Presentation
Underlying diabetes and chronic hypertension with one previous cesarean section scar. Came at twenty six weeks of pregnancy with antepartum hemorrhage.
Patient Data
Bulky anteverted non-gravid uterus with visible gaping over lower uterine segment near the cesarean scar site (scar dehiscence). Heterogeneous and mixed echo content from the uterine lumen tracking via the scar site externally superolaterally towards the right lower abdominal quadrant. The gestational sac and the products of conception have been expelled into the right lower abdominal quadrant.
A single fetus is visualized within the gestational sac with no cardiac activity, but shows no obvious Spalding sign, Roberts sign or subcutaneous tissue edema. Homogeneous soft tissue within the fetal right atrium suggestive of lodged thrombus post-embolism. Extensive anechoic fluid collection within the fetal cerebral space posteriorly terminating at the thalamic region suggesting alobar holoprosencephaly (i.e. monoventricle, thin peripheral cerebral/parenchymal mantle, fused thalami, and absent cavum septum pellucidum and falx cerebri).
Cleft palate is seen, presented as linear hypoechoic gaping/discontinuity. Associated polyhydramnios (maximum pocket depth >8 cm) is also seen.
Spectral Doppler assessment of the maternal bilateral uterine arteries show left sided dicrotic notch within the left uterine arterial waveform with mildly elevated pulsation and resistive index (PI=1.07, RI=0.70) consistent with maternal hypertension. The right uterine artery indices are unremarkable (PI=0.94; RI=0.64).
Case Discussion
A right lower quadrant abdominal ectopic pregnancy (~ 27 weeks gestation by ultrasound, with fetal demise). The ectopia is likely primarily attributed to expulsion of intrauterine contents/products of conception via lower uterine scar dehiscence.
There are associated features of fetal cleft palate and upper cleft lip, alobar holoprosencephaly, and right cardiac atrial chamber thrombus; polyhydramnios (most likely had overstretched the thinned out scar site and subsequently convoluted externally into the abdominal cavity); mildly elevated left sided maternal uterine artery pulsatility and resistive indices (with early dicrotic notching) consistent with current maternal hypertensive state.
Post-exploratory laparotomy findings corroborated the ultrasound findings and showed expelled intra-uterine products of conception via the lower uterine segment scar dehiscence into the right lower abdominal quadrant with a stillborn single male fetus, fetal cleft lip and palate, and lower uterine segment scar dehiscence.
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