SQU Med J, August 2011, Vol. 11, Iss. 3, pp. 399-402, Epub. 
Submitted 19th Jan 11
Revision ReQ. 11th Apr 11, Revision recd. 29th Apr & 24th May 11
Accepted 1st Jun 11

Cornual pregnancy accounts for 2–4% of ectopic pregnancies and can be associated with a mortality rate in the 
range of 2.0–2.5%.1 Cornual pregnancy constitutes 
a medical emergency and its diagnosis and 
management is challenging. We present a rare 
case of an ectopic pregnancy located just under a 
cornual fibroid, at the site of right fallopian tube 
insertion, which did not respond to intensive 
medical management thus necessitating surgical 
intervention.

Case Report
A 25 year-old primigravida presented with a 
history of mild vaginal bleeding, abdominal pain 

and 7 weeks of amenorrhoea. She gave history of 
bleeding per vagina at home during the last four 
days. There were no identifiable risk factors for 
an ectopic pregnancy. On physical assessment, 
the patient was haemodynamically stable and 
not in distress. Abdominal palpation revealed 
a 16-week size mobile non-tender mass in the 
midline. Bimanual examination confirmed an 
enlarged uterus corresponding to 16 weeks with a 
single closed cervix and minimal cervical motion 
tenderness. Abdominal ultrasound showed an 8 cm 
right cornual fibroid and transvaginal ultrasound 
(US) confirmed an empty endometrial cavity 
(endometrial thickness of 19 mm) despite high 
beta human chorionic gonadotropin (β-hcG) levels 
of 6,600 units, normal adnexa and no free fluid 

Departments of 1Obstetrics & Gynaecology and 3Radiology & Molecular Imaging, Sultan Qaboos University Hospital, Muscat, 
Oman; 2Department of Obstetrics & Gynaecology, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat,Oman.
*Corresponding Author email: gowrie61@hotmail.com

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 

aBstract: Cornual pregnancy constitutes an emergency while its diagnosis and management remain a challenge. 
Anatomical abnormalities in the uterus, such as fibroids in the cornual region, make the management even more 
difficult. A nulliparous patient presented with an ectopic pregnancy at the right cornua under a huge fibroid. Despite 
multiple doses of methotrexate for a cornual ectopic gestation, the serum beta human chorionic gonadotropin 
(β-hcG) levels doubled on the fifth day and a viable fetus was demonstrated on imaging. Thus surgical intervention 
in the form of laparoscopy followed by laparotomy, myomectomy of a large cornual fibroid and cornuostomy 
was performed. The serum beta human chorionic gonadotropin result was negative three weeks later.  Surgical 
intervention in the form of myomectomy and cornuostomy was necessary to preserve fertility in this unusual 
presentation of cornual ectopic pregnancy. 

Keywords: Diagnosis; Ectopic pregnancy; Fibroid; Leiomyoma; Methotrexate; Surgery; Case report; Oman

Submyomatous Cornual Pregnancy 
Managed surgically after failed medical management

Lamya Al-Kharusi,1 *Vaidyanathan Gowri,2 Rashid Al-Sukaiti,2 Wadha Al-Ghafri,1 Kuntal Rao1

CASE REPORT



Submyomatous Cornual Pregnancy 
Managed surgically after failed medical management

400 | SQU Medical Journal, August 2011, Volume 11, Issue 3

in the pelvis. A complete blood count revealed 
haemoglobin of 10.7 g/dL, total white cell count 
of 4.2 x 109/L and platelets of 402 x 109/L. Liver 
function tests revealed alanine aminotransferase 
(ALT) 11 iu/L; aspartate aminotranferase (AST)  
18 u/L; bilirubin 4 µmol/L, and alkaline phosphatase 
51 u/L (all within normal limits).  

A right cornual ectopic was suspected in view 
of the location of a sac-like structure and increased 
Doppler flow [Figure 1]. After counselling, she 
opted for conservative management with a 
multidose methotrexate (EBEWE Pharma, Austria) 
regimen as an inpatient. This was given on days 1, 3 
and 5 intramuscularly (50 mg/m2 body surface area) 
with rescue doses of folinic acid (EBEWE Pharma, 
Austria) to reduce bone marrow toxicity on day 2, 
4 and 6. On day 3 (after receiving a second dose 
of methotrexate) she passed some tissue vaginally 
and it was sent for histopathological examination. 
On day 5, after the third dose of methotrexate, the 
repeated β-hcG test result was 12,220 units. She 
started having increasing lower abdominal pain. 
A transvaginal US was repeated and revealed a 
1.5cm gestational sac located very close to a cornual 
fibroid which was now demonstrating fetal heart 
beat activity [Figure 2] and some free fluid in the 
peritoneum. At this time, histopathology was 
reported as a decidual reaction with no chorionic 
villi present in the tissue that was passed a few 
days before. In view of increasing abdominal pain, 
a viable fetus and elevated β-hcG, the concern 
for rupture was high. She consented to surgical 
intervention.

