{"paper_id":"5cf42167-d58b-4808-9586-946ad8c18020","body_text":"Obstetrics and \nGynaecology Cases - Reviews\nPiriyev et al. Obstet Gynecol Cases Rev 2020, 7:166\nVolume 7 | Issue 3\nDOI: 10.23937/2377-9004/1410166\nISSN: 2377-9004\nOpen Access\nPiriyev et al. Obstet Gynecol Cases Rev 2020, 7:166\n• Page 1 of 4 •\nCitation: Piriyev E, Mellin W, Römer T (2020) A Rare Case: Nodular Adenomyosis Can Deceive Cornual \nEctopic Pregnancy. Obstet Gynecol Cases Rev 7:166. doi.org/10.23937/2377-9004/1410166\nAccepted: July 01, 2020: Published: July 03, 2020\nCopyright: © 2020 Piriyev E, et al. This is an open-access article distributed under the terms of the \nCreative Commons Attribution License, which permits unrestricted use, distribution, and reproduction \nin any medium, provided the original author and source are credited.\nA Rare Case: Nodular Adenomyosis Can Deceive Cornual Ectopic \nPregnancy\nElvin Piriyev1* , Walter Mellin² and Thomas Römer¹\nIntroduction\nAdenomyosis refers to the occurrence of the endo -\nmetrial glands and surrounding stroma within the uter-\nine myometrium. A distinction is made between diffuse \nand focal forms: rare nodular forms and adenomyoma \n[1,2]. Adenomyoma is a tumor-like lesion of adenomy-\nosis uteri with structurally complex endometrial glands \nin a hyperplastic stroma consisting of smooth muscles \nor leiomyo fibromatous tissue [2,3]. About 1% of the af-\nfected patients are under 40 years of age, in these cases \nthe reproductive phase of the woman is affected [4].\nEctopic pregnancy (EUG) occurs in about 1.5 to 2.0% \nof pregnancies and can be a life-threatening event. Such \npregnancies cause 6% of all maternal deaths in gyne -\ncology [5]. 2% of all EUG are cornual/intramural preg -\nnancies [6]. Ascornual/intramural gravity is a pregnancy \nimplanted in the myometrium and not surrounded by \ndecidua. Risk factors are previous adnexitis and internal \ngenital surgery, in particular homolateral salpingecto -\nmy, and adenomyosis uteri. Cornual/intramural preg -\nnancies are very rare [7,8].\nCase Report\nA 33-year-old GII/PI patient presented herself with \nvaginal bleeding in the 6 th week of pregnancy in our \nemergency department. Sonographically, one could \n*Corresponding author: Elvin Piriyev, Dr. Med, Department of Obstetrics and Gynaecology, Academic Hospital Cologne-\nWeyertal, University of Cologne, Germany\n1Department of Obstetrics and Gynaecology, Academic Hospital Cologne-Weyertal, University of Cologne, Germany\n2Center for Pathology and Cytology, Weyertal, Germany\nCasE  REPoRT\nCheck for\nupdates\nAbstract\nAdenomyosis refers to the occurrence of ectopic endome -\ntrial glands and the surrounding stroma within the myo-\nmetrium. A distinction is made between diffuse and focal \nforms (rare nodular forms and an adenomyoma). Ectopic \npregnancy (EUG) occurs in about 1.5 to 2.0% of pregnan -\ncies and can be a life-threatening event. 2% of all EUG are \ncornual/intramural ectopic pregnancy. We present the case \nof a 33-year-old women (GII/PI) who complained about vag-\ninal bleeding in the 6th week of pregnancy. The next pres-\nentation took place in 7 + 3 gestational weeks due to con-\ntraction-like pain in the lower abdomen and constant pain \nin the right lower abdomen. Sonographically we discovered \nthe intrauterine amniotic cavity with an abnormal embryonic \ndevelopment, an intracavitary hematoma and a “thickening” \nin the right tube angle. After 4 days (8 + 0 weeks of gesta-\ntion), the patient complained again with constant pain in the \nright lower abdomen comparable to dysmenorrhea. Sono-\ngraphically, an empty amniotic cavity and a cystic mass in \nthe right-angle of fallopian tube continued to be present. \nHCG was 6774 mIU/ml. With the high suspicion of a cornu-\nal ectopic pregnancy, a laparoscopy and a curettage were \nindexed. Intraoperatively, a protrusion in the right-angle \nof fallopian tube was present. The finding was cut with a \nmonopolar needle and a chocolate-like secretion emptied. \nHere, endometrial tissue became apparent. A wedge resec-\ntion was carried out with the removal of the entire ectopic \nendometrial tissue. After the histological processing of the \npreparation, endometriosis with a moderate proliferative \nactivity emerged: Ki 67 of 10%. In the abrasion material a \ngestational sac, as well as parts of pregnancy-typical endo-\nmetrium were detected. In case of a sonographically seen \ngestational sac located at the angle of a fallopian tube, one \nshould think of a cornual/interstitial localization of a EUG. \nHowever, even in nodular adenomyosis a cystic finding may \nform as it was proven in our case. Therefore, in order to for-\nmulate a precise and reliable diagnosis a laparoscopy with \ntissue removal for histological may be necessary.