy includes medical and surgical management. The most common choice of medical management is the use of methotrexate when cornual pregnancies are detected at very early weeks, and the success rate is 83%. The surgical management includes
- Laparotomy with cornual resection or hysterectomy
- Laparoscopy with cornual resection and salpingectomy
- Hysteroscopy with endometrial resection or cornual evacuation under ultrasound or laparoscopic guidance.
The feasibility of the laparoscopic approach depends on the size of cornual gestation. Laparoscopic salpingostomy may be appropriate for gestation <3.5 cm and cornual resection for the gestation of more than 4 cm. The laparoscopic approach is attempted if the surgeon is skilled in laparoscopic techniques and can convert the operation quickly to a laparotomy.
The laparoscopic surgery has many advantages such as minimal skin incision and a short hospital stay period, preserves the uterus for future fertility, improved and fast recovery and less post-operative pain. However, it has some minor disadvantages like hematomas of the abdominal wall occurring near the incisions, some abdominal or pelvic infections, but serious laparoscopy complications are rare.
Laparotomy is the second management line when there is no laparoscopic expertise or when adequate closure or haemostasis is not achieved by laparoscopic surgery. However, it has many risks ranging from anaesthesia and surgery related to post-surgery incisional hernia, infections, bleeding and injury of pelvic or abdominal organs. Furthermore, it is accompanied by more extended hospital stay periods, as reported in some studies compared laparoscopic cornual resection and laparoscopic cornuotomy.
In a study by MacRae et al., 11 cases of cornual ectopic pregnancy, cornual resection was done in 30% and cornuostomy in 70% of cases with a 9.09% conversion to laparotomy, thus showing that it can be managed both by salpingectomy and salpingostomy. Early diagnosis and treatment, therefore, are very crucial and key to prevent mortality.
Nursing management of the mother with cornual pregnancy (Ectopic pregnancy)
1. Nursing diagnosis
Acute pain related to cornual pregnancy (ectopic pregnancy) as shown by the pain score of 10/10, verbalisation of abdominal pain, abdominal rigidity on examination and restlessness.
The mother will show relief of pain as evidenced by pain score of 0/10, stable vital signs and absence of restlessness.
- Assessed the vital signs and characteristics of pain before and after administering medication
- Placed her in semi fowler's position
- Ensured complete bed rest during sever episodes of pain
- Provided non-pharmacological pain relief – Relaxation technique like deep breathing exercises, guided imagery and provision for distraction such as TV and radio was provided
- Post-surgery advised the mother not to perform strenuous activity for few weeks. Advised to support the abdomen when coughing, laughing or moving by placing a pillow over the abdominal area
- Encouraged her to inform the health team if the pain is persistent.
Pain reduced as showed by mother verbalising decrease in the pain and the pain score was 4/10.
2. Nursing diagnosis
Risk for haemorrhage related to to cornual pregnancy (Ectopic pregnancy).
The mother will have less vaginal bleeding and stable vital signs.
- Evaluated the obstetric history
- Assessed the vital signs
- Watched for severe abdominal pain or discomfort, vaginal spotting or bleeding and lower abdominal pain
- Planned periodic activity and rest
- Prepared the mother for surgery
- Gave teaching on cornual pregnancy (ectopic pregnancy) to relief anxiety.
Mother had minimal bleeding. Vital signs were stable.
3. Nursing diagnosis
Risk for deficit fluid volume related to active bleeding secondary to Cornual Pregnancy (Ectopic pregnancy), as showed by decreased blood pressure decreases output and pale clammy skin.
The mother will re-establish a functional body fluid volume.
- Assessed for dehydration
- Monitored input and output
- Prepared the mother for the surgical intervention for cornual pregnancy
- Kept the mother on Nil Per Oral and started on intravenous fluid as per order
- Prepared the mother for blood transfusion.
Fluid volume was supported as showed by normal blood pressure and pulse rate.
