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CASE REPORT
Year : 2017  |  Volume : 20  |  Issue : 3  |  Page : 134-136

Ultrasonographic and postoperative diagnosis of spontaneous viable tubal abortion following slow-leaking ectopic gestation


1 Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Obstetrics and Gyneacology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication16-Jan-2018

Correspondence Address:
Dr. Sadisu Mohammed Maaji
Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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DOI: 10.4103/1118-8561.223166

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  Abstract 


Ruptured ectopic pregnancy is not an uncommon diagnosis in gynecological emergency admissions, but spontaneous tubal abortion with an intact live fetus is a rare event which can be diagnosed preoperatively with ultrasound. The aim of this study is to report a case of spontaneous live tubal abortion following ectopic gestation that was diagnosed ultrasonographically and confirmed intraoperatively.

Keywords: Diagnosis, ectopic, tubal abortion, ultrasound


How to cite this article:
Maaji SM, Gana MA. Ultrasonographic and postoperative diagnosis of spontaneous viable tubal abortion following slow-leaking ectopic gestation. Sahel Med J 2017;20:134-6

How to cite this URL:
Maaji SM, Gana MA. Ultrasonographic and postoperative diagnosis of spontaneous viable tubal abortion following slow-leaking ectopic gestation. Sahel Med J [serial online] 2017 [cited 2019 Oct 15];20:134-6. Available from: http://www.smjonline.org/text.asp?2017/20/3/134/223166




  Introduction Top


Increased incidence of ectopic pregnancy was found during the last decades,[1],[2],[3],[4],[5],[6] mainly attributed to greater degree of socially acceptable sexual behavior, which has led to increased incidence of the pelvic inflammatory disease. The increasing incidence has also been partly attributed to increasing use of assisted conception techniques as well as available diagnostic aids making detection before tubal rupture possible.[7] Tubal pregnancies can grow in the fimbrial end (5% of all ectopic pregnancies), ampullary section (80%), isthmus (12%), and cornual and interstitial part of the tube (2%).[8]

The aim of this study is to report a case of spontaneous live tubal abortion following ectopic gestation that was diagnosed ultrasonographically and confirmed intraoperatively.


  Case Report Top


A 40-year unbooked G7 P6 + 0, A5 presented to the gyneacology emergency clinic of the hospital with 1-month history of lower abdominal pain, epigastric pain, and fever. The lower abdominal pain was said to be gradual in onset, dull, and colicky in nature. Her last menstrual period was 12 weeks previously. The index pregnancy had been uneventful till the time of presentation.

On general examination, the patient was conscious not in any form of distress, but severely pale. Abdominal examination revealed a tender mass at the right lower abdomen; size of the mass could not be ascertained as the patient was not cooperative possibly due to pain. Uterus was bulky, about 12 weeks size. The cardiovascular examination revealed tachycardia (pulse rate of 128 bpm) with a blood pressure of 100/40 mmHg.

On pelvic examination, the uterus was bulky with the cervix atrophic and closed. Gloved fingers were stained with copious whitish discharge and the adnexae were difficult to palpate; however, the pouch of Douglas was full. An assessment of severe anemia secondary to slow-leaking ectopic pregnancy to rule out ovarian cyst in pregnancy was made, and investigations were requested for accordingly. Hematological examination showed hemoglobin of 4.7 g/dL and a hematocrit value of 14%. Blood film showed that malaria parasite was present (MP 1+) and retroviral screening was negative. Pelvic ultrasound showed a bulky empty uterus with homogenous myometrial texture with an intact but slightly thickened. An intact viable extrauterine pregnancy of 13 weeks gestation was noted in the right adnexal region. Free fluid in the peritoneal cavity was also noted [Figure 1]a and [Figure 1]b. An assessment of ruptured ectopic pregnancy was made and emergency exploratory laparotomy revealed hemoperitoneum of approximately 3000 ml. There was a complex right adnexal mass, mainly attached to the fimbrial end, with ruptured surface, well-formed live fetus within the gestational sac. The uterus was bulky about 10 weeks size [Figure 2]. The left  Fallopian tube More Details and both ovaries were grossly normal. In view of the above findings, the patient had right partial salpingectomy with the removal of product of conception which was sent for histopathological analysis. The patient received 2 units of blood with antibiotics (intravenous augmentin and metronidazole) and hematinics postoperatively. Postoperative follow-up was uneventful and the patient was discharged on the 8th day of postoperation.
Figure 1: (a) Pelvic ultrasound showing bulky but empty uterus. (b) Pelvic ultrasound showing an intact live fetus in the right adnexal region