\nKeyword\nNodular adenomyosis, Cornual pregnancy, Ectopic preg-\nnancy, Endometriosis\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410166\nPiriyev et al. Obstet Gynecol Cases Rev 2020, 7:166\n• Page 2 of 4 •\ndetect an intrauterine amniotic cavity corresponding \nto the week of pregnancy. Thus, physical rest and a fol -\nlow-up were initially recommended (Figure 1).\nAt the time of 7 + 3 gestational weeks the patient \npresented herself again with the main complaints of \ncontraction-like pain in the lower abdomen, constant \npain in the right lower abdomen and persistent vaginal \nbleeding. Sonographically, an amniotic sac without an \nembryo and an intracavitary hematoma were found, \nwhich gave rise to the suspicion of an abortus incipiens. \nThis ultrasound showed a “thickening” in the right uter-\nus horn/angle of fallopian tube. The patient reported \nthat she had been suffering from pain of similar nature, \ndescribed as severe dysmenorrhea in the right lower ab-\ndomen already before pregnancy (Figure 2 and Figure \n3).\nThe patient did not want any further therapy at this \ntime.\n4 days later, the patient still suffered from constant \npain in the right lower abdomen, as in dysmenorrhea. \nA vaginal examination in the right lower abdomen was \nvery painful for the patient. The β-HCG value at that \ntime was 6774 mIU/ml. Sonographically, an empty am-\nniotic cavity and a cystic mass at the angle of the right \nfallopian tube continued to be present. There was an ur-\ngent suspicion of a cornual pregnancy, so that laparos -\ncopy and simultaneous curettage were indexed (Figure \n4 and Figure 5).\nThe patient underwent surgery on the same day. In \nthe curettage, a lot of pregnancy-typical material was \nobtained. Subsequently, laparoscopy took place. Intra-\noperatively, a protrusion was present at the angle of the \nright fallopian tube. Through an incision with a monop -\nolar needle and chocolate-like secretion was drained \noff. Also, endometrial-typical tissue emerged. Wedge \nresection was carried out with removal of the entire \nendometrial tissue after injection of diluted adrenalin. \n \nAmniotic cavity \nFigure 1: Uterus in sagittal section (6 gestation weeks).\n \nAmniotic cavity \nhematoma \nFigure 2: Uterus in the sagittal section (7 + 3 gestation weeks).\n \nAmniotic cavity \nthickening \nFigure 3: Uterus in cross section (7 + 3 SSW).\n \ncavity Cyst in \nrightuterus\nhorn \nFigure 4: Uterus in sagittal section (8 + 0 gestation weeks).\n \ncavity Cyst in \nrightuterus\nhorn \nFigure 5: Uterus in cross section (8 + 0 gestation weeks).\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410166\nPiriyev et al. Obstet Gynecol Cases Rev 2020, 7:166\n• Page 3 of 4 •\nadenomyoma is destroying the myometrium whereas \nmyomas merely displace the myometrium [11].\nIf pregnancy is excluded, hormonal therapy can also \nbe performed. Progestins are available in the various \napplication forms. Orally, combined ovulation inhibitors \ncan be used especially in the long-cycle regime as well \nas progestogen-only preparations. Using a LNG-IUS lo -\ncally is also worth considering, because there is a very \ngood data situation for Levonorgestrel containing intra-\nuterine device (LNG-IUS) [12].\nThe treatment of cornual pregnancy is distinguished \nin surgical and drug therapy with methotrexate. Howev-\ner, in cornual pregnancies, wedge resection with remov-\nal of the entire chorial tissue appears to be the therapy \nof choice [13].