Author Information
Mahajan JS*, Samant PY**, Parulekar SV***
(* Third Year Resident, ** Additional Professor, *** Professor and Head of Department
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
A
rare case of ectopia vesicae and intrauterine pregnancy in a 25 years old,
unmarried woman is presented. A medical termination of pregnancy was performed
by dilatation and evacuation.
Introduction
Ectopia
vesicae is a congenital anomaly in which there is failure of development of
lower anterior abdominal wall. It occurs in 1 in 25000-50,000 people, the
incidence in males being twice as in
females. It is seven times more common in babies conceived by in vitro
fertilization. [1] The lower anterior abdominal wall
and the anterior wall of the bladder are absent. The posterior bladder wall and
the ureteric orifices are exposed. The bladder neck and urethra are poorly
defined. The pubic symphysis is widely
separated.[2,3] There are reports of intrauterine pregnancy and successful deliveries in patients with
uncorrected ectopia vesicae. Cesarean section
at term gestation has always been preferred in such cases. A case of
ectopia vesicae in a primigravida with 11 weeks of gestation managed by medical
termination of pregnancy is presented.
Case
report
A 25 years
old unmarried woman presented with chief complaints of amenorrhea for 3
months, pain in abdomen and generalized weakness for 1 week. She had an
ultrasonographic scan showing an intrauterine gestation of 11 weeks. She gave a
history of urinary incontinence from childhood and only spotting monthly from
the orifice below the bladder from the age of puberty at the age of 14 years.
There was a history of interfemoral sexual intercourse. On abdominal examination, the umbilicus was
absent. The open bladder base was at the lower end of the abdominal wall.
An opening was present in the area of the mons pubis which
was extremely tender to digital palpation,. The clitoris was absent, the labia
minora were widely separated, and the pubic rami were absent. On per rectal
examination, a bulky uterus was palpable anterior to rectum. One finger
examination was done through the introital orifice. It was extremely painful.
The uterus could be felt posteriorly, but its size could not be determined. The
cervix could not be felt.
Figure.
1. Ectopia vesicae. The pubic bones and labia minora appear to be parts of lower abdominal wall.
Pubic hair is seen on either side of midline. Introitus appears to be very
small.
Her serum beta-hCG level was 97218 mIU/ml. Ultrasonography showed an
intrauterine fetus of 11 weeks of gestation. Magnetic resonance imaging showed
a single intrauterine gestation. The connection between the gravid uterus and
the external orifice could not be defined.
It also could not be determined if the opening present on mons was
vaginal or urethral.
Examination under general anesthesia showed that the introit opening led to a cavity which had a
normal appearing cervix. It was dilated to 9.5 mm. The products of conception
were evacuated with ovum forceps. A blunt curettage was done. The patient made
an uneventful recovery. She was given contraceptive advice and referred to a
urologist for repair of the ectopia vesicae.
Discussion
Ectopia vesicae or bladder extrophy occurs due
to a failure of development of the lower anterior abdominal wall. That leaves
the posterior wall of the bladder bulging like soft red swelling with multiple
sites of excoriation on it. The condition should be surgically treated in
childhood. A neglect may lead to its persistence in adult life, with increased
risk of ascending infection as openings
of ureters are on the surface, and of development of malignancy in the exposed
mucus membranes. In a combined series of 22 patients, there were 32
pregnancies, of which two aborted spontaneously and two were terminated
medically. There were 27 live births and one intrauterine death of twins.[4]
There were two case reports of continuation of the pregnancy to the
third trimester and successful obstetric outcome was obtained by caesarean
section.[5] In the case
presented, the pregnancy termination was performed for social reason (out of
wedlock pregnancy) rather than ectopia vesicae.
References
1.
Wood HM,
Trock BJ, Gearhart
JP: In vitro
fertilization and the cloacal-bladder exstrophy-epispadias
complex: Is there an association? J Urol 2003;69:1512-1515.
2.
Gearhart JP, Ben-Chaim J, Jeffs RD, Sanders RC. Criteria for the prenatal diagnosis of
classic bladder exstrophy. Obstet Gynecol 1994; 85:961-964.
3.
Woodhouse CRJ. The gynaecology of exstrophy. BJU International 1999;
83(S3):34-38.
4.
Woodhouse CRJ. Long term
results of bladder exstrophy. In Gearhart JP, Mathews R (editors). The
Exstrophy-Epispadias Complex: Research Concepts and Clinical Applications.
First Edition. New York. Kluwer Academic/Plenum Publishers. 1999; p
182.
5.
Mandal A, Chaudhuri S, Manna SS, Jana SK, et al. Successful pregnancy
outcome in a woman with untreated ectopia vesicae: A case report and review of
literature. J Obstet Gynecol Res 2013;39:868–871.
Citation