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CASE REPORT
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A case of cornual molar ectopic pregnancy: Salutary lesson from a rare disease


 Department of Obstetrics and Gynaecology, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission06-Sep-2021
Date of Decision05-Dec-2021
Date of Acceptance07-Dec-2021

Correspondence Address:
Atul Seth,
Department of Obstetrics and Gynaecology, Armed Forces Medical College, Solapur Road, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_735_21

  Abstract 


Cornu of the uterus is one of the uncommon sites of ectopic pregnancy. Molar cornual ectopic pregnancy is extremely rare and only few cases are reported in the literature. A 25-year-old gravida 3, para 1, abortion 1 lady reported with complaints of amenorrhea of 9 weeks and pain in the lower abdomen for 1 day. Sonography revealed an anechoic structure of 20 mm at the left adnexa with evidence of hemoperitoneum. The patient was managed with laparoscopic cornuostomy. Histopathologic analysis demonstrated placental tissue with features consistent with a complete molar pregnancy. It is emphasized that histopathological examination of the retrieved tissues should be considered after each case of surgical management of ectopic pregnancy to rule out molar pregnancy.

Keywords: Ectopic pregnancy, hydatidiform mole, laparoscopy



How to cite this URL:
Mishra RK, Seth A, Prajapati VK. A case of cornual molar ectopic pregnancy: Salutary lesson from a rare disease. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=339948




  Introduction Top


Gestational trophoblastic disease (GTD) is a heterogeneous group of lesions arising from abnormal proliferation of placental trophoblasts. The incidence of GTD varies from 0.6 to 2 per 1000 pregnancy.[1] The incidence of ectopic pregnancy is estimated to be about 0.64% out of which only 2%–3% occur in the cornu of the uterus.[2] The combination of molar pregnancy and ectopic pregnancy is uncommon and the occurrence of cornual molar ectopic pregnancy is extremely rare. Only a very few cases of cornual ectopic with molar pregnancy have previously been reported in the literature.[3],[4],[5],[6],[7] We report a rare case of a complete mole in ectopic pregnancy at the uterine cornu.


  Case Report Top


A 25-year-old gravida 3, para 1, abortion 1 lady with last delivery 1 year back reported to the outpatient department with complaints of amenorrhea of 9 weeks and pain in the lower abdomen for 1 day. This was not associated with any history of vaginal bleeding or discharge. On examination, the patient was hemodynamically stable. The abdomen was soft on palpation. On per vaginal examination, the uterus was bulky and adnexal tenderness was present on the left side. Sonography revealed an anechoic structure of 20 mm at the left adnexa without any fetal pole which was seen separately from the ovary. Free fluid was seen in the pouch of Douglas, paracolic gutters, and hepatorenal pouch suggestive of hemoperitoneum. The patient was planned for laparoscopic exploration with a provisional diagnosis of ruptured ectopic pregnancy with hemoperitoneum.

At laparoscopy, hemoperitoneum of about 400 ml was evacuated. The uterus was found to be asymmetrically enlarged and a prominent bulge was noticed at the left cornu [Figure 1]. The enlarged portion showed bluish discoloration with increased vascularity. There was evidence of oozing from the site of ectopic pregnancy. Both  Fallopian tube More Detailss and ovaries were normal. Hence, a diagnosis of cornual ectopic pregnancy was made intraoperatively. The prominent thin part of the cornual region was incised with monopolar cautery and villous tissue was scooped out. Hemostasis was achieved with bipolar current. The villous tissue was sent for histopathology examination (HPE). The postoperative recovery was uneventful.
Figure 1: Laparoscopic findings showing enlarged left uterine cornu with increased vascularity

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The patient was reviewed after 1 week with HPE report which showed chorionic villi along with areas of exuberant trophoblastic proliferation. The villi appeared enlarged, edematous, and elongated with cistern formation and scalloping of edges suggestive of complete hydatidiform mole [Figure 2] and [Figure 3]. On further evaluation, no evidence of systemic involvement was found. Serum beta-human chorionic gonadotropin (β-HCG) was measured on the same day which was found to be 116 mIU/ml. She did not require any further treatment and was kept on regular follow-up. Serial monitoring of serum β-HCG was performed weekly, which reached a normal level in 6 weeks.
Figure 2: Areas of exuberant trophoblastic proliferation with cistern formation

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Figure 3: The chorionic villi appears enlarged edematous with scalloping of edges

