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9.1 Ectopic Pregnancy inGeneral
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209
(3) when more than one corpus luteum is present
in a natural conception. There are two symptomatic presentations. One is when the intrauterine
pregnancy (IUP) is discovered later than the EP,
mainly because of the typical clinical presentation of EP before the woman is aware of the pregnancy. Another is abdominal pain/acute abdomen/
hemoperitoneum/hemorrhagic shock in a woman
with known early pregnancy. Difculty in diagnosis in this second form is due to ultrasound
(US) ndings of normal IUP pregnancy and a
rare incidence of additional EP.
9.1.6.1 Laboratory Findings
The urine βHCG assay is sensitive to ≤25mIU/
mL, and more than 95% of patients with EPs
have a positive test [35]. Transvaginal US has
replaced transabdominal US for EP diagnosis
and early screening of an IUP.It can visualize an
intrauterine sac at an earlier gestational age. A
gestational sac should always be seen in the
patient with a viable IUP when the serum βHCG
reaches 2000 mIU/mL. The gestational sac is
usually visible at 1000mIU/mL [36]. Following
serum βHCG titer (which should double every
48h in a normal, viable pregnancy) has no role in
a patient with a suspected ruptured EP, as that
patient needs immediate surgical attention.
Depending on the severity of the bleeding, hemoglobin levels might be lowered or even normal
[37]. Misleading and unexpected laboratory values such as hyperglycemia might also be present
[38]. Diagnosis of an EP before rupture cannot
always be obtained because the patient is unaware
of the pregnancy. All women of childbearing age
should have a pregnancy test performed regardless of the date of their last menstrual period.
Among women with symptoms and inconclusive
US assessments, the progesterone test (ve studies with 1998 participants and cutoff values from
3.2 to 6ng/mL) predicted a nonviable pregnancy
with a pooled sensitivity of 74.6%, specicity of
98.4%, the positive likelihood ratio of 45 (7.1–
289), and negative likelihood ratio of 0.26. The
median prevalence of a nonviable pregnancy was
73.2%. The probability of a nonviable pregnancy
was raised to 99.2% if the progesterone was low.
For women with symptoms alone, the progester-
one test had a higher specicity when a threshold
of 10ng/mL was used and predicted a nonviable
pregnancy with a pooled sensitivity of 66.5%,
specicity of 96.3%, the positive likelihood ratio
of 18 (7.2–45), and negative likelihood ratio of
0.35. The probability of a nonviable pregnancy
was raised from 62.9% to 96.8% [39].
9.1.6.2 Transabdominal Ultrasound
The US helps to exclude blighted ovum or threatened abortions. Transabdominal US of HP demonstrates free intraperitoneal uid and a
normal-looking IUP with a positive fetal heart
rate. The sensitivity, specicity, positive predictive value, negative predictive value, and accuracy
of transabdominal US as a diagnostic modality in
the evaluation of suspected EP were 73.1%, 75%,
95%, 30%, and 73.3%, respectively. In comparison, transvaginal US has 92.3% sensitivity, 75%
specicity, 96% positive predictive value, 60%
negative predictive value, and 90% accuracy [40].
Ultrasound is the primary diagnostic
modality, using a transvaginal approach
supplemented by transabdominal imaging
if required. (Royal College of Obstetricians
& Gynaecologists, 2016 [41])
9.1.6.3 Transvaginal Ultrasound
Positive pregnancy test with abdominal pain
mandates bedside US in the emergency department to locate the position of the fetal sac. The
transvaginal technique is preferred because of its
increased sensitivity for detecting an IUP and
superior visualization of the adnexa [3]. Most
patients with EPs have some abnormality on the
US [42]. These abnormal ndings include a cystic or complex adnexal mass (60–90%) and free
uid in the peritoneal cavity (25–35%, higher in
a ruptured EP) and should raise the suspicion of
EP. However, the ndings are nonspecic, and
not visualizing an EP on US can never exclude it
as a possible diagnosis. Ectopic fetal heart activity location conrms EP [29]. There are pitfalls
involved with overreliance on laboratory values
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9 Ruptured Ectopic Pregnancy
in evaluating EP. Serum βHCG above the “discriminatory” level (at which US should be able to
detect an IUP) might lead to a diagnosis of EP
when no IUP is visualized; however, values that
fall below this level do not eliminate the emergent US.In many cases, US might nonetheless be
diagnostic. Recently, a case was diagnosed with
3D US [42].
