2084850 Ultrasound Guided Treatment of Heterotopic Cornual Pregnancy

To demonstrate ultrasound guided treatment of heterotopic cornual pregnancy via aspiration and instillation of hyperosmolar glucose. A 29 yo G2P0010 underwent in vitro fertilization (IVF) for secondary infertility. Two embryos were transferred to the uterus. Transvaginal ultrasound (TVUS, Philips iU22, C10-3v transducer) at 6+4 wk demonstrated a gestational sac in the left superolateral uterus with <3 mm of surrounding myometrium. Diagnosis of cornual ectopic was made. The patient received systemic methotrexate (MTX) but later experienced cornual rupture requiring emergent laparotomy and uterine repair. Three months later, hysterosalpingogram showed a normal uterus, free dye spill from the right tube and no left fill. A second IVF cycle was performed with two embryos transferred. TVUS at 5+1 wk revealed a heterotopic pregnancy with recurrent left cornual ectopic and concomitant intrauterine pregnancy (IUP). Options of systemic MTX, surgical intervention or needle-guided aspiration of the cornual ectopic with instillation of hyperosmolar glucose (D50) were offered. Given strong desire to preserve the IUP and avoid repeat surgery, the patient chose aspiration. A 16-gauge needle attached to a TVUS transducer (Philips C8-4v) was used to aspirate the cornual gestational sac using ultrasound guidance. The sac was noted to collapse and D50 (2 cc) was instilled. TVUS confirmed IUP viability at procedural start and end. No complications occurred. Serial TVUS revealed ongoing IUP development and a hyperechoic area in the left cornu at the site of the obliterated gestational sac. Incidence of ectopic pregnancy after IVF is 2%. Only 2% of ectopics are cornual. Heterotopic pregnancies occur in 1:30,000 natural conceptions but more often in women with assisted reproduction. We report a case of heterotopic pregnancy with recurrent cornual ectopic and concomitant IUP that was successfully treated in a non-surgical, TVUS-guided manner. Aspiration and instillation of D50 appears to be effective for select patients with early heterotopic or ectopic pregnancies. Particularly in cases where patients desire to minimize risk to the IUP, using glucose may be more attractive than local instillation of MTX or potassium chloride.