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  Discussion Top


An ectopic pregnancy is one in which the fertilized ovum implants in tissues other than the endometrial lining of the uterine cavity.[1] Fallopian tube is the most common site of ectopic pregnancy, contributing to nearly 95% of cases. An ectopic pregnancy located in the cornual portion of the uterus occurs in 2%–3% of ectopic pregnancies, making the incidence as 2 per 10,000 pregnancies.[1],[2] The diagnosis of cornual ectopic remains a challenge both clinically and radiologically. The surgical management of such cases is challenging since the bleeding is difficult to control, more so if the pregnancy is at an advanced gestational age. Cornual ectopic pregnancy is associated with a higher risk of hemorrhagic shock and maternal mortality when compared to other types of ectopic pregnancy due to delayed diagnosis and high vascularity of the myometrium.

The incidence of molar cornual ectopic pregnancy is estimated to be 1.5 cases in one million pregnancies.[4] Upon our literature search of PubMed and PubMed Central, we found that only five cases have been reported previously. Molar ectopic pregnancy is similar in presentation to those of nonmolar ectopic pregnancy. They can present with abnormal vaginal bleeding or pain abdomen with or without amenorrhea.[5] Although the advances in ultrasonography have led to the early diagnosis of intrauterine molar pregnancy, the radiological diagnosis of ectopic molar pregnancy still remains elusive. The definitive diagnosis can only be made in the postoperative period after histopathological examination.[8] The β-hCG levels are similar in both molar and nonmolar ectopic pregnancies, especially in early period of gestation. Hence, molar pregnancy cannot be differentiated from nonmolar ectopic pregnancy solely on the basis of β-hCG levels.[9] In the present case, the molar transformation of ectopic pregnancy was detected only after histopathological examination.

The mode of treatment can be either by laparoscopy or by laparotomy. Recent advances in laparoscopic surgeries have enabled less invasive surgical management. Chemotherapy (methotrexate) may be required in selected cases in the post-operative period. However, serial β-hCG monitoring is essential in patients with molar ectopic pregnancy due to the probability of malignant trophoblastic changes.


  Conclusion Top


Molar ectopic pregnancy should be kept in mind while dealing with cases of ectopic pregnancy. The authors are of the opinion that histopathological examination of the retrieved tissues should be considered after each case of surgical management of ectopic pregnancy. This will avoid inadvertent missing of this potentially serious and rare clinical entity. Follow-up with serial β-hCG monitoring is essential in such cases to rule out malignant transformation.

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 initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Berek JS, Novak E. Berek & Novak's Gynecology. 15th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2020. p. 1503.  Back to cited text no. 1
    
2.
Hoover KW, Tao G, Kent CK. Trends in the diagnosis and treatment of ectopic pregnancy in the United States. Obstet Gynecol 2010;115:495-502.  Back to cited text no. 2
    
3.
Chauhan MB, Chaudhary P, Dahiya P, Sangwan K, Sen J. Molar cornual ectopic pregnancy. Acta Obstet Gynecol Scand 2006;85:625-7.  Back to cited text no. 3
    
4.
Zite NB, Lipscomb GH, Merrill K. Molar cornual ectopic pregnancy. Obstet Gynecol 2002;99:891-2.  Back to cited text no. 4
    
5.
Hwang JH, Lee JK, Lee NW, Lee KW. Molar ectopic pregnancy in the uterine cornus. J Minim Invasive Gynecol 2010;17:239-41.  Back to cited text no. 5
    
6.
Chen PL, Jhuang JY, Lin HH, Hsiao SM. Successful treatment of gestational trophoblastic neoplasia in the uterine cornus with laparoscopic cornuostomy and postoperative methotrexate injection. Taiwan J Obstet Gynecol 2017;56:261-3.  Back to cited text no. 6
    
7.
Yamada Y, Ohira S, Yamazaki T, Shiozawa T. Ectopic molar pregnancy: Diagnostic efficacy of magnetic resonance imaging and review of the literature. Case Rep Obstet Gynecol 2016;2016:7618631.  Back to cited text no. 7
    
8.
Rotas M, Khulpateea N, Binder N. Gestastional choriocarcinoma arising from a cornual ectopic pregnancy: A case report and review of the literature. Arch Gynecol Obstet 2007;276:645-7.  Back to cited text no. 8
    
9.
Chase JS, Check JH, Nowroozi K, Wu CH. First-trimester serum levels of the beta-subunit of human chorionic gonadotropin in a tubal molar pregnancy. Am J Obstet Gynecol 1987;157:910.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

 
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