Since EPs are usually discovered and removed
early in the pregnancy, an US may not nd the
additional pregnancy inside the uterus. When
βHCG levels continue to rise after the removal of
the EP, there is a chance that a pregnancy inside
the uterus is still viable. This is usually discovered with an US.
The US criteria of a cesarean scar pregnancy
include [43]: (1) an empty uterine cavity and cervical canal, (2) development of the gestational
sac in the anterior portion of the lower uterine
segment, and (3) absence of healthy myometrium
between the bladder and the gestational sac.
IUP with hemorrhagic corpus luteum can simulate HP/EP clinically and on US [44]. Other
acute abdominal conditions may simulate HP
making clinical diagnosis challenging. Bicornuate
uterus with gestation in both cavities simulates an
HP. High-resolution transvaginal color Doppler
US shows increased ow with a signicantly
reduced resistance index for the trophoblastic tissue in the adnexa from HP [13].
9.1.6.4 Abdominal CT
An abdominal CT shows EP commonly as a ringenhancing adnexal cystic mass surrounded by
hemoperitoneum (Fig.9.4).
9.1.6.5 Abdominal MRI
Cervical pregnancy, cervical abortion, and uterine scar pregnancy should be distinguished. If the
3D US is not available, MRI conrms cervical
pregnancy, as tissue characterization is better
with MRI, especially in doubtful cases [46]. The
MRI ndings of cervical pregnancy include [46]:
(1) a mass with heterogeneous signal intensity
and (2) partial or complete dark rim on
T2-weighted images (Fig.9.5).
MRI sensitivity, specicity, and accuracy for
EP are up to 95%, 100%, and 96%, respectively.
9.1.6.6 Culdocentesis
Culdocentesis may gain additional information.
A needle is inserted through the vaginal wall into
the posterior cul-de-sac with possible ndings:
• a dry tap is inconclusive,
• a few cubic centimeters of clear uid (peritoneal uid) rule out a ruptured EP, but neither
rule out an unruptured EP,
• a lightly bloody uid (hematocrit <15) is
inconclusive. This could be from a traumatic
tap or early, mild bleeding from an EP,
Fig. 9.4 (a) A coronal multiplanar reconstruction and (b)
axial contrast-enhanced CT shows well-vascularized
solid-cystic mass 45× 40 mm, with a strong and early
peripheral contrast enhancement in the right adnexal area.
(Reproduced with permission from [45])
9.1 Ectopic Pregnancy inGeneral
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Fig. 9.5 A coronal multiplanar T2-weighted MRI sagittal
section of the pelvis shows a gestational sac with a fetal
pole in the closed cervix (arrow) and hour-glass conguration of the uterus with thickened endometrium.
(Reproduced with permission from [47] under the CC BY
3.0)
211
Fig. 9.6 Laparoscopic view of a 30×20mm unruptured
left ampullary pregnancy. The intermediate portion of the
Fallopian tube is distended and blue. (Reproduced with
permission from [49] under the CC BY 4.0)
• moderately bloody uid (hematocrit >15)
indicates hemoperitoneum consistent with
ruptured EP, but is nonspecic, and any internal bleeding (hemorrhagic ovarian cyst) can
give this result,
• bright red, clotting blood usually indicates a
traumatic tap or aspiration of blood from a
vessel.
Today, it has lost its signicance due to inva-
siveness, low specicity, and accuracy of abdominal CT. Approximately 50% with a positive
culdocentesis have a ruptured Fallopian tube
[48].
9.1.6.7 Diagnostic Exploration
EP is commonly diagnosed during abdominal
exploration (Fig. 9.6). Primary ovarian pregnancy is usually diagnosed at operation,
although it may resemble a hemorrhagic corpus
luteum cyst (Fig.9.7). A correct intraoperative
diagnosis was 28% [51]. Figure9.8 shows recommended approaches to investigating rst-trimester pain or bleeding in the hemodynamically
stable patient.
Fig. 9.7 Laparoscopic view of an unruptured right ovarian pregnancy. Ut uterus, POD pouch of Douglas, Ect
ectopic pregnancy, Ov right ovary, Tu Fallopian tube.
