Azhar Erum, Green Landen, Mohammadi Salma, Waheed Abdul
Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, USA.
Public Health Sciences, Penn State University College of Medicine, Hershey, USA.
Cureus. 2020 May 25;12(5):e8276. doi: 10.7759/cureus.8276.
Ectopic pregnancy can be a life-threatening cause of acute abdomen. Broad ligament pregnancy accounts for 1% of ectopic abdominal pregnancies and complications can be calamitous. This case report highlights a 27-year-old G2P0010 female who presented with amenorrhea and acute right lower quadrant and pelvic pain. By last menstrual period (LMP), she was at seven weeks and two days gestation. Her past surgical history was significant for a prior right salpingo-oophorectomy. The physical examination was significant for severe right lower quadrant tenderness with guarding. The urine pregnancy test was positive with the serum quantitative beta-human chorionic gonadotrophin (Beta hCG) of 28011 MIU/ML (normal range <5 MIU/ML). The transvaginal ultrasonography demonstrated an empty uterus and a gestational sac containing a fetal pole in the right adnexal area. The crown-rump length was 7.2 mm, consistent with six weeks and four days, with a positive fetal heart rate and moderate free fluid in the cul-de-sac. The patient was taken for immediate diagnostic laparoscopy, which was converted to open laparotomy due to active bleeding from the right broad ligament and pelvic wall close to large pelvic vessels. In addition to the hemoperitoneum, intraoperative findings revealed a normal left fallopian tube and ovary and absent right fallopian tube and ovary. Right ureterolysis was done and hemostasis of the bleeding broad ligament and right pelvic sidewall was established. An adherent tissue was dissected from the right broad ligament and sent to pathology. The patient did well postoperatively. The final pathology showed an ectopic pregnancy with immature chorionic villi in the broad ligament. The diagnosis of ectopic pregnancy in the broad ligament is challenging. The location could be close to the major pelvic vessels and anatomic structures like the ureter and bowel, hence, it can cause massive hemorrhage with maternal morbidity and mortality. Diagnosis is often missed preoperatively and made intraoperatively. Hence, we emphasize that this differential be considered in reproductive-aged women who present with atypical presentations of acute abdomen and amenorrhea.
异位妊娠可能是导致急腹症的危及生命的原因。阔韧带妊娠占异位腹腔妊娠的1%，其并发症可能是灾难性的。本病例报告重点介绍了一名27岁、孕2产0010的女性，她出现闭经以及右下腹和盆腔急性疼痛。根据末次月经日期（LMP），她妊娠7周零2天。她既往有右侧输卵管卵巢切除术史。体格检查显示右下腹有明显压痛并伴有肌卫。尿妊娠试验呈阳性，血清定量β-人绒毛膜促性腺激素（β-hCG）为28011 MIU/ML（正常范围<5 MIU/ML）。经阴道超声检查显示子宫内空虚，右侧附件区有一个包含胎芽的妊娠囊。头臀长度为7.2 mm，符合妊娠6周零4天，有胎心搏动阳性，直肠子宫陷凹有中等量游离液体。患者立即接受诊断性腹腔镜检查，由于右侧阔韧带和靠近盆腔大血管的盆腔壁有活动性出血，手术转为开腹手术。除了腹腔积血外，术中发现左侧输卵管和卵巢正常，右侧输卵管和卵巢缺如。进行了右侧输尿管松解术，并对出血的阔韧带和右侧盆腔侧壁进行了止血。从右侧阔韧带分离出一块粘连组织并送病理检查。患者术后恢复良好。最终病理显示阔韧带内异位妊娠伴未成熟绒毛膜绒毛。阔韧带内异位妊娠的诊断具有挑战性。其位置可能靠近盆腔主要血管以及输尿管和肠道等解剖结构，因此，可能导致大量出血，引起孕产妇发病和死亡。诊断通常在术前漏诊，术中才能明确。因此，我们强调，对于出现急性腹痛和闭经非典型表现的育龄妇女应考虑这种鉴别诊断。