4. Nursing diagnosis
Anticipatory grieving related to loss of pregnancy secondary to cornual pregnancy as evidence by distress, changed in communication pattern and changes in quality of sleep.
The mother and her partner will share their grief over the loss of their pregnancy, will employ effective coping mechanism and verbalise a desire to move through the established stages of mourning in her own pace.
- Developed a trusting relationship
- Recognised signs of grief such as denial and despair
- Checked on lack of interest in life, disturbed sleep, suicidal ideation and despair
- Encouraged grief expression by offering privacy and enabling support individuals of choice to visit
- Used the stage of grieving to guide nursing interventions
- Communicated with the mother and family to clear information about diagnosis and treatment
- Informed the patient and partner about the benefits of counselling.
She expressed that she was able to understand the condition and said she would accept counselling if needed.
| Conclusion|| |
Cornual pregnancy is one of the rare forms of ectopic pregnancies, and it is more dangerous than other ectopic pregnancies. When diagnosed and treated early, the uterus can be saved for subsequent pregnancies. When diagnosed at the early stage through ultrasonography, it can be best managed through laparoscopic-guided surgical management by resecting the cornua, which eventually prevents the recurrence of pregnancy at the same site.
Nursing care of women with corneal pregnancy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bradley RJ. Lecture Notes on Obstetrics and Gynaecology. New York: Wiley Online Library; 2000.
Chaudhary P, Manchanda R, Patil VN. Retrospective study on laparoscopic management of ectopic pregnancy. J Obstet Gynaecol India 2013;63:173-6.
Sel G, Özaydın D, Tekin AO, Harma M, Harma Mİ. Laparoscopic management of cornual pregnancy: A case report. J Surg Med 2019;3:456-8.
Safiee AI, Ghazali WA. Laparoscopic wedge resection in a late second trimester cornual pregnancy. Gynecol Minim Invasive Ther 2021;10:47-9. [Full text]
Fantahun Y, Tesfaye K, Hassen S. A case report of advanced unruptured cornual. Ethi J Reprod Health 2020;12:69-72.
Diari J, Darido J, Bouzind N. A Case Report: Misdiagnosed Ectopic Cornual Rupture with Positive Fetal Heart at 13 Weeks Gestation. Gynecol Reprod Health 2020;4:1-5. [Doi: 10.33425/2639 9342.1110].
Rizk B, Holliday CP, Abuzeid M. Challenges in the diagnosis and management of interstitial and cornual ectopic pregnancies. Middle East Fertil Soc J 2013;18:235-40.
Finlinson AR, Bollig KJ, Schust DJ. Differentiating pregnancies near the uterotubal junction (angular, cornual, and interstitial): A review and recommendations. Fertil Res Pract 2020;6:8.
Baadi F, Gakosso C, Fakhir B, Zouita I, Jalal H. Cornual pregnancy discovered on CT scan : sA case report. Sch Int J Obstet Gynecol 2021;4:17-21.
Habana A, Dokras A, Giraldo JL, Jones EE. Cornual heterotopic pregnancy: Contemporary management options. Am J Obstet Gynecol 2000;182:1264-70.
Okuyan E, Altundal C, Bayramoglu Z. Safe, easily applicable mini-laparotomic surgical steps in cornual ectopic pregnancy: Case report and demonstration of surgical technique. Ann Med Res 2020;27:1824.
Chowdhury TS, Hasan H, Chowdhury T. Cornual pregnancy – An unusual site of pregnancy: A case report and literature review. BIRDEM Med J 2019;10:64-7.
Marchand G, Taher Masoud A, Sainz K, Azadi A, Ware K, Vallejo J, et al.
A systematic review and meta-analysis of laparotomy compared with laparoscopic management of interstitial pregnancy. Facts Views Vis Obgyn 2021;12:299-308.
MacRae R, Olowu O, Rizzuto MI, Odejinmi F. Diagnosis and laparoscopic management of 11 consecutive cases of cornual ectopic pregnancy. Arch gynec obst 2009;280:59-64.