(Reproduced with permission from [50] under the CC BY
3.0)
9.1.7 Treatment
When the diagnosis of EP can be neither established nor excluded by a complete diagnostic
workup, management depends upon many factors. The overall condition and stability of the
patient, the availability of close follow-up care
with an obstetrician/gynecologist, and the proximity of the patient to the hospital are important
considerations for early discharge. Decisions
regarding the disposition of such patients
should be made with a consulting obstetrician/
gynecologist, and in some cases, admission to
the hospital or surgical exploration might be
preferred option.
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Positive pregnancy test in
woman of reproductive age
Hemodynamically stable
•
• No concerns of
intraperitoneal bleeding
Assessment of history,
risk factors, TV USS ±
serum HCG
Tubal ectopic pregnancy
diagnosed or suspected
Hemodynamic instability
•
• Concerns of significant
intraperitoneal bleeding
• Significant pain
• Adnexal mass >35 mm
• Fetal heart beat present
• Serum HCG >5000 IU/IL
• No significant pain
• Adnexal mass <35 mm
• No visible fetal heart beat
• No intrauterine pregnancy
• Minimal free fluid
9 Ruptured Ectopic Pregnancy
Urgent surgical management
Urgent escalation of care
Urgent volume replacement
• HCG 1500-5000 IU/L
• HCG <1500 IU/L
• Prefers medical
management
Surgical
management
Medical
management
• HCG <1000 IU/L
• Prefers expectant
management
Fig. 9.8 Recommended approach to investigating rst-trimester pain or bleeding in the emergency department. HCG
human chorionic gonadotropin, TV USS transvaginal ultrasonography. (Reproduced with permission from [52])
9.1.7.1 Historical Perspective
In 1849, Harbert of Louisville was the rst to
perform surgery early enough to stop fatal
bleeding [53]. After several autopsies on
women, Robert Lawson Tait in London recognized that appropriate dissection and ligation of
bleeding vessels would be effective in treating
EP.He successfully performed a laparotomy to
ligate the broad ligament and removed a ruptured tube. By 1885, Tait had accumulated a
relatively large number of successful cases of
salpingectomies [54, 55].
Hunter Robb, in 1907, proved experimentally
that a hemorrhage would cease in from 15 to
20min. He also maintained that a woman who
weighs 130lb must lose 4lb of blood before she
succumbs from the bleeding. So large amounts of
blood are rarely found in the free abdominal cavity during an operation or postmortem examination. Robb further contends that the sudden
removal of a large quantity of recently accumulated uid in the abdominal cavity before the vessels have had time to adapt themselves to the
altered mechanical conditions is dangerous and
may be followed by syncope. He maintained that
patients in whom the bleeding wound is sufcient
to cause death are rarely seen in time to be saved
by the operation. So long as there is reasonable
evidence that an immediate operation may be the
wrong procedure, we must hold our hands and
leave something to nature [56]. Ralph Waldo, in
1910, at the American Association of
Obstetricians and Gynecologists meeting, presented the results at Lebanon Hospital of the
deferred operation for extrauterine pregnancy. He
collected 81 cases, and 70% were brought into
the hospital in profound shock. None of the
patients were operated on unless they showed
signs of recovery from the shock which followed
the hemorrhage. It was argued that a woman suffering from a ruptured EP seldom, if ever, dies of
the hemorrhage, but of the shock which usually
follows the bleeding. If the patient is subjected to
the additional shock of the operation, the chances
of recovery are minimized.
In 1913, Hartmann’s textbook stated, “every
ectopic should be operated upon when diagnosed.” Expectant management led to 86% of
maternal mortality, while surgery saved 85% of
women [57]. The introduction of asepsis, anesthesia, antibiotics, blood transfusions, and MTX
saved the lives of many women with EP and
eliminated the need for the operation in the
selected group.
Expectant
management
9.1 Ectopic Pregnancy inGeneral
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213
Robert B. Hope (USA), in 1937, suggested
peritoneoscopy in diagnosing EP [58]. For 3years,
he assisted the American internist John C.Ruddock
(1891–1964). Ruddock concentrated on cardiology in the 1920s. He was an active member of the
American College of Cardiology and, in 1931,
became president of the California Heart
Association. Ruddock used the McCarthy cystoscope and presented his peritoneoscope in 1934.
9.1.7.2 Medical Treatment
For unruptured tubal pregnancy, conservative
therapy with maternal IM MTX injections is the
method of choice, preventing severe complications in subsequent gestations [59]. Ovarian
reserve and subsequent ART cycle outcomes
(without a time-dependent effect) were reassuring
after MTX for unruptured EP.No adverse impact
of MTX was detected [60]. Close follow- up might
be considered in consultation with the obstetrician/gynecologist [3]. Any location EP can be
successfully treated with maternal IM MTX [61].
