Abdominal ectopic pregnancy
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30 weeks pregnant, G3P2, with severe abdominal pain and shortness of breath.
Initially, patient was electively admitted for induction of labor, after confirmed intrauterine death from ultrasound scan. After one cycle of induction, patient was complaining of severe abdominal pain, shortness of breath and vital signs showed tachycardia.
Proceeded with urgent contrast-enhanced CT abdomen and pelvis.
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Fetal skeleton in the intraperitoneal space at the right lumbar and midline pubic regions, where the fetal skeleton appears to be located within a complete "amniotic sac". No obvious adherance of this "amniotic sac" with surrounding structures.
The “amniotic sac” adhered to soft tissue mass which attached to the right superior aspect of the uterus. Multiple areas of higher attenuation within the soft tissue mass are suggestive of acute hematoma. Large amount of hyperdense ascitic fluid (30-50 HU attenuation number) within the pelvic region, interloop region, perihepatic, perisplenic, both paracolic gutters and peri-amniontic sac, suggestive of hemorrhagic fluid.
The uterus is too small in size for the patient’s gestation. The contour of uterus appears intact. Minimal hydrometra in the endometrial cavity.
Right mild hydronephrosis and proximal hydroureter. No bowel loops dilatation.
Bibasal mild pleural effusion with passive atelectasis at both lung bases.
Emergency laparotomy was performed. The dead fetus was extracted uneventfully. A total abdominal hysterectomy was performed. The uterus was grossly intact with the placenta adhered to the uterine fundus.
Abdominal ectopic pregnancy is an extremely rare diagnosis. This case shows the importance of antenatal ultrasound to confirm the location of the pregnancy. It is especially crucial to confirm intrauterine pregnancy prior to induction of labor. In this case, failure to diagnose the ectopic pregnancy, due to the late presentation of this patient and the absence of routine antenatal check-ups in a developing country, led to a futile induction of labor causing severe hemoperitoneum.
Another differential diagnosis to consider in this case is uterine rupture resulting in the expulsion of a previously intrauterine fetus into the peritoneal space. It is unlikely in this case, as from an imaging point of view, the uterus is too small for a 30-week gestation as there is no obvious rupture seen at the uterine contour.
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