Case ReportABSTRACT
Broad ligament ectopic is one of rarest types of ectopic pregnancy and its diagnosis is very difficult.
Case Report: We present a case of right sided broad ligament ectopic which was diagnosed accidentally and managed by surgical removal.
Introduction
One of the rarest types of ectopic pregnancy is to be implanted between the leaves of the broad ligament. Because of being rare condition, diagnosis is very difficult [1]. It was first described in 1816 by Loschge [2]. Champion and Tessitore summarized the largest series of 62 cases and reported the incidence as one in 183,900 pregnancies [3]. Pathophysiology of this condition is not well understood. It was classified as secondary abdominal pregnancy after ruptured tubal or ovarian one into peritoneal cavity and implanted in another location [4]. It was found that broad ligament pregnancy can occur in patients underwent salpingectomy. The possibility of microscopic fistulous tract which transfer embryos through abdominal cavity was explained [4]. Its symptoms usually are wide range but most of them mimic symptoms of ectopic pregnancy which include abdominal pain and vaginal bleeding with extremes degrees of both presentations from mild to severe symptoms [4].
Case Report
A 30-year-old women P1+ 5 last one was ectopic pregnancy upon which she underwent right salpingectomy. She sought El-Demerdash obstetric emergency with history of 11 weeks’ amenorrhea complaining of episodes of spotting per vagina, mild intermittent abdominal pain mainly at right iliac fossa. She had regular antenatal care and she was accidentally diagnosed as having tubal ectopic pregnancy followed by laparoscopic procedure which revealed mass in para vesical space and no adnexal mass. She was vitally stable. On abdominal examination, there was mild tenderness in right fossa with no palpable mass and mild tenderness at sites of laparoscopic entry. There was no cervical motion tenderness per vaginal examination. Laboratory investigations showed that serum BHCG measured 69661 Miu\ml. Her hemogram was normal. Transvaginal ultrasonography revealed an empty uterus, extra uterine pregnancy with fetal cardiac activity was noted, CRL 40 mm (11 weeks) possibly pregnancy in rudimentary horn. Because of this conflict between ultrasound finding and patient history, casualty team revised patient laparoscopic operative procedure and there was normal uterine anatomy, surgically removed right fallopian tube, normal left fallopian tube, mass in right broad ligament is noted (Figures 1 & 2). Since the findings suggest presence of hematoma which was started to be developed along right adnexa, laparotomy was done on the same day due to un availability of laparoscopic set up even at tomorrow morning. Upon entering peritoneal cavity, there was small hematoma above right ovary, bleeding from posterior leaflet of the broad ligament and the stump of right tube and mass at right broad ligament about 5x6 cm. The right broad ligament was opened, and the sac was excised, products of conceptions extruded. There was bleeding from the site, which was controlled by compression, complete removal of right tube, exploration of right ureter and right-sided great vessels which all were normal. She had no postoperative complications, but we lost to follow up after initial postoperative checkup at 2 weeks (Figure 3).
Figure 1: Ultrasound finding
1) Ectopic pregnancy,
2) Uterus,
3) Site of mentioned hematoma.
Figure 2: Site of broad ligament ectopic in laparoscope.
Figure 3: Products of conception.
Discussion
Abdominal pregnancy represents 1% of all ectopic pregnancies and 1 in 10,000 births. It is defined as implantation in the peritoneal cavity outside uterus and the fallopian tube [5]. Other potential sites of abdominal pregnancy are broad ligament, pelvic side wall, abdominal organs like liver or spleen and diaphragm [6]. Unlike tubal pregnancy which can be diagnosed easily after involution in ultrasound with high specificity reaching 99% combined with serum Beta HCG, diagnosis of broad ligament pregnancy is very difficult [1]. In our case, the patient was lucky to diagnosed accidentally via laparoscopy. Management of such cases usually by surgical intervention via laparotomy because of high risk of massive intraoperative blood loss which what done in our case. Laparoscopic approach for these cases was described but usually depends on surgical expertise of the operator [7].
Conclusion
There is little information to guide diagnosis and management of broad ligament ectopic but most cases in literature favor surgical intervention especially with availability of laparoscopy. Our case was misdiagnosed as tubal ectopic pregnancy, accidentally discovered during laparoscopic intervention, and was managed properly in our department without complications.
Acknowledgement
6-unit casualty team and casualty professors.
References
- Nair SS, Nayar J (2016) Thoracic endometriosis syndrome: a veritable Pandora’s Box. Journal of Clinical and Diagnostic Research 10(4): QR04.
- Loschge (1818) Arch F Med Erfahr 2: 218.
- Champion PK, Tessitore NJ (1938) Intraligamentary pregnancy: A survey of all published cases of over 7 calendar months, with the discussion of an additional case. Am J Obstet Gynecol 36: 281-293.
- Fiorentzis S, Margetousakis T, Georgellis C, Kotridis P, Oikonomopoulou D, et al. (2019) Broad Ligament Pregnancy. Non-tubal Ectopic Pregnancy 2019. Intech Open.
- Binder DS (2003) Thirteen-week abdominal pregnancy after hysterectomy. J Emerg Med 25(2): 159-161.
- Fader AN, Mansuria S, Guido RS, Wiesenfeld HC (2007) A 14-week abdominal pregnancy after total abdominal hysterectomy. Obstet Gynecol 109(2): 519-521.
- Sheethal CH (2017) Full term viable secondary broad ligament pregnancy–A rare case. Case Reports in Women's Health 13: 4-5.
