A case
is reported of advanced abdominal ectopic pregnancy secondary to primary
ovarian pregnancy. The placental implantation was in the posterior
wall of uterus burrowing into the myometrium and the right tube and
ovary.
Introduction
Abdominal pregnancy is a reasonably uncommon entity. The frequency
ranges from 1 in 11361 to 1 in 50,820.2 The frequency seem influenced
by socio-economic factors race and standards of obstetrics care.
Case Report
Mrs. M, a 26 year old, married since 15 years, a G4P2L2A1 with 7 months
amenorrhoea came in the emergency services on 9th April 2003 referred
from peripheral government Hospital in view of anaemia with impending
cardiac failure in preterm labour. The patient gave complaints on
admission of breathlessness since 2 days, bilateral pedal oedema since
10 days, with pain in abdomen since 10 days. There was no significant
past history of medical illness. Obstetric history revealed two full
term normal vaginal deliveries, one 8 year old male child and a six-year
old female child. Here third conception had developed an IUFD at 5
months of gestational age. There was a history of failed induction
of abortion for which procedure of hysterotomy had to be performed.
Further details of the operative procedure were not available.
On examination, pulse was 100/min, regular low volume, blood pressure
was 100/70 mm Hg, cardio-vascular examination revealed soft, haemic
murmur. Respiratory system examination revealed bilateral equal air
entry. Pallor was present, bilateral pedal oedema, grade II was present.
On per abdomen examination, uterus was 28-30 weeks corresponding fundal
height with transverse lie with foetal heart sounds localised on sonography.
On per vaginal examination, cervix was anterior, tubular external
os was closed.
Emergency investigations revealed
Hb = 7 gm% Total WBC count = 6000/mm
BUN = 12 mg% Neutrophils : 62 T. proteins = 4.8 gm%
Lymphocytes : 38 Albumin = 2.6 gm%
Obstetric sonography revealed a 30-31 weeks of single live intrauterine
gestation with adequate liquor with placenta anterior, reaching internal
os.
Medical reference was done along with ECG and X-ray chest PA view
which showed no signs of any cardiac failure. Patient was treated
for preterm labour with anaemia with hypoproteinaemia. Patient was
then symptomatically better with abatement of breathlessness.
On day 8 after admission repeat NST and obstetric ultrasound revealed
foetal distress and suspicion of abnormal placentation on ultrasonography,
the placenta appeared to have been implanted over the whole of the
anterior wall in the upper and lower uterine segment. The placenta
appeared extremely thick, almost 7 cm in some areas.
Decision for emergency LSCS was taken. On opening the peritoneal cavity,
the uterus appeared 24 weeks in size. Careful examination of the peritoneal
cavity revealed a gestational sac outside the uterus, lying behind
and above it suggesting advanced secondary abdominal ectopic pregnancy.
The walls of the gestational sac were formed by the posterior wall
of the uterus. The thinned out right tube and ovary, right infundibulo
pelvic ligament, the small bowel, omentum and postero -inferiorly
by the right wall of the sigmoid colon, rectum and recto -vaginal
septum. The sac was ruptured, delivering a female body with birth
weight of 1.970 kg. The baby had a poor Apgar score and was handed
over to the neonatologist after clamping and cutting the umbilical
cord. The placental attachment was noted to the posterior wall of
the uterus, the right adnexa -tube and ovary, right infundibulo pelvic
ligament and inferiorly into the recto -vaginal septum (Fig. 1). The
uterus and right tube and ovary both being expendable, the placental
removal was done. On removing the placenta, it was seen to be burrowing
into the myometrium. (Fig. 2) Obstetric hysterectomy with right salpingo-oophorectomy
was performed.
The small and
large bowel and the omentum were traced in collaboration with the
general surgeon and found to be intract. Portex drain was placed in
the right paracolic gutter and pelvis.
The patient received adequate blood and plasma products. The baby
showed signs of pulmonary hypoplasia, skeletal and craniofacial abnormalities
secondary to oligohydramnios. Baby subsequently developed disseminated
intravascular coagulation and expired on day 18 of life. Baby had
no evidence of any congenital malformations.
Patient had tension sutures removed on day 14 of surgery and recovered
unevenfully from the ordeal. Histopathology of the placenta and gestational
sac showed ovarian tissue, which confirmed that it was a primary ovarian
ectopic pregnancy producing a secondary abdominal pregnancy.
Discussion
Most cases of advanced abdominal pregnancy are secondary, in these
the pregnancy is first implanted either in the fallopian tube, or
ovary or uterus.3
This pregnancy primarily was a right ovarian ectopic pregnancy, as
is evidence by the fact that the right tube and ovary were stretched
out over the gestational sac and also histopathology of the placenta
showed presence of ovarian tissue in the wall. Because of the placental
attachment into the posterior wall of the uterus, burrowing into the
myometrium, placental circulation was well established allowing the
foetus to grow up to 32 weeks of pregnancy and hence, hysterectomy
had to be done in order to achieve haemostasis.
On clinical examination, the foetal heart sounds were found in the
left hypochondrium and the body was in transverse lie; the baby’s
positions was thought to be bizarre. Hence a clinical diagnosis of
secondary abdominal pregnancy was made even though ultrasonography
revealed intra-uterine gestation.
Conclusion
The maternal deaths in Abdominal pregnancy are usually consequent
to haemorrhage and infection. Despite the increased use and available
of blood transfusions antibiotics, and improvements in anaesthesia
and surgical techniques abdominal pregnancy retain associated with
significant mortality rate.4 Foetal mortality ranges from 50%5 to
95%6 has been reported one of the major factors in foetal survival
is related to the status of amniotic sac.
References
1. Fosger HW, More DT. Abdominal pregnancy report of 12 cases.
Obstetric and Gynecological 1967; 2 : 249.
2. Tan KL, Goon SM, Wee JH. The paediatric aspects of advanced abdominal
pregnancy. Br J Obstet Gynaeco 1947; 44 : 487.
3. Jeffcoates principles of Gynaecology, Edition V 2001 Arnold Publishers,
C, Ectopic pregnancy Pg. 212-225.
4. Leslie Iffy, David Charles operatively perinatology. Invasive obstetric
techniques. Macmillan publishing 1st edition 1984. Pg. 376-384 Chapter
27.
5. Dixon HG, Stewart DB. Advanced extra uterine pregnancy. Br Med
J 1960; 2 : 1103.
6. Becham WD, Hernquist, et al. Abdominal pregnancy at Charity hospital
in New Orleans. Am J Obstet Gynecol 1962; 84 : 1257.
