IJCRI 201 2;3(8):1 –4.
Sachan et al.
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CASE SERIES
1
OPEN ACCESS
Second trimester unruptured ampullary ectopic pregnancy
with variable presentations: Report of two cases
Rekha Sachan, Pooja Gupta, ML Patel
ABSTRACT
Introduction: Ninety­five percent of ectopic
pregnancies occur in the fallopian tube.
Diagnosis and exact location of ectopic
pregnancy is usually easy during the 1st
trimester of pregnancy by ultrasonography.
Ampulla is the most common site for ectopic
tubal pregnancies. Case Series: Here we report
two cases of ampullary ectopic pregnancy with
variable presentation. First case was a 27­year­old
female
who
presented
with
bleeding
pervaginum following IUCD insertion in
lactational amenorrhea period. She was
diagnosed as a case of viable, unruptured, tubal
ampullary ectopic pregnancy of 14 weeks
gestational age with copper­T in situ. Second
case presented with seven months amenorrhea
with dead fetus and repeated failed attempts of
induction of labour. Later on she was diagnosed
as a case of 26 weeks unruptured ampullary
ectopic
pregnancy
with
a
dead
fetus.
Conclusion: Second trimester unruptured tubal
pregnancy is rare among ectopic pregnancies.
Ultrasonography is still the diagnostic modality
of choice. The probability of ectopic pregnancy
should be born in mind in cases of IUCD with
spotting pervaginum and repeated failure of
labour induction even at advanced gestational
age.
Rekha Sachan 1 , Pooja Gupta 1 , ML Patel 2
Affiliations: 1 Department of Obstetrics and Gynecology,
CSM Medical University, Lucknow, 2Department of
Medicine, CSM Medical University, Lucknow.
Corresponding Author: Dr. Rekha Sachan, MS, FICOG,
Professor, Department of Obstetrics & Gynaecology, CSM
Medical University, Lucknow; Ph: +91 9839009290; Email:
[email protected]
Received: 1 0 March 201 2
Accepted: 06 May 201 2
Published: 01 August 201 2
Keywords: Ampullary, Ectopic pregnancy,
IUCD,
Intrauterine
contraceptive
device,
Laparotomy, Ultrasonography
*********
Sachan R, Gupta P, Patel ML. Second trimester
unruptured ampullary ectopic pregnancy with variable
pesentations: Report of two cases. International Journal
of Case Reports and Images 2012;3(8):1–4.
*********
doi:10.5348/ijcri­2012­08­154­CS­1
INTRODUCTION
Ampulla is the commonest site for ectopic pregnancy
[1]. Most of the tubal ectopic pregnancies rupture
between 5–11 weeks of gestation [2]. Ectopic pregnancy
is a leading cause of pregnancy­related death in early
pregnancy [3]. However, in extremely rare conditions
they may be carried upto an advanced gestational age
and may be associated with diagnostic difficulty. We
hereby report two cases of unruptured tubal ampullary
ectopic pregnancies with variable presentations. In the
first case, the woman presented with 14 weeks viable
ampullary tubal pregnancy with IUCD in situ. The
second case was a non­viable 26 weeks unruptured,
ampullary ectopic pregnancy which was diagnosed
during exploratory laprotomy, after repeated attempts
of induction of labour.
CASE REPORT
Case 1: 27­year­old para 3+0 had copper­T
insertion
in
lactational
amenorrhea
period
approximately three months after giving birth to her
third child. Approximately three weeks post insertion,
she started experiencing bleeding per vaginum. She
IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 8, August 201 2. ISSN – [0976-31 98]
IJCRI 201 2;3(8):1 –4.
Sachan et al.
www.ijcasereportsandimages.com
interpreted this bleeding as resumption of her menses.
However, when the spotting continued for three
months, she consulted in our out patient department
(OPD).
On examination pulse rate was 90 beats/minute,
blood pressure was 110/70 mmHg with moderate
pallor. On abdominal examination a 6x8 cm sized
suprapubic mass, firm in consistency with restricted
side to side mobility was present. A closed cervical os
with CuT thread and slight bleeding coming through os
was visible on per speculum examination. Bimanual
examination revealed a slightly enlarged uterus with
cervical motion tenderness with a lump of 8x10 cm
palpable through right adnexa in continuation with
abdominal mass.