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Figure 2: Operative finding showing the fimbrial end of the right fallopian tube where the fetus was attached

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  Discussion Top


Ruptured ectopic pregnancy is not an uncommon diagnosis in gynecological emergency admissions, but spontaneous tubal abortion with an intact live fetus is a rare event which can be diagnosed preoperatively with ultrasound. A high index of suspicion for an ectopic pregnancy is of great importance.

The main problem of ectopic pregnancy is clinical presentation.[9] Symptoms can vary from vaginal spotting to vasomotor shock with hemoperitoneum.[10],[11] The classic triad of delayed menses, irregular vaginal bleeding, and abdominal pain are most commonly not encountered, but the exact frequency of clinical signs and symptoms is hard to assess.[1] The case under review presented with lower abdominal pain with 12 weeks history of amenorrhea.

Ultrasonography (but more precisely, transvaginal sonography) has become the “gold standard” diagnostic modality for the effective and fast detection of ectopic pregnancy. An important advantage of most currently used transvaginal transducers is the ability to perform simultaneous and spectral Doppler studies, allowing easy identification of the ectopic peritrophoblastic flow. However, due to nonavailability of transvaginal probes in addition to religious and cultural beliefs in our environment, transabdominal ultrasound was used to diagnose this particular case that is here presented. Transabdominal ultrasonography (TAUS) cannot reliably diagnose ectopic pregnancy except when a live fetus is demonstrated in the abdominal cavity. In only 3–5% of the cases, an ectopic gestational sac with embryonic echoes and clear heart activity can be demonstrated.[12] In our patient, the TAUS was able to demonstrate an intact extrauterine viable fetus with active cardiac activity and well developed fetal parts at 12 weeks gestations in the right adnexal region.

Accurate ultrasound diagnosis of ectopic pregnancy depends strongly on radiologist experience. Adnexal abnormalities may be difficult to identify because of confusion with other adnexal structures such as bowel or other pelvic structures.[13]

There are other adnexal structures that may resemble an ectopic pregnancy and should be correctly identified.[14] One is the corpus luteum, which is eccentrically located within the ovary, surrounded by ovarian tissue and possibly creating the impression of a sac-like structure. Other mimickers that need to be correctly differentiated from an ectopic gestation are a thick-walled ovarian follicle, the small intestine, and tubal pathology conditions, such as hydrosalpinx containing fluid. All these possible differential diagnoses were excluded during the scanning of this case. Using the protocol of combination of clinical examination, serum βeta human chorionic gonadotropin assay, and transvaginal ultrasound examination, it is possible to diagnose ectopic pregnancy with a sensitivity of 100% and specificity of 99%.[15]

Treatment consists of medical therapy (methotrexate [MTX]) or surgical intervention (salpingectomy or salpingostomy) by laparotomy or laparoscopy.[16],[17] MTX treatment might fail to treat ectopic twin pregnancies, a surgical approach may be the most appropriate option in these cases [18] as in the case here presented.


  Conclusion Top


Fimbrial ectopic pregnancy resulting with a live fetus is a very rare entity. This case illustrates a case of 13 weeks viable fetus at the right fimbrial end of the fallopian tube diagnosed with ultrasound and confirmed after surgery. Therefore, careful tracing the fallopian tube in its entire length is strongly suggested so that ectopic pregnancy cannot be missed which can be fatal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/ her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Speroff L, Glass RH, Kase NG, editors. Ectopic pregnancy. In: Clinical Gynecologic Endocrinology and Infertility. London: Williams and Wilkins; 1999. p. 1149-67.  Back to cited text no. 1
    
2.
Timor-Tristch IE, Monteagudo A. Ectopic pregnancy. In: Kupesic S, de Ziegler D, editors. Ultrasound and Infertility. UK: Partenon Publishing Group; 2000. p. 215-39.  Back to cited text no. 2
    