9.1.7.3 Fallopian Tube Pregnancy
Fallopian Tube-Sparing Surgery
Tube-sparing surgery is accomplished by removing the EP from the Fallopian tube via linear salpingostomy by making an incision on the
antimesenteric portion of the tube over the bulge
of the EP, removing the pregnancy, achieving
hemostasis, and allowing the tube to heal by secondary intention. There are no differences in subsequent spontaneous pregnancy rates, adhesion
formations, or stula formation with or without
closure of the incision site [62, 63], but lead more
often to recurrent ipsilateral EP site, bleeding, and
persistent trophoblastic tissue [64]. Trophoblastic
tissue persists in approximately 5% [65].
A mbrial expression consists of “milking”
the pregnancy out of the Fallopian tube. This
technique probably should be reserved for EPs
located at or very near the mbria itself.
Postoperative βHCG measurements are
mandatory.
Salpingectomy
Salpingectomy is the procedure of choice (1) if
the woman has no desire for further pregnancies,
(2) for hemostatic control of an attempted salpingostomy, or (3) if the Fallopian tube appears
unsalvageable. Salpingectomy is the standard
procedure for a hemodynamically unstable
patient or a woman with infertility. In a subset of
patients, it results in equivalent pregnancy rates
and a decrease in recurrent EP [66].
Hemodynamically Unstable Patient
Hemodynamic instability requires emergency
median laparotomy. Before the surgical intervention, ruptured EP might require vigorous and
immediate resuscitation with uids and blood
products. Oxygen should be applied, and an
emergent obstetric consultation obtained.
Laparoscopy
Laparotomy was gradually replaced by laparoscopy. First trimester pregnancies have been
exposed to laparoscopy to rule out EP, allowing
progress to term gestations [67].
Shapiro and Adler [68] reported laparoscopic
salpingectomy using electrocoagulation followed
by excision for an EP in 1973. Salpingotomy by
laparoscopy was rst reported using multiple
punctures in 1980 [69]. DeCherney etal. in 1982
described linear salpingotomy with a cutting current [70]. A laparoscopy reduces morbidity,
recovery, costs, and equivalent future fertility
rates compared with laparotomy [71, 72].
Conservative (salpingotomy) or radical (salpingectomy) treatment in women who wish to
preserve reproduction has long been debated.
Salpingotomy does not improve time to spontaneous ongoing pregnancy and leads more often to
persistent trophoblast when contralateral tubal
pathology is absent [64].
In women with a desire for future pregnan-
cies with a tubal EP in a solitary tube or the
presence of contralateral tubal pathology,
(laparoscopic) salpingotomy is the treat-
ment of choice [73, 74].
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9 Ruptured Ectopic Pregnancy
Approximately 3% of early EPs are not visualized by laparoscopy. If a pregnancy has been previously determined to be nonviable by serum βHCG
or an undesired pregnancy, endometrial sampling
by suction curettage determines whether an IUP
was present. If chorionic villi are obtained from the
uterine cavity, a concurrent EP with IUP is unlikely.
Sampling the endometrium with biopsy instruments is inadequate and should not be used.
9.1.7.4 Cervical Pregnancy
If US measurements show no cardiac activity in
clinically stable patients and the gestational
period is <9weeks, systemic MTX may be tried
[75]. A gestational period >9 weeks with the
presence of cardiac activity demonstrated on US
in a clinically stable patient may require the
addition of intra-amniotic potassium chloride in
addition to systemic MTX [75]. Second or thirdtrimester diagnosis may warrant hysterectomy.
Treatment options for bleeding are tamponade
with a Foley balloon, large vessel ligation, or
angiographic embolization. Hysterectomy is
reserved for intractable bleeding [75]. Often,
more than one method is used to terminate cervical pregnancy [75].
9.1.7.5 (Incidental) Appendectomy
See Sect. 15.9.1.2.
9.1.8 Prognosis
While the number of EPs has increased, the death
rate from this disorder has steadily declined. The
mortality rate in 1952in the USA was 2.4% [76],
with an estimated 876 USA deaths between 1980
and 2007 [77]. Still, the maternal mortality rate in
the USA ranged from 200 to 400/10,000 cases of
EPs and accounted for 13% of all pregnancyrelated deaths [2]. The decreased mortality rate is
secondary to early detection and intervention. With
the advent of conservative surgery, the emphasis on
early diagnosis and increased awareness of this
condition may be an important factor in further
reducing the morbidity and mortality of EP.
