**7. Management of cornual ectopic**

Early diagnosis allows a varied choice of treatment options with a high possibility of preserving fertility.

Modern Management of Cornual Ectopic Pregnancy 243

The Body surface area is calculated and a single dose 50 mg/m2 is given Intra-muscularly. This dose has been shown to be effective with < 15% needs additional treatment with least side effects compared to other regimens. (Royal College of Obstetricians and Gynaecologists, 2004; Yao M& Tulandi T, 1997; Sowter M& Frappell J, 2002; Kelly H et al, 2006; Teal SB, 2006) The possible side effects of Methotrexate includes, GIT upset, Conjunctivitis and photosensitivity, pneumonitis, reversible alopecia, liver or renal impairment, myelosuppression and possible teratogenicity, so the patient should not conceive within 3 months of completion of treatment. (Royal College of Obstetricians and Gynaecologists,

Following the injection of Methotrexate, follow-up β hCG should be done on day 4 and day 7 after the treatment aiming check to for the decreasing levels. An initial rise may be observed but an expected drop of > 15% is expected between day 4 and day 7 in successfully treated ectopics. (Yao M& Tulandi T, 1997; Sowter M& Frappell J, 2002)A weekly follow-up is needed till non pregnant levels of β hCG. (Royal College of Obstetricians and

Liver function tests may need to be repeated at the same time as the β hCG due to the possible side effects of Methotrexate on Liver Function. Throughout the follow–up duration, the patients should maintain an easy access to the hospital and informed to come back if

The systemic route of administration offers advantages over local injection of the ectopic gestation as it is less invasive and not operator dependent. (Royal College of Obstetricians

Methoterxate can be injected directly into the ectopic sac through the myometrium under transvaginal ultrasound guidance or alternatively during the laparoscopic procedure.

Either of these treatment options aimed to reduce the systemic exposure and side effects of Methotrexate with a chance of spontaneous resolution of ectopics in some studies can be as

Local potassium chloride injection has been used as alternative to Local Methotrexate with promising results. It is used mainly if the patient is keen on conceiving soon after the

Surgical management depends mainly on the presenting condition of the patient and the skills of the operating surgeon. Cornual ectopic has been reported to be treated by variation of procedures mainly cornuotomy, cornual resection and a more radically a hysterectomy. The latter has only a role in a life saving condition when other methods has been tried and exhausted. However, in experienced hand, it is nearly always possible to avoid a hysterectomy even in haemodynamically unstable patients with ruptured ectopic

In cornuotomy or cornual resection, the usage of diathermy or harmonic scalpel in the dissection can help in the reduction of blood loss. Intracorporeal knots of the PDS or Vicryl stitches can be used to close the cornual resection site. The round ligament could be used to

they experience pain or bleeding. (Sowter M et al, 2001; Mol B et al, 1999)

(Timor-Tritsch IE, 1997; Benifla JL et al, 1996; Onderoglu LS et al, 2006)

2004; Barnhart KT et al, 2003).

Gynaecologists, 2004)

and Gynaecologists, 2004)

**7.1.2 Local methotrexate** 

high as 100%. (Monteagudo A et al, 2005)

ectopic. (Doubilet PM et al, 2004)

**7.2 Surgical management 7.2.1 Surgical techniques** 

pregnancy.

Fig. 4. Left cornual ectopic

#### **7.1 Medical treatment**

#### **7.1.1 Systemic methotrexate**

An increasing number of cornual ectopic have been treated with Methotrexate. This is mainly due to the accuracy of the ultrasound scan in confirming the diagnosis as well as the wide spread experience in the use of Methotrexate in the management of ectopic pregnancies.

Patients suitable for medical management should have minimal or no symptoms, be haemodynamically stable (Royal College of Obstetricians and Gynaecologists, 2004) , and with β hCG < 3000 IU. (Yao M& Tulandi T, 1997; Sowter M& Frappell J, 2002; Kelly H et al, 2006; Teal SB, 2006). It is more successful if no fetal heart beats(Yao M& Tulandi T, 1997; Sowter M& Frappell J, 2002) are detected in the ectopic pregnancy and the ectopic size is < 4 cm. Patients should be willing to attend regular follow up and have no contraindication for Methotrexate. (Royal College of Obstetricians and Gynaecologists, 2004)

There is no clear data regarding the effect of ectopic size on the treatment outcome but the larger the ectopic the more likely the treatment fails. (Lipscomb G et al, 1999)The patient should be given clear and written information about the Methotrexate treatment protocol, its success rate and the possible adverse effects. (Royal College of Obstetricians and Gynaecologists, 2004) A clear follow-up protocol should be explained to the women with explanation of possible symptoms or ruptured ectopic. (Royal College of Obstetricians and Gynaecologists, 2004) The possible need for further treatment either electively or as an in case of emergency should be documented and the women should be given a contact number for advice or emergency. (Royal College of Obstetricians and Gynaecologists, 2004)

Identified patients for medical treatment should have blood tests for Full Blood Count, Liver Function Tests and Renal function tests before starting the Methotrexate treatment. (Royal College of Obstetricians and Gynaecologists, 2004; Kelly H et al, 2006; Teal SB, 2006).

