Cornual type 3 retained products of conception – a fertility-sparing win with methotrexate

Abstract

Retained products of conception (RPOC) with marked vascularity represent a diagnostic and therapeutic challenge due to the high risk of hemorrhage associated with surgical evacuation. Cornual localization further complicates management because of minimal myometrial thickness and proximity to major vascular structures. Cornual ectopic pregnancies are broadly classified into interstitial, angular, and true cornual types, each differing in anatomical location and clinical implications. Advanced imaging and individualized management are crucial, particularly in women desiring future fertility. We report a case of a 34-year-old multiparous woman with prior cesarean section who presented with amenorrhea of 2 months following dilatation and curettage for a blighted ovum. The patient was examined and was vitally stable. Further investigations were done. Her ultrasound with color Doppler demonstrated a highly vascular lesion with high peak systolic velocity in uterine cornua, with thin myometrium and findings to be correlated with beta human chorionic gonadotropin (β-hCG) and magnetic resonance imaging (MRI) SOS. Her β-hCG was negligible. Magnetic resonance imaging revealed a well-defined hyperintense lesion in the right uterine cornua with beak-like communication with the endometrial cavity, consistent with hyper vascular cornual RPOC. The patient was hemodynamically stable and desirous of future fertility and was managed conservatively with multidose methotrexate therapy. Serial Doppler follow-up demonstrated progressive reduction in vascularity and lesion size, followed by spontaneous expulsion. This case represents a diagnostic conundrum, as the patient presented with persistent amenorrhea following curettage rather than the typical bleeding seen with retained products of conception. The key differential diagnoses include Asherman syndrome, retained products of conception, chronic endometritis, and persistent trophoblastic activity. This case also highlights the need for a high index of clinical suspicion in atypical presentations, with supportive investigations aiding in differentiating hypervascular RPOC from cornual ectopic pregnancy and uterine arteriovenous malformation. Conservative medical management with methotrexate can be a safe and fertility-preserving option in carefully selected patients.