Mortality of a tubal pregnancy at the isthmus
or within the uterus (interstitial pregnancy) is
higher as there is increased vascularity that may
result more likely in sudden major internal
bleeding.
The survival rate of the uterine fetus of an EP
is around 70%. Successful pregnancies have
been reported from a ruptured tubal pregnancy,
continuing by the placenta implanting on abdominal organs or outside the uterus.
9.2 Ruptured Cornual Pregnancy
9.2.1 Denition
The rudimentary horn of a unicornuate uterus
arises due to partial development of one uterine
horn and incomplete fusion of the two Müllerian
ducts. In more than 75% of cases of the unicornuate uterus, a contralateral rudimentary horn is
present. Most rudimentary horns contain functional endometrium and do not communicate
with the unicornuate uterus [78–80]. However,
the rudimentary horn has been described in the
literature under various terms, including unicor-
nuate uterus with rudimentary horn, uterus
bicornis unicollis with rudimentary horn, uterus
bicornis unicollis with atretic horn, uterus bicor-
nis with accessory horn, Roberts’ uterus, and
hernia uterus inguinale. This freedom of termi-
nology makes an assessment of this condition
more difcult.
Contrary to the American Fertility Society
classication of uterine anomalies, rudimentary
horns may occur without a corresponding unicornuate uterus. In the bicornuate uterus, if
pregnancy occurs in the well-developed horn, it
usually continues. A signicantly increased
uterine rupture risk exists when conception
occurs in the rudimentary horn [81]. In contrast,
others claim that all rudimentary horn pregnancies rupture [78]. Francois Mauriceau, in 1669,
reported the rst case of rudimentary horn rupture [82].
9.2 Ruptured Cornual Pregnancy
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9.2.2 Incidence
andPathophysiology
Noncommunicating horns account for 70–92% of
cases [78–80]. Pregnancy in a noncommunicating
rudimentary horn has a reported incidence of
1/76,000–1/150,000 [78, 83], with more than 600
cases published [78–80, 84, 85]. Of all ruptures,
13% occur in the rst, 67% in the second, and
20% in the third trimester [78]. There is no signicant difference in rupture rates of communicating
and noncommunicating horns (52% and 47%,
respectively). Since 1900, 30% of pregnancies
went to term, but from 1990 to 1999, this was
reduced to 6% because of earlier detection and
intervention [78]. Rupture of the uterine horn
occurs because of the inability of the malformed
uterus to expand with increasing gestational age.
It occurs following the transperitoneal migration
of sperm or fertilized ovum zygote [80]. Pregnancy
in a rudimentary horn can rupture between 10 and
20weeks of gestation with associated life-threatening bleeding [86] due to poorly developed musculature that cannot stretch. It is highly uncommon
for such cases to result in a viable fetus as they
often result in rupture of the horn before the third
trimester [87]. Only 10% reach term, and the fetal
salvage rate is 2% [88, 89]. Rupture occurs commonly because of underdevelopment, variable
thickness, and poor distensibility of the myometrium and dysfunctional endometrium.
Rudimentary horn pregnancy can be further complicated by placenta percreta due to the poorly
developed musculature, scant decidualization,
and small horn size, the reported incidence being
11.9% [90, 91] or by twin pregnancy [90].
Implantation in a rudimentary horn of a uterus
has an exceptionally high risk of rupture (≤81%)
associated with the induction of labor [92]. Sir
Harold Beckwith Whitehouse (Fig. 9.9) rst
observed the phenomenon in 1912. The decision
for labor induction in women with a congenital
anomalous uterus, especially in cases of a previous CS, must be carefully considered, given the
higher incidence of UR.Although the UR rate for
unscarred anomalous uteri during pregnancy is
increased relative to normal uteri, the precise
increase in risk associated with the different types
of uterine malformations remains uncertain.
