Case Report

Thirteen-week cornual Ectopic pregnancy Abstract

We present the unusual case of a 13-week cornual ectopic pregnancy with fetal movement. The patient presented with a protuberant abdomen, intoxicated with cocaine and alcohol, and in Hemodynamic compromise. Bedside emer- gency ultrasonography led to rapid diagnosis and treatment.

A 39-year-old woman, gravida 9, para 8, was brought to the emergency department via emergency medical services with complaints of abdominal and chest pain. Very little history was able to be obtained from the patient because she was confused and not answering clearly. As per the patient’s friend who accompanied her, she was between 3 and 4 months pregnant and had received no prenatal care. She was reportedly using cocaine and alcohol that day in attempt to cause an abortion and was found on the kitchen floor complaining of abdominal and chest pain. Otherwise, no past medical problems, current medications, or significant problems with her other pregnancies were known.

Upon arrival, initial vital signs included blood pressure of 83/42 mm Hg, pulse rate of 88 beats per minute, respiratory

rate of 20 breaths per minute, temperature of 95.5?F (35.3?C), and pulse oximetry of 100% on room air. The patient was lethargic and confused. Mucous membranes were dry. Lungs were clear to auscultation with good aeration. Cardiac examination was normal with no murmurs noted. Abdominal examination revealed a gravid uterus, appearing about 28 weeks, which was otherwise soft and diffusely tender on palpation. No obvious Vaginal bleeding was present. No back tenderness was present. Skin was warm and without diaphoresis. Neurologic examination revealed no gross motor or sensory deficits. She would respond to verbal stimulus but was confused and only mildly cooperative.

Given her obstetrical status, pain, hypotension, and physical examination, a bedside ultrasound was performed as part of her overall workup. A focused assessment with sonography for trauma revealed free fluid in the perihepatic window (Fig. 1). In addition, a transabdominal focused pelvic ultrasound revealed a second trimester fetus with visualized fetal heart beats in a displaced position within the uterus (Figs. 2 and 3). While aggressive crystalloid and blood resuscitation was in process, an emergent obstetrical surgery consult was obtained. A bedside ultrasound by the obste- trician confirmed a cornual pregnancy with free intra- abdominal fluid. In addition, laboratory evaluation revealed

Fig. 1 Perihepatic fluid in Morrison’s pouch on focused assessment with sonography for trauma examination.

Fig. 2 The crown rump length of this moving ectopic fetus was consistent with 13 weeks of gestational age.

0735-6757/$ - see front matter.

900.e2 Case Report

4% of ectopic pregnancies [2-4]. The mortality of such ectopic pregnancies is estimated at 2% compared with 0.14% for tubal ectopic pregnancies [3,4]. The cornual ectopic pregnancy is capable of developing in a highly vascularized area to the second trimester before rupture, which may lead to severe hemorrhage [1,5]. In one study, almost one third of cornual ectopic pregnancies were diagnosed after rupture and involved significant hemoperitoneum related to this possi- bility of advanced gestation [2].

Fig. 3 Sagittal view of uterus. Note the discrepancy of the Gestational sac from the endometrial stripe and the high placement in the fundus.

metabolic acidosis with a pH of 7.095, elevated lactic acid of

7.3 mmol/L, anemia with a hematocrit of 25.6%, and pre- sence of alcohol and cocaine. The initial electrolytes, cardiac markers, and Coagulation studies were unremarkable. An electrocardiogram showed normal sinus rhythm with a rate of 91 beats per minute, and no signs of an acute ischemia were noted. An initial chest radiograph was unremarkable as well. The patient was taken emergently to the operating room where she underwent an Exploratory laparotomy. The obstetricians found approximately 2500 mL of hemoper- itoneum. A 13-week cornual pregnancy that was extruding through the right cornu of the uterus was identified and removed via wedge resection. The ovaries, fallopian tubules, and remainder of the uterus was without defect. The patient was transferred to the surgical intensive care unit and

recovered well from the episode.

A pregnancy implanted in the cornu asymmetrically and medial to the round ligament is considered a cornual ectopic pregnancy [1]. Some studies have shown that cornual ectopic pregnancies such as this one occur in approximately 2% to

Karen Gaber-Patel DO

Emergency Medicine

MetroHealth Cleveland Clinic

Case Western Reserve University

Cleveland, OH, USA E-mail address: [email protected]

Michael D. Smith MD Emergency Medicine MetroHealth Medical Center Cleveland, OH, USA

Case Western Reserve University

Cleveland, OH, USA

doi:10.1016/j.ajem.2008.11.005

References

1. Valsky DV, Yagel S. Ectopic pregnancies of unusual location: management dilemmas. Ultrasound Obstet Gynecol 2008;31:245-51.
2. Bouyer J, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 2002;17(12):3224-30.
3. Molinaro TA, Barnhart KT. Ectopic pregnancies in unusual locations. Semin Reprod Med 2007;25(2):123-30.
4. Tang A, Baartz D, Keat S. A medical management of interstitial ectopic pregnancy: a 5-year clinical study. Aust N Z J Obstet Gynaecol 2006;46: 107-11.
5. Jurkovic D, Mavrelos D. Catch me if you scan: ultrasound diagnosis of ectopic pregnancy. Ultrasound Obstet Gynecol 2007;30:1-7.