\nConclusion\nThe clinical differential diagnosis between nodular \nadenomyosis in an angle of fallopian tube during preg -\nnancy and a cornual ectopic pregnancy is very difficult. \nSonography can be a valuable tool in diagnosis. In the \ncase of a gestational sac in an angle of fallopian tube, \none should think of an interstitial or cornual localiza -\ntion of a EUG. However, even in nodular adenomyosis \na cystic finding may form as it was proven in our case. \nTherefore, in order to formulate a precise and reliable \ndiagnosis a laparoscopy with tissue removal for histo -\nlogical may be necessary.\nConflict of Interest\nThe authors declare that they have no conflict of in -\nterest.\nSource of Funding\nThis manuscript was not funded.\nInformed Consent\nThe patient has consented to this manuscript.\nEthics Approval\nThis manuscript was carried out in consensus with \nour university´s ethics guidelines.\nReferences\n1. Bergeron C, Amant F, Ferenczy A (2006) Pathology and \nphysiopathology of adenomyosis. Best Pract Res Clin Ob-\nstet Gynaecol 20: 511-521.\n2. Nawroth F, Romer T (2015) Diagnostics and therapy of fe-\nmale sterility. De Gruyter.\n3. Rabe T, Schweppe KW, Ebert AD, Mlynek-Kersjes ML, \nMerkle E, et al. (2017) Adenomyosis uteri. J Reprodukti -\nonsmed Endokrinol 14: 211-218.\n4. Devlieger R, D’Hooghe T, Timmerman D (2003) Uterine \nadenomyosis in the infertility clinic. Hum Reprod Update 9: \n139-147.\n5. Barnhart KT (2009) Ectopic Pregnancy. N Engl J Med 361: \n379-387.\nThe wound was treated with resorbable suture material \n(Figure 6).\nPostoperatively, the patient became free of com-\nplaints. After inconspicuous checks, she was discharged \nafter two days in good health.\nHistological processing of the obtained material \nshowed following results:\nI. Abortion material: Gestational sac with hydropic re -\ngressive changes and part of pregnancy-typical en-\ndometrium.\nII. Uterine exudation: An endometriosis with a moder-\nate degree of proliferative activity: Ki 67 of 10%.\nIn this case two findings were seen at once: On one \nhand, there was a pregnancy and subsequent early \nspontaneous abortion. On the other hand, the patient \nhad a nodular adenomyosis in the right uterine horn, \nwhich developed further during pregnancy. The β-HCG \nvalue fell to 1288 mIU/ml on the first postoperative day. \nThe further postoperative controls were inconspicuous.\nDiscussion\nIn local adenomyosis, uterine-preserving resection \ncan take place. In nodular adenomyosis, a resection or \na volume reduction of adenomyosis can be sought. The \nadenomyoma should be resected, similar to the man-\nagement of uterine fibroids, especially in patients who \nwish to have children with findings > 4 cm [9,10]. How-\never, the procedure of resecting adenomyoma is techni-\ncally more demanding than extracting myomas, because \n \n \nUterus righthorn \nEndometrium \nTube \nUterus \nUterus righthorn \nFigure 6: Wedge resection was carried out with removal of \nthe entire endometrial tissue.\n\nISSN: 2377-9004\nDOI: 10.23937/2377-9004/1410166\nPiriyev et al. Obstet Gynecol Cases Rev 2020, 7:166\n• Page 4 of 4 •\n10. Zepiridis LI, Grimbizis GF, Tarlatzis BC (2016) Infertility and \nuterine fibroids. Best Pract Res Clin Obstet Gynaecol 34: \n66-73.\n11. Grimbizis GF, Mikos T, Tarlatzis B (2014) Uterus-sparing \noperative treatment for adenomyosis. Fertil Steril 101: 472-\n487.\n12. Romer T, Buhling KJ (2019) Updated consensus recom-\nmendation on the use of LNG-IUS. Drug Report 1-32.\n13. Auslender R, Arodi J, Pascal B, Abramovici H (1983) Inter-\nstitial pregnancy: Early diagnosis by ultrasonography. Am J \nObstet Gynecol 146: 717-718.\n6. James AH (2019) Bleeding and the management of hem-\norrhagic disorders in pregnancy. Consultative Hemostasis \nand Thrombosis (Fourth Edition).\n7. Lermann J, Muller A, Schulze C, Becker S, Boosz A, et al. \n(2009) Die Extrauteringraviditat. Frauenheilkunde 383-402.\n8. Pritchard JA, MacDonald PC, Gant NF, J Whitridge Willi-\nams (1985) Williams obstetrics. (17\nth edn), Appleton-Centu-\nry Croft, Norwalk, Connecticut, 423-438.\n9. Schindler AE (2008) Surgical and drug therapy for endome-\ntriosis/adenomyosis. J Gynakol Endokrinol 18: 18-26.","source_license":"CC0","license_restricted":false}