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.www.ijcasereportsandimages.com

Second trimester unruptured ampullary ectopic pregnancywith variable presentations: Report of two casesRekha Sachan, Pooja Gupta, ML Patel

ABSTRACTIntroduction: Ninety­five percent of ectopicpregnancies occur in the fallopian tube.Diagnosis and exact location of ectopicpregnancy is usually easy during the 1sttrimester of pregnancy by ultrasonography.Ampulla is the most common site for ectopictubal pregnancies. Case Series: Here we reporttwo cases of ampullary ectopic pregnancy withvariable presentation. First case was a 27­year­oldfemale who presented with bleedingpervaginum following IUCD insertion inlactational amenorrhea period. She wasdiagnosed as a case of viable, unruptured, tubalampullary ectopic pregnancy of 14 weeksgestational age with copper­T in situ. Secondcase presented with seven months amenorrheawith dead fetus and repeated failed attempts ofinduction of labour. Later on she was diagnosedas a case of 26 weeks unruptured ampullaryectopic pregnancy with a dead fetus.Conclusion: Second trimester unruptured tubalpregnancy is rare among ectopic pregnancies.Ultrasonography is still the diagnostic modalityof choice. The probability of ectopic pregnancyshould be born in mind in cases of IUCD withspotting pervaginum and repeated failure oflabour induction even at advanced gestationalage.

Keywords: Ampullary, Ectopic pregnancy,IUCD, Intrauterine contraceptive device,Laparotomy, Ultrasonography*********

Sachan R, Gupta P, Patel ML. Second trimesterunruptured ampullary ectopic pregnancy with variablepesentations: Report of two cases. International Journalof Case Reports and Images 2012;3(8):1–4.*********

doi:10.5348/ijcri­2012­08­154­CS­1

INTRODUCTIONAmpulla is the commonest site for ectopic pregnancy[1]. Most of the tubal ectopic pregnancies rupturebetween 5–11 weeks of gestation [2]. Ectopic pregnancyis a leading cause of pregnancy­related death in earlypregnancy [3]. However, in extremely rare conditionsthey may be carried upto an advanced gestational ageand may be associated with diagnostic difficulty. Wehereby report two cases of unruptured tubal ampullaryectopic pregnancies with variable presentations. In thefirst case, the woman presented with 14 weeks viableampullary tubal pregnancy with IUCD in situ. Thesecond case was a non­viable 26 weeks unruptured,ampullary ectopic pregnancy which was diagnosedduring exploratory laprotomy, after repeated attemptsof induction of labour.

CASE REPORTCase 1: 27­year­old para 3+0 had copper­Tinsertion in lactational amenorrhea periodapproximately three months after giving birth to herthird child. Approximately three weeks post insertion,she started experiencing bleeding per vaginum. She

CASE SERIES OPEN ACCESS

Rekha Sachan1 , Pooja Gupta1 , ML Patel2

Affi l iations: 1Department of Obstetrics and Gynecology,CSM Medical University, Lucknow, 2Department ofMedicine, CSM Medical University, Lucknow.Corresponding Author: Dr. Rekha Sachan, MS, FICOG,Professor, Department of Obstetrics & Gynaecology, CSMMedical University, Lucknow; Ph: +91 9839009290; Email :drrekhasachan@gmail .com

Received: 1 0 March 201 2Accepted: 06 May 201 2Published: 01 August 201 2

Sachan et al. 1

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.www.ijcasereportsandimages.com Sachan et al. 2

interpreted this bleeding as resumption of her menses.However, when the spotting continued for threemonths, she consulted in our out patient department(OPD).On examination pulse rate was 90 beats/minute,blood pressure was 110/70 mmHg with moderatepallor. On abdominal examination a 6x8 cm sizedsuprapubic mass, firm in consistency with restrictedside to side mobility was present. A closed cervical oswith CuT thread and slight bleeding coming through oswas visible on per speculum examination. Bimanualexamination revealed a slightly enlarged uterus withcervical motion tenderness with a lump of 8x10 cmpalpable through right adnexa in continuation withabdominal mass.Patient’s hemoglobin was 8 g/dL, blood group was Apositive, serum β­HCG was 41,840 mIU/mL withnormal liver and kidney function tests. Transabdomialsonography revealed an extrauterine gestational sac of14 weeks 1 day with fetal heart rate of 180/min. Uteruswas seen separate from the gestational sac on the leftside, with minimal collection in the cavity withintrauterine contraceptive device in situ. Minimal fluidwas present in the cul­de­sac.Exploratory laprotomy revealed a right sided tubalampullary lump of 10x12 cm with adherent right ovary,with no evidence of hemoperitoneum (Figure 1). Rightsided salpingo­ophorectomy with left sided tuballigation was done. Fetal movements were noted insidethe sac. Cut section of tubal ampullary lump revealed alive fetus of about 14 weeks gestational age (Figure 2).Case 2: A 25­year­old gravida 1, para 0 ladypresented to our OPD with chief complaints ofamenorrhea of seven months with absent fetalmovements. Her previous menstrual history wasnormal, however, she was not sure about her lastmenstrual period. On general examination BP was124/80 mmHg. Systemic examination was withinnormal limits.Obstetrical examination revealed 26–28 weeksgravid uterus sized suprapubic lump, soft consistency,non­tender and external ballotment was absent. Onauscultation fetal heart sounds could not be heard. Onper vaginum examination, cervical os was closed, uterusseemed to be of normal size, deviated to left side and aseparate mass was felt through the right adnexa whichwas of about 26–28 weeks size and soft in consistency.Her hemoglobin was 8.9 g/dL, blood group was Bnegative, liver function, kidney function andcoagulation profile was within normal limits.Ultrasonography revealed single dead fetuscorresponding to 26 weeks of gestational age butconfirmation of exact location was not possible. Astrong suspicion of pregnancy in one horn of bicornuateuterus was raised due to advanced gestational age of thefetus. Induction of labour was done with 100 µg ofmisoprostol four hourly upto a maximum doses of 2000µgm but it failed to initiate labor.Exploratory laprotomy was done and per operativelyuterus was found to be of normal size and right sided

