Keywords : abdominal pregnancy ● ectopic pregnancy ● preganncy after hysterectomy with bilateral oophorectomy
A 35 year old woman married for 18 years was seen on 17th April, 2003 with complaints of severe pain in the abdomen, giddiness for the past 4 days, and vomiting and diarrhea for one day. She was semi-literate and belonged to the lower middle class status. She had two vaginal deliveries, the last one 14 years back. Two months earlier she had had a total abdominal hysterectomy with bilateral salpingo-oophorectomy in a private nursing home in a rural area for complaints of irregular vaginal bleeding.
On examination she was markedly pale with a regular heart rate of 110/min. and blood pressure of 90/50 mmHg. There was a infraumbilical midline well healed scar. The abdomen was distended particularly in the supra-pubic region. Tenderness was present all over the abdomen with guarding and rigidity. On vaginal examination, the vault was well supported, tender, and gave a feeling of fullness.
An urgent ultrasound scan of the abdomen showed marked ascites and a sac-like structure with fetal pole. A peritoneal tap showed a bloody aspirate. Urinary pregnancy test was positive.
Investigations showed the following results - Hb 3.5g/dL, blood group - ‘O’ Rh positive, lucocyte count - 25,000/ mm3. HIV-negative, HBsAg-negative.
She was immediately taken up for laparotomy. On opening the abdominal cavity marked hemoperitoneum was found with about 2.5 litres of free blood. Uterus, tubes and ovaries were absent. A white sac-like structure which had ruptured, could be seen between the right round ligament, pouch of Douglas, rectum and ileal loop. A fetus of about 10 weeks gestational age ( CRL=3.3 cm), attached to the placenta with a short cord was recovered along with the clots. Hemostasis was secured by taking interrupted sutures and using gel foam. Ileal loop was separated from adhesions by blunt and sharp dissection. Peritoneal lavage was done and a drain put in the pouch of Douglas. She received four units of blood transfusion and antibiotic coverage. She was discharged on 9th post- operative day with a Hb of 9.3 g/dL.
A literature search revealed that 36 cases of pregnancy following hysterectomy have been reported so far since 1895, the last one being in May 2002 1-6. In 22 cases conception occurred some time before hysterectomy, in the remaining thereafter. Ectopic pregnancy after a total hysterectomy can occur if a fertilized ovum is in the fallopian tube at the time of hysterectomy or if a fistulous tract exists between the vagina and the ovaries. In our case hysterectomy had been done two months prior to this event for the clinical picture simulating dysfunctional uterine bleeding. As was evident from the laparotomy findings both the ovaries had also been removed. So the conception had occurred prior to the operation. The most interesting fact was that in the absence of ovaries the conceptus had survived and had grown by its functioning villi alone. In the literature we did not come across any case in which this entity had occurred after bilateral salpingo-oopherectomy. Acute abdomen any time after any variety of hysterectomy in a younger woman should include ectopic pregnancy in the differential diagnosis. It is a rare event and ultrasound scan may aid in the diagnosis.