Laparoscopy revealed an 8 cm subserous 
fibroid at the right cornua and visible pulsations 
just under it (on the posterior aspect) suggesting 

the location of the ectopic pregnancy. The adnexa 
were normal. It was not technically feasible to 
complete her management laparoscopically. Hence 
a 7cm Pfannenstiel incision was made and the 
laparoscopy findings were confirmed [Figure 3]. 
Needle aspiration of the cornual end was attempted 
blindly (as US guided aspiration was not possible in 
the operating room) to locate the ectopic gestation. 
Since even that did not show any evidence of the 
exact location of the pregnancy, a myomectomy was 
performed. The fibroid appeared to have undergone 
some degeneration as it was soft. The ectopic 
pregnancy was identified as a circular mass with 
a tiny black dot, likely representing the embryo, at 
the base of the myoma bed and this was evacuated. 
During the procedure, the endometrial cavity was 
not entered. A classical wedge resection was not 
carried out. The myoma bed was closed in layers 
with interrupted vicryl no. 1  sutures (Polyglactin 
910, Ethicon, Johnson & Johnson) and  2/0 vicryl 
to the serosa. The uterus was reconstituted and 
looked normal at the end of the procedure. The 
intraoperative blood loss was 300 ml.

The serum β-hcG test results were as follows: on 
admission 2,035 mIU; 48 hours later 6,684 mIU; on 
day 5 (after the third dose of methotrexate) 12,647 
mIU; one day after cornuostomy 2200 mIU.

The postoperative period remained uneventful 
and the β-hcG was monitored weekly. It became 
negative after three weeks. She was advised to have 
early evaluation at the next pregnancy to rule out a 
recurrent ectopic. In addition, she was advised to 
have an elective cesarean section during her next 
pregnancy. She resumed normal periods in about 4 
weeks and remains well at the time of writing.

 
Figure 1: Transvaginal ultrasound scan of right adnexal 
region demonstrating a gestational sac and yolk sac 
(arrow).

 
Figure 2: Transvaginal ultrasound scan of right adnexal 
region demonstrating a positive fetal heart activity in 
M-mode (arrow).



Lamya Al-Kharusi, Vaidyanathan Gowri, Rashid Al-Sukaiti, Wadha Al-Ghafri, Kuntal Rao

Case Report | 401

Discussion
Despite recent advances, cornual pregnancy remains 
a diagnostic and therapeutic challenge. The three 
criteria defined by Timor et al. have increased the 
rate of diagnosis.2 Fortunately, diagnosis was made 
early in our nulliparous patient and conservative 
measures were taken initially. Systemic treatment 
with multiple doses of methotrexate was given in 
this patient as she was haemodynamically stable, 
willing for follow-up and there were no absolute 
contraindications. In a prospective observational 
study at St George’s Hospital Medical School, 
London, 17 out of 20 women with cornual pregnancy 
were treated with single-dose intramuscular 
methotrexate, which was administered on day 0. 
A second dose of methotrexate was given if the 
β-hcG levels had not fallen by 15%.3 All women 
with cornual pregnancy presenting with initial hcG 
values of <5000 mIU were treated successfully with 
single-dose methotrexate, but almost all women 
with an initial hcG of >5000 mIU required two doses 
according to the Royal College of Obstetricians and 
Gynecologists, UK.4 Medical treatment is not free 
of complications; it can be associated with uterine 
rupture and catastrophic haemorrhage. 

A large ectopic pregnancy and the presence 
of a heartbeat are relative contraindications to 
medical treatment.1 Multiple dose methotrexate 
is recommended by many authors for interstitial/ 
cornual pregnancy despite the lack of strong 
evidence for or against a multidose methotrexate 
regimen.5

 
Figure 3: Intraoperative photograph of the uterus with 
the myoma (arrow) in the right cornual region. 

A US guided local injection of methotrexate/
potassium chloride is described by Monteagudo et 
al. with immediate cessation of fetal heart activity.6 
There was no time difference in the resolution 
of the ectopic whether they used potassium 
chloride or methotrexate and they reported a 
100% success rate. Many studies have reported 
the use of laparoscopy for local methotrexate 
injection into a cornual pregnancy.7 In this case, 
local injection of methotrexate was not feasible 
either by US or laparoscopy due to the position of 
the ectopic under the myoma. Cornual excision, 
salpingostomy and repair are other approaches 
reported by many authors for cornual gestation.8 
Successful cornuostomy has been reported by some 
other authors;9,10 however, a laparoscopic cornual 
excision and salpingostomy was not possible as an 
8 cm myoma was sitting on the ectopic pregnancy; 
even visualising the pregnancy completely was 
impossible in this case. Hence a laparotomy and 
myomectomy, followed by a cornuostomy, were 
performed.

Conclusion
This is a rare case of cornual pregnancy situated 
under a cornual subserous fibroid. It was successfully 
managed by myomectomy and cornuostomy thus 
preserving the future fertility of the patient.

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Submyomatous Cornual Pregnancy 
Managed surgically after failed medical management

402 | SQU Medical Journal, August 2011, Volume 11, Issue 3

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