mass suggestive of unruptured, ampullary tubal ectopicpregnancy of about 20x16 cm size with prominentvessels, invading the broad ligament was present. Only asmall fimbrial distal portion of the tube with adherentright ovary was visualized (Figure 3). Left side tube andovary was normal (Figure 4). Right sided salpingo­ophorectomy was done. Cut section of specimen showeda dead fetus of around 700 g with fully developedplacenta and decreased liquor (Figure 5). There was noevidence of hemoperitoneum.

DISCUSSIONEctopic pregnancies account for 3–4% of pregnancy­related deaths. During 1999–2008, the ectopicpregnancy mortality rate in the United States was 0.6deaths per 100,000 live births. The Centers for Disease

Figure 1: Peroperative finding shows an ampullary tubalpregnancy of 10x12 cm size with adherent ovary (Case 1).

Figure 2: Developed placenta with fetus of 14 weeksgestational age (Case 1).

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.www.ijcasereportsandimages.com Sachan et al. 3

Control and Prevention reported a higher rate inFlorida, 2.5 deaths per 100,000 live births during2009–2010. The 11 ectopic pregnancy deaths in Floridaduring 2009­2010 contrast with a total of 14 deathsidentified in national statistics for 2007 [4].In the developing countries, hospital based studieshave reported ectopic pregnancy case fatality rate ofabout 1–3% which is 10 times higher than that reportedfrom developed countries [5]. After a 10­year populationbased study of 1800 cases concluded that only 4.5%ectopic pregnancies were extratubal ectopic pregnancies(ovarian and abdominal) and about 73% tubalpregnancies were ampullary [6]. Late diagnosis ofectopic pregnancy leads to major complications inalmost all cases and needs emergency surgicalintervention. However, in both the cases inspite ofprolongation of ectopic pregnancy up to 14 weeks and 26weeks of gestational age, the patients werehemodyanamically stable.We have reported a rare case of viable tubalampullary ectopic pregnancy of 14 weeks gestation withcopper­T in situ. Another case was reported by Rujinet al. [7] in which a patient had large intact tubalpregnancy of 10 weeks gestation. As literature supports,IUCD used for contraception does not increase the riskof ectopic pregnancy [8]. In our case the patientpresented with viable ectopic pregnancy of 14 weekswith IUCD in situ which is rare. Amenorrhea of 6–8weeks with spotting and pain in abdomen is thehallmark of ectopic pregnancy [8]. One should notforget that if a woman with IUCD in situ presents to usin lactational amenorrhea period with spotting pervaginum, ectopic pregnancy should be ruled out becausespotting is often considered side effect of IUCD bygynecologists.In the second case, the diagnosis of ectopic pregnancywas difficult as patient presented to us at advancedgestational age. In the 1st trimester of pregnancyultrasound examination is very reliable in diagnosingectopic pregnancy [9]. In the 2nd trimester it is difficultto determine the exact location of pregnancy byultrasonography [10]. Wabong et al. reported a case of26­week ectopic pregnancy which was diagnosed asintrauterine pregnancy with dead fetus after severalunsuccessful attempts of induction of labor. Finally theyresorted to laprotomy which was diagnostic of ectopicpregnancy [11]. Similarly, in our case diagnosis wasconfirmed by laprotomy. It is difficult to do conservativesurgery in such type of large ectopic pregnancy even if thepatient has desire for future child bearing due toexcessive deformation of fallopian tube, so in our casesalpingo­oophorectomy was done. Hence, the authorsrecommend that the probability of ectopic pregnancyshould be borne in mind in cases of repeated failures oflabour induction even at advanced gestational age.

CONCLUSIONThere has been a rise in the incidence of ectopicpregnancies since 1970s. Second trimester unruptured

Figure 3: Peroperative finding showed an ampullary ectopic of20x16 cm size with normal uterus and fimbrial end (Case 2).

Figure 4: Peroperative finding showed an ampullary ectopic of20x16 cm size with normal uterus, left side tube and ovary(Case 2).

Figure 5: Well developed placenta with a fetus of 26 weeksgestational age seen after dissection of sac (Case 2).

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.www.ijcasereportsandimages.com Sachan et al. 4

tubal pregnancy is a rare ectopic pregnancy.Ultrasonography is still a diagnostic modality.Probability of ectopic pregnancy should be born in mindin cases of IUCD with spotting pervaginum andrepeated failure of labour induction even at advancedgestational age.*********

Author ContributionsRekha Sachan – Substantial contributions to conceptionand design, Acquisition of data, Drafting the article,Revising it critically for important intellectual content,Final approval of the version to be publishedPooja Gupta – Substantial contributions to Drafting thearticle, Final approval of the version to be publishedML Patel – Substantial contributions to conception anddesign, Acquisition of data, Revising it critically forimportant intellectual content, Final approval of theversion to be publishedGuarantorThe corresponding author is the guarantor ofsubmission.Conflict of InterestAuthors declare no conflict of interest.Copyright© Rekha Sachan et al. 2012; This article is distributedunder the terms of Creative Commons Attribution 3.0License which permits unrestricted use, distributionand reproduction in any means provided the originalauthors and original publisher are properly credited.(Please see www.ijcasereportsandimages.com/copyright­policy.php for more information.)

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