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23 weeks non ruptured tubal pregnancy: case report.

1. Introduction

Ectopic pregnancy is the most common life-threatening condition in early pregnancy. The vast majority of ectopic pregnancies implant in the fallopian tube which is either interstitial (2.4%), isthmic (12.0%), ampullary (70.0%) or fimbrial (11.1%); however, the product of conception may implant in the ovaries, the cervix, or the abdomen. Subsequent presentation of ectopic pregnancy varies from being asymptomatic to hemodynamic instability. Tubal pregnancy has always been considered as a complication of the first trimester pregnancy and tubal rupture usually occurs around the 7th week of gestation. However, this case presents a rare advanced second trimester tubal pregnancy and how the patient was managed. A study performed in 2008 at the University of Texas Southwestern Medical Center identified 10 extra uterine pregnancies above 18 weeks of gestation between 1980-2005 of which only 6 were diagnosed preoperatively [1].

2. Case Report

A 19 years old pregnant woman 2 para 2 came to the emergency room with sudden onset of severe lower abdominal pain more intense in the right lower quadrant. She could not recall the first day of her last menstrual period; she never visited a general practitioner or an obstetrician during this pregnancy. She was neither lactating nor using any contraceptive method in the preceding year. She originated from a rural area and had limited education and low social status--having limited access to medical care. Both her personal and family history were negative.

The patient was stable with blood pressure of 112/63 mmHg, pulse rate of 64 bpm, 79 kg, 1.65 meters height with a BMI of 29. General examination was within normal limits except for the rare colicative hypogastric pain. Her bowel sounds were normal. She presented secondary pregnancy signs and active fetal movements. In the lower abdomen a suprapubic mass was present, cystic in consistency, mobile, with superior limit at the level of the umbilicus, non tender that was first thought to be the pregnant uterus, reactive, with slightly elevated tonus.

On pelvic examination cervix and vagina appeared normal; there was no bleeding or amniotic fluid discharge through the external cervical bone; thick white-yellowish vaginal discharge was present. On bimanual examination the cervix was long and closed and the previously described mass that was considered to be the enlarged, cystic, reactive uterus, without cervical motion tenderness or sensitive Douglas.

Laboratory tests revealed an elevated WBC count (13,700), low hemoglobin level (7.42 g/dl) and hematocrit value (21.3%) with normal platelet count (325,000). Coagulation profile, liver and renal function tests were within normal limits. The blood type was BIII positive.

The abdominal ultrasound showed a mono fetal pregnancy with normal amniotic fluid index, normal fetal movements, BPD 52.7 mm (24 weeks and 1 days), HC 165.31 mm (23 weeks and 3 days), AC 150.08 mm (22 weeks and 4 days), FL 31.6 cm (23 weeks and 5 days), EFW 580g, GA (AUA) 23 weeks and 2 days, normal fetal heart rate (146/min), posterior granum 0 placenta with no signs of retro placental hematoma.

No transvaginal ultrasound exam was available at the time.

Based on the information obtained, the diagnosis of 23 weeks pregnancy, threatened abortion and moderate anemia was made.

We admitted the patient to the hospital and started her on tocolytic therapy, i.v. beta 2 sympathomimetic agents and anti anemic therapy.

The clinical status of the patient deteriorated in the following hours presenting acute continuous pain in the lower abdomen and vomiting; BP 90/50 mmHg, HR 92 /minute; repeated lab tests showed decreasing serum hemoglobin 6.69 g/dL ([down arrow] 7.42 g/dL). A repeated obstetric ultrasound reveals liquid in the pouch of Douglas and unreassuring fetal heart rate of 88 bpm (fig 1). Based on these findings, emergency laparotomy was performed for the suspicion of abruption placentae.

Intraopertory we found about 300mL of blood in the peritoneal cavity and the ampullary region of the right tube was distended with a 15 x 12 cm mass containing a fetus and placental tissue corresponding to a 23 week gestation pregnancy. The right ovary was intimately adherent to the ectopic pregnancy--with active bleeding from a 5 cm long torn portion of the right tube (Fig. 2 and 3). The uterus, left adnexa and the other intraperitoneal organs were normal. Right adnexectomy is performed, peritoneal washing and intraperitoneal drain was left. Cut section of the specimen showed a dead masculine fetus of around 400 g with fully developed placenta (Fig, 4 and 5).

The pathologic examination confirmed the diagnosis of tubal pregnancy--containing masculine 450 g fetus with 200 g placenta.

Post operatory the patient recovered uneventfully with antibiotic prophylaxis, anticoagulant, analgesics and anti-inflammatory medication. 1 unit of RBC was administered postoperatively.

