Ectopic pregnancy accounts for 1–2% of all pregnancies, with cornual pregnancies representing 2–4% of these cases [1]. Due to its myometrial implantation, cornual ectopic pregnancy poses a higher risk of rupture and severe hemorrhage compared to tubal pregnancies [2].

Cornual pregnancy, also referred to as interstitial pregnancy, occurs when the gestational sac implants within the interstitial portion of the fallopian tube that traverses the muscular wall of the uterus. This unique location allows the pregnancy to grow undetected longer than typical tubal ectopics, increasing the risk of life-threatening rupture.

Risk factors include a history of pelvic inflammatory disease, previous ectopic pregnancy, assisted reproductive techniques (ART), and uterine anomalies such as rudimentary horns or prior uterine surgeries like cesarean section [3].

Diagnosis is often delayed due to non-specific clinical symptoms including abdominal pain and vaginal bleeding, which mimic other gynecologic or gastrointestinal conditions. Transvaginal ultrasound is the key imaging modality, though it requires a high level of suspicion and expertise. The “interstitial line sign” is considered a valuable sonographic marker [4].

Recent epidemiological data suggest that the incidence of cornual pregnancies is increasing due to greater use of ART and improved imaging techniques [5]. However, they still remain rare and potentially catastrophic events, underlining the importance of timely diagnosis and appropriate management.

A 32-year-old woman, gravida 2 para 1, presented to the emergency department with severe, sharp pelvic pain rated 8/10 on the visual analog scale, and mild vaginal bleeding at six weeks of gestation. She had no significant medical history, and her previous pregnancy was uneventful.

Upon examination, the patient was hemodynamically stable: blood pressure was 110/70 mmHg, pulse rate was 84 bpm, respiratory rate 16/min, and temperature 36.8 °C. Abdominal palpation revealed mild tenderness in the right lower quadrant without guarding or rebound tenderness. There were no signs of peritoneal irritation.

Transvaginal ultrasonography demonstrated an empty endometrial cavity with a hematosalpinx measuring 3 cm in the right cornual region, surrounded by myometrium of less than 5 mm thickness (Figure 1).

Laboratory investigations revealed a hemoglobin level of 12.5 g/dL and a serum beta-hCG level of 15,000 mIU/mL, consistent with an early viable pregnancy. White blood cell count and inflammatory markers (CRP) were within normal limits.

Given the risk of rupture, a laparotomic approach was preferred. Intraoperatively, a distended right cornual mass was visualized without signs of rupture. The ectopic pregnancy was carefully removed while preserving the cornual region. Hemostasis was successfully achieved, and the procedure was well tolerated (Figure 2 and Figure 3).

The patient recovered uneventfully and was discharged on postoperative day three with a beta-hCG follow-up plan.

Cornual pregnancies are rare but associated with high morbidity and mortality due to their late presentation and risk of catastrophic hemorrhage [6].

Management strategies include medical treatment with methotrexate, surgical removal via laparotomy or laparoscopy, and interventional radiology in select cases [7],[8]. Laparotomy is often preferred in cases where laparoscopic management is not feasible or when uterine preservation is prioritized [9].

Several case reports have documented the successful management of cornual pregnancies using minimally invasive techniques, including laparoscopic cornual resection or ultrasound-guided local injection of methotrexate [6],[7]. However, in cases where there is significant risk of rupture or hemodynamic instability, laparotomy remains the safest approach. In our case, laparotomy was chosen due to the advanced gestational age, the need for direct visualization, and the desire to minimize intraoperative bleeding and preserve future fertility.

Recent guidelines suggest that early diagnosis using transvaginal ultrasound and timely intervention are key to reducing maternal morbidity and mortality. Conservative surgery that preserves the uterus is recommended for women desiring future pregnancies, provided that hemostasis and uterine integrity can be maintained [8],[9].

From a diagnostic standpoint, cornual pregnancy must be differentiated from angular pregnancy, which occurs within the uterine cavity but near the cornual region, and from interstitial pregnancy, which involves the intramural segment of the fallopian tube. The distinction is critical as the management and prognosis differ.

Moreover, in women with a history of prior abdominal or pelvic surgery, rare conditions such as gossypiboma (retained surgical sponge) should also be considered. These may present with non-specific abdominal pain or mass and can mimic ectopic pregnancy on imaging. As noted by Sheikh et al., retained surgical materials can remain undetected for years and should not be overlooked when establishing differential diagnoses [10],[11].

This case emphasizes the importance of individualized treatment planning and the role of conservative yet safe surgical intervention. Fertility counseling and follow-up are also crucial components of comprehensive care.

Cornual ectopic pregnancy remains a diagnostic and therapeutic challenge. Early recognition using transvaginal ultrasound and prompt surgical intervention are crucial in preventing life-threatening complications.

This case highlights the importance of conservative surgical management through laparotomy as a safe and effective treatment option, particularly when uterine preservation is a priority.

Postoperative follow-up is essential, including serial beta-hCG monitoring to ensure complete resolution. Patients should also receive appropriate counseling regarding the risk of recurrence in future pregnancies and the potential need for early transvaginal ultrasound in subsequent gestations to confirm intrauterine implantation.