Patient’s hemoglobin was 8 g/dL, blood group was A
positive, serum β­HCG was 41,840 mIU/mL with
normal liver and kidney function tests. Transabdomial
sonography revealed an extrauterine gestational sac of
14 weeks 1 day with fetal heart rate of 180/min. Uterus
was seen separate from the gestational sac on the left
side, with minimal collection in the cavity with
intrauterine contraceptive device in situ. Minimal fluid
was present in the cul­de­sac.
Exploratory laprotomy revealed a right sided tubal
ampullary lump of 10x12 cm with adherent right ovary,
with no evidence of hemoperitoneum (Figure 1). Right
sided salpingo­ophorectomy with left sided tubal
ligation was done. Fetal movements were noted inside
the sac. Cut section of tubal ampullary lump revealed a
live fetus of about 14 weeks gestational age (Figure 2).
Case 2: A 25­year­old gravida 1, para 0 lady
presented to our OPD with chief complaints of
amenorrhea of seven months with absent fetal
movements. Her previous menstrual history was
normal, however, she was not sure about her last
menstrual period. On general examination BP was
124/80 mmHg. Systemic examination was within
normal limits.
Obstetrical examination revealed 26–28 weeks
gravid uterus sized suprapubic lump, soft consistency,
non­tender and external ballotment was absent. On
auscultation fetal heart sounds could not be heard. On
per vaginum examination, cervical os was closed, uterus
seemed to be of normal size, deviated to left side and a
separate mass was felt through the right adnexa which
was of about 26–28 weeks size and soft in consistency.
Her hemoglobin was 8.9 g/dL, blood group was B
negative, liver function, kidney function and
coagulation profile was within normal limits.
Ultrasonography
revealed
single
dead
fetus
corresponding to 26 weeks of gestational age but
confirmation of exact location was not possible. A
strong suspicion of pregnancy in one horn of bicornuate
uterus was raised due to advanced gestational age of the
fetus. Induction of labour was done with 100 µg of
misoprostol four hourly upto a maximum doses of 2000
µgm but it failed to initiate labor.
Exploratory laprotomy was done and per operatively
uterus was found to be of normal size and right sided
2
Figure 1: Peroperative finding shows an ampullary tubal
pregnancy of 10x12 cm size with adherent ovary (Case 1).
Figure 2: Developed placenta with fetus of 14 weeks
gestational age (Case 1).
mass suggestive of unruptured, ampullary tubal ectopic
pregnancy of about 20x16 cm size with prominent
vessels, invading the broad ligament was present. Only a
small fimbrial distal portion of the tube with adherent
right ovary was visualized (Figure 3). Left side tube and
ovary was normal (Figure 4). Right sided salpingo­
ophorectomy was done. Cut section of specimen showed
a dead fetus of around 700 g with fully developed
placenta and decreased liquor (Figure 5). There was no
evidence of hemoperitoneum.
DISCUSSION
Ectopic pregnancies account for 3–4% of pregnancy­
related deaths. During 1999–2008, the ectopic
pregnancy mortality rate in the United States was 0.6
deaths per 100,000 live births. The Centers for Disease
IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 8, August 201 2. ISSN – [0976-31 98]
IJCRI 201 2;3(8):1 –4.
Sachan et al.
www.ijcasereportsandimages.com
Figure 3: Peroperative finding showed an ampullary ectopic of
20x16 cm size with normal uterus and fimbrial end (Case 2).
Figure 4: Peroperative finding showed an ampullary ectopic of
20x16 cm size with normal uterus, left side tube and ovary
(Case 2).
Figure 5: Well developed placenta with a fetus of 26 weeks
gestational age seen after dissection of sac (Case 2).
3
Control and Prevention reported a higher rate in
Florida, 2.5 deaths per 100,000 live births during
2009–2010. The 11 ectopic pregnancy deaths in Florida
during 2009­2010 contrast with a total of 14 deaths
identified in national statistics for 2007 [4].
