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CASE REPORTS
Primary Ovarian Ectopic Pregnancy Progressed to 28 Weeks, Mimicking An Intrauterine Foetal Death
Punam M Satpute, Sneha D Shirodkar, Vaishali Patil, Vijay R Badhwar
Primary ovarian ectopic of 28 wks gestation mimicking an intrauterine foetal death is rare. The diagnosis is usually surgical, however, an unyielding cervical os and failure of medical induction of labour, should alert the obstetrician of an extrauterine gestation. Presented here is a 28 weeks primary ovarian ectopic with foetal death, that mimicked an intrauterine foetal death clinically, was missed by 2 transabdominal USG scans and was suspected only after failed medical induction of labour. Timely surgical intervention before disseminated intravascular coagulopathy sets in, is recommended.
INTRODUCTION
Primary ovarian ectopic pregnancy is an uncommon ectopic gestation and accounts to 0.3-3% of all ectopic gestations. It is rare to progress upto 28 weeks. It is usually known to mimic an ovarian tumour, but to mimic a 28 week intrauterine gestation with foetal death clinically, and mislead by ultrasound, makes this an interesting case.
CASE REPORT
A 30 year primigravida with 7 months of amenorrhoea, conceived spontaneously after 11 yrs of infertility, was referred as a c/o IUFD. O/E - A single IUFD of 28 wks in a longitudinal lie with cephalic presentation and a relaxed uterus were noted. Pervaginum - 2.5 cm long tubular uneffaced cervix with a pinpoint external os and a closed internal os were seen. USG confirmed an IUFD of 28 wks (spalding sign+). Since it was a precious conception, patient repeated and confirmed the IUFD with her own sonologist. Routine investigations were WNL. Coagulation tests (BT-50 secs, CT - 4 1/2 minutes) were also WNL.
A medical induction of labour with EAEI was resorted to, however the tip of the Foley’s catheter could not navigate the internal os and would coil within the cervical canal on manual pressure. Hence, cervical ripening with PGE2 gel was repeated twice over 24 hours. It had no result. Even slow intravenous pitocin induction over the next 48 hours had no result. Clotting time by now had increased to 13 minutes and an extrauterine gestation was suspected and surgical exploration was undertaken.
A dead foetus of 28 wks was lying in a bluish vascular sac to the right of a bulky (10 wk sized) uterus, and had occupied the pelvis and the abdomen, mimicking a gravid uterus (Fig 1). The uterus itself was pushed to the extreme left and underwent a 45o anticlockwise torsion. The right tube was traced intact from the right cornua to the fimbrial end and was anterior to the sac (Fig. 2). Right ovary was absent. Left ovary and tube were normal. Only after adhesiolysis (between sac wall and the colon, the bladder, the right infundibulopelvic ligament) a vascular attachment of the sac to the uterus was identified.
Evacuation of the stillbirth, 250 gms of clots and placenta was done with excision of the sac. Uterus being bulky, a D and C was done. H/P/E showed sac wall with multiple follicles of ovarian origin, thickness varying between 4-10 mm and decidualisation changes in the endometrium.
DISCUSSION
1o Primary ovarian ectopic progressing up to 28 wks is rare as the ovary can accommodate the pregnancy for a short duration upto 3 wks, after which it bursts.1 Another such 2nd trimester ectopic has been reported by Seki et al in Japan.2 Ovarian hyperstimulation, intrauterine contraceptive device and assisted reproduction technologies are the reported aetiologies.3-5 But in our case, it had occurred spontaneously after prolonged period of infertility (which was uninvestigated). Small ectopics simulate ovarian tumours and are diagnosed an hCG and TVS; but these are of little value for the ectopic size encountered by us. Torsion of the uterus could augment the unyielding nature of the internal os, which along with failure of medical induction of labour are signs to alert the obstetrician of an extrauterine gestation. Ultrasound can be misleading and the obstetrician may get carried away from the clinical signs. Usually in an IUFD labour sets in 3 wks time; in our case, the ovarian capsule presentation if a conservative approach for IUFD was taken. Surgical decision of exploration should be taken before DIC sets in. Von Speigelberg’s 4 criteria for ovarian ectopic were met in our case.1 Heterotopic gestations (ovarian + intrauterine) are known hence D and C was also done.6 Placenta removal is known to cause severe haemorrhage needing Ectoposide therapy,2 but we had no such problems.
The foetus outgrew its blood supply causing the foetal death. The entire ovarian tissue was consumed in the huge ectopic sac and due to absent healthy ovarian tissue on the right side, it could not be salvaged.
ACKNOWLEDGEMENTS
We thank our Dean and the Head of the department to permit us to publish our hospital data.
REFERENCES
1. Jeffcoate’s Principles of Gynaecology. VR Tindall, Butterworths, 5th edition. 222.
2. Seki H, et al. J Obstet Gynaecol Res 1997; 23 (6) : 543-6.
3. Bontis J, et al. J Human Reproduction 1997; 12 (2) : 376-8.
4. Einenkel J, et al. J Human Reproduction 2000; 15 (9) : 2037-40.
5. AL - Meshari AA. Int J Gynaecol Obstet 1993; 41 (3) : 269-72.
6. Diallo D, et al. Gynaecol Obstet Biol Reproduction (Paris) 2000; 29 (2) : 131-41.
VITAMIN D THREE TIMES A YEAR CAN PREVENT FRACTURES
Supplementation with vitamin D every four months for five years reduced the number of first fractures in men and women aged 65 and older living in the community. Trivedi and colleagues found that supplementation with 100 000 IU oral vitamin D reduced the incidence of fracture by 22%. Most fracture prevention trials have focused on clinically defined high risk groups and women, and many effective interventions may not be feasible or cost effective in the general populations. This simple, safe, and low cost intervention may reduce osteoporotic fractures in the general community.
BMJ, March, 2003; 326 : 469.
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