3.
Kurjak A, Kupesic S. Ectopic pregnancy. In: Kurjak A, editors. Ultrasound in Obstetrics and Gynecology. Boston: CRC Press; 1990. p. 225-35.  Back to cited text no. 3
    
4.
Kupesic S, Kurjak A. Color Doppler assessment of ectopic pregnancy. In: Kurjak A, Kupesic S, editors. An Atlas of Transvaginal Color Doppler. London: Parthenon Publishing; 2000. p. 137-47.  Back to cited text no. 4
    
5.
Boufous S, Quartararo M, Mohsin M, Parker J. Trends in the incidence of ectopic pregnancy in New South Wales between 1990-1998. Aust N Z J Obstet Gynaecol 2001;41:436-8.  Back to cited text no. 5
    
6.
Rajkhowa M, Glass MR, Rutherford AJ, Balen AH, Sharma V, Cuckle HS. Trends in the incidence of ectopic pregnancy in England and Wales from 1966 to 1996. BJOG 2000;107:369-74.  Back to cited text no. 6
    
7.
Seifer DB, Gutmann JN, Grant WD, Kamps CA, DeCherney AH. Comparison of persistent ectopic pregnancy after laparoscopic salpingostomy versus salpingostomy at laparotomy for ectopic pregnancy. Obstet Gynecol 1993;81:378-82.  Back to cited text no. 7
    
8.
Speroff L, Glass RH, Kase NG. Clinical Gynecological Endocrinology and Infertility. 6th ed. Baltimore: Lippincott Williams & Wilkins; 1999. p. 1149.  Back to cited text no. 8
    
9.
Sagaster P, Zojer N, Dekan G, Ludwig H. A paraneoplastic syndrome mimicking extrauterine pregnancy. Ann Oncol 2002;13:170-2.  Back to cited text no. 9
    
10.
Hick JL, Rodgerson JD, Heegaard WG, Sterner S. Vital signs fail to correlate with hemoperitoneum from ruptured ectopic pregnancy. Am J Emerg Med 2001;19:488-91.  Back to cited text no. 10
    
11.
Birkhahn RH, Gaeta TJ, Bei R, Bove JJ. Shock index in the first trimester of pregnancy and its relationship to ruptured ectopic pregnancy. Acad Emerg Med 2002;9:115-9.  Back to cited text no. 11
    
12.
Kurjak A, Zalud I, Volpe G. Conventional B-mode and transvaginal color Doppler in ultrasound assessment of ectopic pregnancy. Acta Med Iugosl 1990;44:91-103.  Back to cited text no. 12
    
13.
Wojak JC, Clayton MJ, Nolan TE. Outcomes of ultrasound diagnosis of ectopic pregnancy. Dependence on observer experience. Invest Radiol 1995;30:115-7.  Back to cited text no. 13
    
14.
Timor-Tritsch IE, Yeh MN, Peisner DB, Lesser KB, Slavik TA. The use of transvaginal ultrasonography in the diagnosis of ectopic pregnancy. Am J Obstet Gynecol 1989;161:157-61.  Back to cited text no. 14
    
15.
Barnhart K, Mennuti MT, Benjamin I, Jacobson S, Goodman D, Coutifaris C. Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet Gynecol 1994;84:1010-5.  Back to cited text no. 15
    
16.
Talwar P, Sandeep K, Naredi N, Duggal BS, Jose T. Systemic methotrexate: An effective alternative to surgery for management of unruptured ectopic pregnancy. Med J Armed Forces India 2013;69:130-3.  Back to cited text no. 16
    
17.
Shrestha J, Saha R. Comparison of laparoscopy and laparotomy in the surgical management of ectopic pregnancy. J Coll Physicians Surg Pak 2012;22:760-4.  Back to cited text no. 17
    
18.
Pérez-Martín L, De León Luis J, Gámez-Alderete F, Bravo C, Pérez F, Aguarón A, et al. Laparoscopic management of a spontaneous live monochorionic monoamniotic twin tubal ectopic pregnancy. A case report. Ginecol Obstet Mex 2013;81:612-5.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]



 

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