In the developing countries, hospital based studies
have reported ectopic pregnancy case fatality rate of
about 1–3% which is 10 times higher than that reported
from developed countries [5]. After a 10­year population
based study of 1800 cases concluded that only 4.5%
ectopic pregnancies were extratubal ectopic pregnancies
(ovarian and abdominal) and about 73% tubal
pregnancies were ampullary [6]. Late diagnosis of
ectopic pregnancy leads to major complications in
almost all cases and needs emergency surgical
intervention. However, in both the cases inspite of
prolongation of ectopic pregnancy up to 14 weeks and 26
weeks of gestational age, the patients were
hemodyanamically stable.
We have reported a rare case of viable tubal
ampullary ectopic pregnancy of 14 weeks gestation with
copper­T in situ. Another case was reported by Rujin
et al. [7] in which a patient had large intact tubal
pregnancy of 10 weeks gestation. As literature supports,
IUCD used for contraception does not increase the risk
of ectopic pregnancy [8]. In our case the patient
presented with viable ectopic pregnancy of 14 weeks
with IUCD in situ which is rare. Amenorrhea of 6–8
weeks with spotting and pain in abdomen is the
hallmark of ectopic pregnancy [8]. One should not
forget that if a woman with IUCD in situ presents to us
in lactational amenorrhea period with spotting per
vaginum, ectopic pregnancy should be ruled out because
spotting is often considered side effect of IUCD by
gynecologists.
In the second case, the diagnosis of ectopic pregnancy
was difficult as patient presented to us at advanced
gestational age. In the 1st trimester of pregnancy
ultrasound examination is very reliable in diagnosing
ectopic pregnancy [9]. In the 2nd trimester it is difficult
to determine the exact location of pregnancy by
ultrasonography [10]. Wabong et al. reported a case of
26­week ectopic pregnancy which was diagnosed as
intrauterine pregnancy with dead fetus after several
unsuccessful attempts of induction of labor. Finally they
resorted to laprotomy which was diagnostic of ectopic
pregnancy [11]. Similarly, in our case diagnosis was
confirmed by laprotomy. It is difficult to do conservative
surgery in such type of large ectopic pregnancy even if the
patient has desire for future child bearing due to
excessive deformation of fallopian tube, so in our case
salpingo­oophorectomy was done. Hence, the authors
recommend that the probability of ectopic pregnancy
should be borne in mind in cases of repeated failures of
labour induction even at advanced gestational age.
CONCLUSION
There has been a rise in the incidence of ectopic
pregnancies since 1970s. Second trimester unruptured
IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 8, August 201 2. ISSN – [0976-31 98]
IJCRI 201 2;3(8):1 –4.
Sachan et al.
www.ijcasereportsandimages.com
tubal pregnancy is a rare ectopic pregnancy.
Ultrasonography is still a diagnostic modality.
Probability of ectopic pregnancy should be born in mind
in cases of IUCD with spotting pervaginum and
repeated failure of labour induction even at advanced
gestational age.
*********
Author Contributions
Rekha Sachan – Substantial contributions to conception
and design, Acquisition of data, Drafting the article,
Revising it critically for important intellectual content,
Final approval of the version to be published
Pooja Gupta – Substantial contributions to Drafting the
article, Final approval of the version to be published
ML Patel – Substantial contributions to conception and
design, Acquisition of data, Revising it critically for
important intellectual content, Final approval of the
version to be published
Guarantor
The corresponding
submission.
author
is
the
guarantor
8.
Josiel
L.
Tenore­ectopic
pregnancy­February
15,2000­American Academy of family problem
oriented diagnosis; 2 & 4.
9. Petersen KR, Larsen GK, Norring K, Jensen FR.
Misdiagnosis of interstitial pregnancy followed by
uterine corneal rupture during induced midtrimester
abortion.
Acta
Obstet
Gynecol
Scand
1992;71(4):316–8.
10. Glew SS, Sivanesaratnam V. Advanced extrauterine
pregnancy mimicking intra­uterine fetal death: Case
Reports.
Aust
NZJ
Obstet
Gyneacol
1989;29(4):450–1.
11. Elie Nkwabong, Eveline Foguem Tincho. A Case of a
26 weeks ampullary pregnancy mimicking
intrauterine fetal death. Antol J of Obstet Gynaecol
2012;1:2.
of
Conflict of Interest
Authors declare no conflict of interest.
Copyright
© Rekha Sachan et al. 2012; This article is distributed
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IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 8, August 201 2. ISSN – [0976-31 98]