3. Discussion

It is rare for ectopic pregnancies to present so late in gestation. Early pregnancy trans-vaginal sonographic examination, which becomes a common practice nowadays, helps to identify the site of the pregnancy and to diagnose ectopic pregnancy earlier than the occurrence of tubal rupture which can be life-threatening. However, in many undeveloped countries that lack health education and proper prenatal care (including some rural areas that our center serves), early diagnosis is often missed.

We consider that the availability of transvaginal ultrasound could have avoided the misdiagnosis. It is important to perform this test in all threatened abortion cases to measure the length of the cervix and to check the continuity of the cervical canal with the uterine cavity [7]. This way we could have observed the presence of the normal sized uterus lateral to the ectopic pregnancy.

Late diagnosis of ectopic pregnancy leads to major complications in almost all the cases and needs emergency surgical intervention. However in our presented case in spite of the advanced second trimester ectopic pregnancy (23 weeks of gestation), the patient was hemodynamically stable at admission.

Few reports refer to patients that were diagnosed with late second trimester tubal pregnancy. We found a reported case of a 26 weeks unruptured ampullary ectopic pregnancy with a dead fetus. [1]

The challenging point in such cases is to consider tubal pregnancy as a possible diagnostic option in a second trimester pregnant patient complaining of acute abdomen with or without vomiting, particularly if the patient is still hemodynamic stable. Also surgical causes of abdominal pain (appendicitis, pancreatitis, duodenal or gastric ulcer, gastroenteritis, bowel obstruction, herniation and diverticulitis) [4,6] should always be excluded as well as other genitourinary causes (ovarian cyst rupture, adnexal torsion [5], ureteral calculus, ureteral obstruction) and other.

It is important to recognize that tubal pregnancy is not always a first trimester condition and that it is always a possibility in pregnant women with acute abdomen particularly those who are not reliably followed up.

It is also of note that in rural areas, people with no health insurance have limited or no access to medical care. This way they are brought to the hospital without reliable medical history which can be a challenging differential diagnostic in emergency situations.

Crangu A. Ionescu

antoniuginec@yahoo.com

Carol Davila University of Medicine, St Pantelimon Hospital, Bucharest

Irina Pacu

irinapacu@hotmail.com

Carol Davila University of Medicine, St Pantelimon Hospital, Bucharest

Gladys Al Jashi

dr.jashi@yahoo.com

St Pantelimon Hospital, Bucharest

Mihai Banacu

mbanacu@gmail.com

St Pantelimon Hospital, Bucharest

Horatiu Haradja

hharadja@gmail.com

Carol Davila University of Medicine, St Pantelimon Hospital, Bucharest

Conflict of interests

Authors declare no conflict of interests.

REFERENCES

[1.] Sachan, Rekha, Pooja Gupta, and Patel, M. L. (2012), "Second Trimester Unruptured Ampullary Ectopic Pregnancy with Variable Presentations: Report of Two Cases," International Journal of Case Reports and Images 3(8): 1-4.

[2.] Gueye, Mame Diarra Ndiaye, Mamour Gueye, Ibou Thiam, Magatte Mbaye, Abdou Magib Gaye, Abdoul Aziz Diouf, Mouhamadou Mansour Niang, Jean Charles Moreau (2013), "Unruptured Tubal Pregnancy in the Second Trimester," South Sudan Medical Journal 6(4): 95-96.

[3.] Worley, Kevin C., Hnat Michael D., Cunningham F. Gray (2008), "Advanced Extrauterine Pregnancy: Diagnostic and Therapeutic Challenges," American Journal of Obstetrics and Gynecology 198(3): 297.e1-7.

[4.] Taylor, Dana (2012), "Acute Abdomen and Pregnancy," Medscape, Jan.

[5.] Origoni, M., Cavoretto, P., Conti, E., and Ferrari, A. (2009), "Isolated Tubal Torsion in Pregnancy", European Journal of Obstetrics & Gynecology and Reproductive Biology 146(2): 116-120.

[6.] Ankouz, A., Ousadden, A., Majdoub, K. I., Chouaib, A., Maazaz, K., and Taleb, K. A. (2009), "Simultaneous Acute Appendicitis and Ectopic Pregnancy," Journal of Emergencies, Trauma and Shock 2(1): 46-47.

[7.] Condous, G. S. (2007), "Ultrasound Diagnosis of Ectopic Pregnancy," Seminars in Reproductive Medicine 25(2): 85-91.

Caption: Fig. 1 Preoperatoty ultrasound reevaluation

Caption: Fig. 2 Intraoperatory aspects

Caption: Fig. 3 Intraoperatory aspects

Caption: Fig. 4 Postoperatory aspects

Caption: Fig. 5 Postoperatory aspects

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Author:Ionescu, Crangu A.; Pacu, Irina; Jashi, Gladys Al; Banacu, Mihai; Haradja, Horatiu
Publication:American Journal of Medical Research
Article Type:Case study
Date:Apr 1, 2014
Words:1460
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