Mrs. S, aged 27 years, G2P1A0, having one alive and healthy child delivered 7 years back by cesarean section, presented to emergency unit of our hospital, with complaints of amenorrhea for one and half months and continuous pain in lower abdomen, giddiness, and bleeding per vaginum since one day. Her general condition was satisfactory, with pulse 100/min, BP 110/70 mmHg, and normal temperature. There was no pallor, and her respiratory system and CVS were normal. On per abdominal examination, there was minimal guarding and tenderness present, and no mass was felt. Per speculum examination revealed minimal bleeding through os. Vaginal examination showed that uterus was of normal size, anteverted, and cervical movements were nontender. Right fornix was clear, but in left fornix illdefined tender mass of 3×3 cm was felt. Mild tenderness was present in left fornix.
Laboratory investigations showed positive urine pregnancy test and serum ß-HCG levels of 1,600 IU/I. Her hemoglobin was 9.3 gm%, white cell count 13,000/mm3, differential count of N81,L17, E1, M1, ESR 25 mm/hour, whereas the results for rest of the routine investigations were within normal limits. Ultrasound showed a large mixed echogenic left adenexal lesion of 6.2×3×5 cm3 size with solid and cystic components, and large amount of free fluid in pouch of Douglas, suggestive of ruptured left ectopic gestation. Uterus was empty and of normal size, shape, and echo texture. Both ovaries were normal in size and shape. Emergency laparotomy was done which revealed ruptured gestational sac implanted on sigmoid colon, 200cc of hemoperitonium was present. Products of conception and clots were removed. Part of the chorionic plate was firmly adherent to the bowel and was left behind to avoid bowel injury. Saline wash was given. Complete hemostasis was achieved. Tubercles were seen on anterior surface of uterus. Previous lower segment caesarean section scar was intact. The abdomen was closed after securing complete hemostasis. The patient withstood the surgery well. On postoperative day 8 ßHCG level was 380 mlU/ml and ultrasound of pelvis was normal. The patient was discharged on postoperative day 10. Follow-up of patient in outpatient department after 7 days of discharge showed ßHCG 34 mlU/ml. She was advised Anti Koch's treatment. Diagnosis of primary abdominal pregnancy was made according to Studdiford's criteria1. Both tubes and ovaries were in normal condition with no evidence of recent or remote injury. No evidence of uteroperitoneal fistula was found. The pregnancy was related exclusively to the peritoneal surface and was early enough to eliminate the possibility that it is a secondary implantation following a primary implantation in the tube.
Keywords : primary abdominal pregnancy, ectopic pregnancy
Mrs. S, aged 27 years, G2P1A0, having one alive and healthy child delivered 7 years back by cesarean section, presented to emergency unit of our hospital, with complaints of amenorrhea for one and half months and continuous pain in lower abdomen, giddiness, and bleeding per vaginum since one day. Her general condition was satisfactory, with pulse 100/min, BP 110/70 mmHg, and normal temperature. There was no pallor, and her respiratory system and CVS were normal. On per abdominal examination, there was minimal guarding and tenderness present, and no mass was felt. Per speculum examination revealed minimal bleeding through os. Vaginal examination showed that uterus was of normal size, anteverted, and cervical movements were nontender. Right fornix was clear, but in left fornix illdefined tender mass of 3×3 cm was felt. Mild tenderness was present in left fornix. Laboratory investigations showed positive urine pregnancy test and serum ß-HCG levels of 1,600 IU/I. Her hemoglobin was 9.3 gm%, white cell count 13,000/mm3, differential count of N81, L17, E1, M1, ESR 25 mm/hour, whereas the results for rest of the routine investigations were within normal limits. Ultrasound showed a large mixed echogenic left adenexal lesion of 6.2×3×5 cm3 size with solid and cystic components, and large amount of free fluid in pouch of Douglas, suggestive of ruptured left ectopic gestation. Uterus was empty and of normal size, shape, and echo texture. Both ovaries were normal in size and shape. Emergency laparotomy was done which revealed ruptured gestational sac implanted on sigmoid colon, 200 cc of hemoperitonium was present. Products of conception and clots were removed. Part of the chorionic plate was firmly adherent to the bowel and was left behind to avoid bowel injury. Saline wash was given. Complete hemostasis was achieved. Tubercles were seen on anterior surface of uterus. Previous lower segment caesarean section scar was intact. The abdomen was closed after securing complete hemostasis. The patient withstood the surgery well. On postoperative day 8 ßHCG level was 380 mlU/ml and ultrasound of pelvis was normal. The patient was discharged on postoperative day 10. Follow-up of patient in outpatient department after 7 days of discharge showed ßHCG 34 mlU/ml. She was advised Anti Koch's treatment. Diagnosis of primary abdominal pregnancy was made according to Studdiford's criteria1. Both tubes and ovaries were in normal condition with no evidence of recent or remote injury. No evidence of uteroperitoneal fistula was found. The pregnancy was related exclusively to the peritoneal surface and was early enough to eliminate the possibility that it is a secondary implantation following a primary implantation in the tube.
Abdominal pregnancy is rarest of all types of extrauterine pregnancies. Report of the frequency of abdominal pregnancy varies from 1 in 3,371 deliveries and 0.03% of extra uterine gestation1. Today with highresolution transvaginal sonography combined with highly sensitive test available for ßHCG, ectopic pregnancy diagnosis has shown a sensitivity of 93% and specificity of 99%2. Moreover, cases of advanced abdominal pregnancy that were diagnosed only at cesarean section have been reported3. A case of ruptured 10 weeks abdominal ectopic pregnancy originally diagnosed and treated as pelvic inflammatory disease was previously reported4, thus highlighting differential diagnosis of abdominal pregnancy as pelvic inflammatory disease. A case of primary omental pregnancy was reported, which was preoperatively diagnosed as ruptured tubal pregnancy. Only after surgical exploration it was diagnosed as primary omental pregnancy, as bilateral tubes and ovaries were intact5. Even in our case transvaginal sonography could not diagnose the exact site of ectopic gestation. It was diagnosed only through exploratory laparotomy. The gestation sac was seen implanted on sigmoid colon and bilateral tubes and ovaries were intact.
Primary implantation of extrauterine pregnancy is
extremely rare and is a potentially life-threatening
variation of ectopic pregnancy, representing a grave risk
to maternal health, because of high incidence of pelvic
abscess, peritonitis, sepsis, massive rectal bleeding, or
rectal passage of fetal bones secondary to the formation
of celointestinal fistula1
. In abdominal pregnancy rupture
seldom occurs in general peritoneal cavity, as the site is
sealed by inflammation and adhesions6, but in our case
the patient presented earlier with ruptured ectopic
pregnancy in peritoneal cavity, may be because of
absence of inflammation and adhesions. Thus by early
intervention and prompt management maternal
morbidity and mortality was prevented.