215
Fig. 9.9 Sir Harold Beckwith Whitehouse (26 October
1882, Tipton, Staffordshire—28 July 1943, London). He
succeeded Thomas Wilson in 1921 as a senior gynecological surgeon at the General Hospital and in 1924 as
professor of midwifery and diseases of women at the
University of Birmingham, becoming the third holder of
this combined chair, the gynecological component rst
held by Robert Lawson Tait. He was long interested in the
British Red Cross Society, became president of the
Birmingham branch in 1937 and, during the war, acting
county director and controller in 1940. In 1913–1914,
when only thirty, Whitehouse was a Hunterian professor
at the Royal College of Surgeons, lecturing on uterine
bleeding. (Reproduced with permission from [93])
9.2.3 Clinical Presentation
As rudimentary horn pregnancies are always
associated with catastrophic outcomes, every
effort should be made to diagnose them before
pregnancy or early gestation. A detailed history
during the rst visit includes complaints of severe
dysmenorrhea. However, the rudimentary horn
may be underdeveloped, with nonfunctional
endometrium and dysmenorrhea absent in 50%
[79, 87]. The incidence of endometriosis in functional rudimentary horns is similar to the incidence in women with normal uteri (<15%) [78].
Müllerian anomalies are commonly associated
with spinal, cloacal, and renal anomalies (45–
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60%) [94–97]. The association of unilateral renal
agenesis or ectopia, uterine duplication or unicornis, and vaginal agenesis has been described [98].
Unilateral renal agenesis predicts an ipsilateral
obstructive Müllerian anomaly in 55–70% [99],
but the reverse is not true. A signicant rate (29–
44%) of rudimentary horns is associated with
abnormal renal anatomy [79]. The unicornuate
uterus with a rudimentary horn may be associated with complications such as hematometra,
endometriosis, infertility, recurrent miscarriages,
preterm labor, malpresentation, and placenta
accreta [100]. A possible explanation of complications is the noncommunicating horn in
70–90%, and fertilization is thought to occur by
transperitoneal migration of gametes or in the
pouch of Douglas. The most common reasons for
hospitalization in women who were found later to
have rudimentary horns were an EP (25%),
chronic pelvic pain (20%), pelvic tumor (20%),
and primary infertility (15%) [97].
A pelvic examination detects deviated uterus
with a palpable adnexal mass causing deviation
of the uterus and cervix to one side [101, 102], or
a bicornuate uterus with the horns a wide distance apart should arouse suspicion of a Müllerian
anomaly.
9.2.4 Diagnosis
Preclinical and preoperative detection of a rudimentary horn is persistently low (14% overall)
[78]. The preclinical detection for obstetric presentations is 8%, which has not changed much
(5–6%) since the 1960s [80, 97]. Diagnostic criteria for pregnancy in a rudimentary horn include
[103]:
• Detection of a single interstitial tube in
an empty uterus adjacent to the
pregnancy,
• Free mobility and the presence of a vascular pedicle adjoining the gestational
sac and the lateral aspect of the empty
uterus.
9 Ruptured Ectopic Pregnancy
Fig. 9.10 US at the 7th week of pregnancy shows a
bicornuate uterus with a gestational sac in the smaller
right horn (arrow). The fetal pole is within the sac (arrow-
head). (Reproduced with permission from [107] under the
CC BY 4.0)
9.2.4.1 Abdominal Ultrasound
The sensitivity of US for diagnosing rudimentary
horn pregnancy is 30% [104, 105], with the rst
case of cornual pregnancy diagnosed with US in
1983 [106]. Previously stated criteria can be used
with relative ease in the rst trimester (Fig.9.10),
but as pregnancy progresses, it becomes more
challenging to diagnose pregnancy in the rudimentary horn [108]. Furthermore, it is difcult to
demonstrate the subtle anomalies associated with
this condition. 3D US is useful in evaluating uterine anomalies [103, 104, 108]. Even corneal HP
(Fig.9.11) can be detected with transvaginal US
[109].
9.2.4.2 Hysterosalpingography
Hysterosalpingography can miss a noncommunicating uterine horn [110]. Diagnostic hysteroscopy may indicate a major midline malformation
if tubal ostia are absent [111], although the procedure often needs to be done in conjunction with
laparoscopy and dye studies. There is a high level
of agreement between 3D US, hysterosalpingography, and laparoscopy in the classication of
uterine morphology [112, 113]. The enlarging
horn with thinned myometrium can obscure the
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217
Fig. 9.11 The image in the left panel shows an intrauterine gestation (black arrow) coexisting with an ectopic cornual pregnancy (*) with a sac of 25 mm in diameter,
containing an embryo with a crown-rump length of
13mm. The image in the right panel shows the ectopic
adjacent anatomic structures, and the sensitivity
decreases as the gestation increases.
