**6.1 Ultrasound**

Trans vaginal ultrasound scan is the corner stone for the early diagnosis of cornual ecopic. The ultrasonographic diagnosis of cornual ectopic is challenging and needs expert hands. The eccentric position of the gestational sac with an empty uterine cavity and the presence of a thin (less than 5 mm) or even absent myometrium surrounding the sac are highly suggestive of cornual ectopic pregnancy. (Timor-Tritsch IE et al, 1992; Johnson PT& Shah C). The diagnosis may be helped with the use of Doppler studies showing increase vasculature around the gestational sac. (Abraham D& Silkowski C, 2010). This is sometimes described as a ring of vessels (Ring of fire). It also helps to exclude pseudosac due to endometrial reaction. The gestational sac is usually seen away from the thickened endometrium associated with the pregnancy.

The ultrasound picture of cornual ectopic can be very similar to that of an early pregnancy in a bicornuate uterus or a fibroid uterus. Therefore the diagnosis of cornual ectopic should be made with caution, keeping in mind the possible differential diagnosis. (Abraham D& Silkowski C, 2010).

In experienced hands, trans-vaginal ultrasound can establish diagnosis of cornual ectopics in nearly 71% of cases.(Tulandi T& Al-Jaroudi D, 2004).

Fig. 2. Cornual ectopic located eccentrically within uterine cavity. Note the thin layer of myometrial tissue on the lateral aspect of gestational sac.

Trans vaginal ultrasound scan is the corner stone for the early diagnosis of cornual ecopic. The ultrasonographic diagnosis of cornual ectopic is challenging and needs expert hands. The eccentric position of the gestational sac with an empty uterine cavity and the presence of a thin (less than 5 mm) or even absent myometrium surrounding the sac are highly suggestive of cornual ectopic pregnancy. (Timor-Tritsch IE et al, 1992; Johnson PT& Shah C). The diagnosis may be helped with the use of Doppler studies showing increase vasculature around the gestational sac. (Abraham D& Silkowski C, 2010). This is sometimes described as a ring of vessels (Ring of fire). It also helps to exclude pseudosac due to endometrial reaction. The gestational sac is usually seen away from the thickened endometrium

The ultrasound picture of cornual ectopic can be very similar to that of an early pregnancy in a bicornuate uterus or a fibroid uterus. Therefore the diagnosis of cornual ectopic should be made with caution, keeping in mind the possible differential diagnosis. (Abraham D&

In experienced hands, trans-vaginal ultrasound can establish diagnosis of cornual ectopics

Fig. 2. Cornual ectopic located eccentrically within uterine cavity. Note the thin layer of

myometrial tissue on the lateral aspect of gestational sac.

**6. Diagnosis 6.1 Ultrasound** 

associated with the pregnancy.

in nearly 71% of cases.(Tulandi T& Al-Jaroudi D, 2004).

Silkowski C, 2010).

Fig. 3. Bicornuate uterus mimicking cornual ectopic pregnancy. Transverse transabdominal view shows bicornuate uterus with a pregnancy in right horn

The use of 3-D and 4-D improves sensitivity of establishing the diagnosis especially when contrast is used. (Lee GS et al, 2005; Chou MM et al, 2005). However, lack of its availability in many units limits their use as the recommended methods.

#### **6.2 Serial β hCG**

Ectopic pregnancy is known to be associated with a suboptimal increase or plateau of serum β hCG. (Banerjee S et al, 1999; Hajenius P et al, 1995) With a detection rate of 97% and a specificity of 77%, serial serum β hCG is useful to establish the diagnosis of ectopic pregnancy in association of the sonographic findings. (Cacciatore B et al, 1990)

In cornual ectopics, there are reports of doubling of serum β hCG, therefore the value of performing serial serum β hCG is doubtful and the results should be interpreted with caution. (Abraham D & Silkowski C, 2010)

#### **6.3 Role of laparoscopy**

Laparoscopy is an essential diagnostic tool as well as a possible treatment method route for suspected cornual ectopics. However, in cornual ectopics, difficulty arises with small ectopic masses that can be missed.

Experienced laparoscopic operator is crucial in such cases in order to have the ability to deal with possible high risk of heavy bleeding when treatment of cornual ectopics is accomplished laparoscopically.
