Surgical management with either cornual resection or cornuostomy may be performed via laparotomy or laparoscopy, depending on patient hemodynamic stability and surgeon expertise (Hofman, 2016; Zuo, 2012). With either approach, intraoperative intramyometrial vasopressin injection may limit surgical blood loss, and 3-hCG levels should be monitored postoperatively to exclude remnant trophoblast. Cornual resection removes the gestational sac and surrounding cornual myometrium by means of a wedge excision (Fig. 19-8). Alternatively, cornuostomy involves incision of the cornua and suction or instrument extraction of the pregnancy. Both instances require myometrial closure.
With early diagnosis, medical management may be considered. But because of the low incidence, consensus regarding methotrexate regimens is lacking. In their small series, J ermy and associates (2004) reported a 94-percent success with systemic MTX using a dose of 50 mg/m2 X BSA. Others have described direct MTX injection into the gestational sac (Framarino-dei-Malatesta, 2014). Importantly, because these women typically have higher initial serum 3-hCG levels, longer surveillance is usually needed.
The risk of uterine rupture with subsequent pregnancies following either medical or surgical management is unclear. hus, careful observation of these women during pregnancy, along with strong consideration of elective cesarean delivery, is warranted.
FIGURE 19-8 During cornual resection, the pregnancy, surrounding myometrium, and ipsilateral fallopian tube are excised en bloc. The incision is angled inward as it is deepened. This creates a wedge shape into the myometrium, which is then closed in layers with delayed-absorbable suture. The serosa is closed with subcuticular style suturing. (Reproduced with permission from Hofman BL, Corton MM: Surgeries for benign gynecologic conditions. In Hofman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 2016.)
Distinct from interstitial pregnancy, the term angular pregnany describes implantation within the endometrial cavity but at one cornu and medial to the uterotubal junction and round ligament. An angular pregnancy displaces the round ligament upward and outward, whereas an interstitial tubal pregnancy does not shift it (Arleo, 2014). This distinction is important because angular pregnancies can sometimes be carried to term but with increased risk of abnormal placentation and its consequences Qansen, 1981).
This term describes implantation within the myometrium of a prior cesarean delivery scar. Its incidence approximates 1 in 2000 normal pregnancies and has increased along with the cesarean delivery rate (Ash, 2007; Rotas, 2006). he pathogen esis of cesarean scar pregnancy (CSP) has been likened to that rhage (Timor-Tritsch, 2014a,b). It is unknown if the incidence increases with multiple cesarean deliveries or if it is afected by either one-or two-layer uterine incision closure during cesarean.
Women with CSP usually present early, and pain and bleed ing are common. Still, up to 40 percent of women are asymp tomatic, and the diagnosis is made during routine sonographic examination (Rotas, 2006). Sonographically, diferentiating be diicult (Moschos, 2008a; Timor-Tritsch, 2016). According to Godin (1997), four sonographic criteria should be satisied for the diagnosis and are described in Figure 19-9. Although TVS is the typical first-line imaging tool, MR imaging is useful when sonography is inconclusive (Huang, 2014; Osborn, 2012).