9.2.4.3 Abdominal CT
Abdominal CT or MRI is indicated if transabdominal or transvaginal US is equivocal in a stable patient. Free peritoneal uid and the location
of corneal pregnancy can be visualized
(Fig.9.12).
9.2.4.4 Abdominal MRI
MRI accurately diagnoses pregnancy with a
Müllerian anomaly and placenta percreta [114].
MRI can dene a didelphys uterus with a fetus in
one of the uterine bodies (Fig.9.13). The placental invasion could remain elusive even with
abdominal MRI and is diagnosed only at laparotomy [87]. Intraoperatively, an extrauterine
pregnancy with a well-dened placenta differentiates a rudimentary horn pregnancy from an
abdominal pregnancy because the placenta ts
into the connes of the horn.
9.2.5 Treatment
pregnancy (*) located in the right cornual region in continuity with the uterine cavity, in a funnel-shaped area in the
upper uterine body that receives the insertion of the right
Fallopian tube (white arrow). (Reproduced with permission from [109] under the CC BY 3.0)
Fig. 9.12 Abdominal CT (coronal section) shows a
gravid uterus at the 7th week of pregnancy with a gestational sac towards the right side (arrow). A moderate
amount of free uid in the abdomen, especially around the
liver (arrowhead). (Reproduced with permission from
[107] under the CC BY 4.0)
9.2.5.1 Intra-Abdominal Access
Laparoscopic treatment of rudimentary horn
pregnancy is increasing [115–117]. Though the
gold standard for surgical management of hemodynamically stable women with EP, laparoscopy
had long been considered a contraindication in
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Fig. 9.13 Abdominal MRI (T2 coronal view) shows the
uterus (U) and the left rudimentary horn (R) pregnancy.
(Reproduced with permission from [84] under the CC BY
4.0)
women with hypovolemic shock. There is always
a concern of increased intra-abdominal pressure
on the diaphragm and stomach, posing a signicant threat to resuscitation and aspiration and
pressure on the blood vessels, resulting in reduced
cardiac output (see Chaps. 2 and 3). Most secondtrimester rudimentary horn pregnancies have been
managed by laparotomy [78, 80, 86, 118–120]
with some exceptions [121]. The reason is more
profuse bleeding from the enlarged uterus with
hemorrhagic shock. Regardless of the intraabdominal access, the fetus and the placenta
should be removed.
9.2.5.2 Procedures
Excision ofRudimentary Horn
withIpsilateral Salpingectomy
When diagnosed early, excision of the rudimentary horn with ipsilateral salpingectomy provides
the best prognosis. It eliminates the remote possibility of EP due to transperitoneal migration of
embryos [115, 122, 123]. Laparotomy is better
(Fig. 9.14) for signicant bleeding. In other
cases, laparoscopy (Fig. 9.15) is advantageous.
Tracking the course of the ureter on the side of
the horn is essential to avoid accidental injury.
Instilling vasopressin (20IU/mL in a dilution of
9 Ruptured Ectopic Pregnancy
Fig. 9.14 Caudal view of the left noncommunicating
horn (R) and the uterus (U) through Pfannenstiel incision.
(Reproduced with permission from [84] under the CC BY
4.0)
1:60 with normal saline) at the horn’s attachment
site aids in hemostasis [121]. The attachment of
the horn to the uterus can be divided by a medial
or lateral approach, depending upon the type of
attachment of the horn. A medial to lateral
approach is preferred if the horn is attached to the
uterus by a bromuscular band [115]. Here, the
uterine vessel medial to the horn is divided early
in dissection, preventing excessive blood loss
during surgery. The lateral to medial approach is
utilized if the horn has a broad sessile attachment
and the uterine vessel courses lateral to the horn.
Electrocoagulation, harmonic scalpel, or stapling
device can be used.
Even a spontaneous cornual rupture in the second trimester can undergo a direct repair of a
defect closed in two layers with absorbable interrupted intracorporeal mattress sutures [121].
Pregnancy can continue under strict monitoring,
followed by delivery via elective Cesarean section (CS) [125].
Cornuotomy andCornual Resection
Laparoscopic cornuotomy yields similar clinical results as cornual resection. Laparoscopic
cornuotomy may reduce operation time with a
similar incidence of persistent interstitial pregnancy [126]. However, laparoscopic cornuotomy is sometimes combined with MTX therapy
in ruptured EP complicated by persistent disease [127].
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