An increasing number of cornual ectopic have been treated with Methotrexate. This is mainly due to the accuracy of the ultrasound scan in confirming the diagnosis as well as the wide spread experience in the use of Methotrexate in the management of ectopic pregnancies. Patients suitable for medical management should have minimal or no symptoms, be haemodynamically stable (Royal College of Obstetricians and Gynaecologists, 2004) , and with β hCG < 3000 IU. (Yao M& Tulandi T, 1997; Sowter M& Frappell J, 2002; Kelly H et al, 2006; Teal SB, 2006). It is more successful if no fetal heart beats(Yao M& Tulandi T, 1997; Sowter M& Frappell J, 2002) are detected in the ectopic pregnancy and the ectopic size is < 4 cm. Patients should be willing to attend regular follow up and have no contraindication for

There is no clear data regarding the effect of ectopic size on the treatment outcome but the larger the ectopic the more likely the treatment fails. (Lipscomb G et al, 1999)The patient should be given clear and written information about the Methotrexate treatment protocol, its success rate and the possible adverse effects. (Royal College of Obstetricians and Gynaecologists, 2004) A clear follow-up protocol should be explained to the women with explanation of possible symptoms or ruptured ectopic. (Royal College of Obstetricians and Gynaecologists, 2004) The possible need for further treatment either electively or as an in case of emergency should be documented and the women should be given a contact number

Identified patients for medical treatment should have blood tests for Full Blood Count, Liver Function Tests and Renal function tests before starting the Methotrexate treatment. (Royal

for advice or emergency. (Royal College of Obstetricians and Gynaecologists, 2004)

College of Obstetricians and Gynaecologists, 2004; Kelly H et al, 2006; Teal SB, 2006).

Methotrexate. (Royal College of Obstetricians and Gynaecologists, 2004)

Fig. 4. Left cornual ectopic

**7.1 Medical treatment 7.1.1 Systemic methotrexate**  The Body surface area is calculated and a single dose 50 mg/m2 is given Intra-muscularly. This dose has been shown to be effective with < 15% needs additional treatment with least side effects compared to other regimens. (Royal College of Obstetricians and Gynaecologists, 2004; Yao M& Tulandi T, 1997; Sowter M& Frappell J, 2002; Kelly H et al, 2006; Teal SB, 2006) The possible side effects of Methotrexate includes, GIT upset, Conjunctivitis and photosensitivity, pneumonitis, reversible alopecia, liver or renal impairment, myelosuppression and possible teratogenicity, so the patient should not conceive within 3 months of completion of treatment. (Royal College of Obstetricians and Gynaecologists, 2004; Barnhart KT et al, 2003).

Following the injection of Methotrexate, follow-up β hCG should be done on day 4 and day 7 after the treatment aiming check to for the decreasing levels. An initial rise may be observed but an expected drop of > 15% is expected between day 4 and day 7 in successfully treated ectopics. (Yao M& Tulandi T, 1997; Sowter M& Frappell J, 2002)A weekly follow-up is needed till non pregnant levels of β hCG. (Royal College of Obstetricians and Gynaecologists, 2004)

Liver function tests may need to be repeated at the same time as the β hCG due to the possible side effects of Methotrexate on Liver Function. Throughout the follow–up duration, the patients should maintain an easy access to the hospital and informed to come back if they experience pain or bleeding. (Sowter M et al, 2001; Mol B et al, 1999)

The systemic route of administration offers advantages over local injection of the ectopic gestation as it is less invasive and not operator dependent. (Royal College of Obstetricians and Gynaecologists, 2004)

#### **7.1.2 Local methotrexate**

Methoterxate can be injected directly into the ectopic sac through the myometrium under transvaginal ultrasound guidance or alternatively during the laparoscopic procedure. (Timor-Tritsch IE, 1997; Benifla JL et al, 1996; Onderoglu LS et al, 2006)

Either of these treatment options aimed to reduce the systemic exposure and side effects of Methotrexate with a chance of spontaneous resolution of ectopics in some studies can be as high as 100%. (Monteagudo A et al, 2005)

Local potassium chloride injection has been used as alternative to Local Methotrexate with promising results. It is used mainly if the patient is keen on conceiving soon after the ectopic. (Doubilet PM et al, 2004)
