Author Information
Shah NH*, Mourya S**, Paranjpe S***.
(* Consulting Gynecologist/Obstetrician & Hon. Endosopic Surgeon Wadia Hospital & Railway Hospital, ** Consulting Gynecologist/Obstetrician, *** Director: Velankar Hospital & Paranjpe Maternity Home, Mumbai, India.)
Abstract
Ectopic pregnancy causes significant maternal morbidity and also maternal mortality. Broad ligament pregnancy is very rare type but has high maternal mortality. Diagnosis of this condition is seldom done with imaging techniques. Definitive diagnosis is usually done intraoperatively either during exploratory laparotomy or by minimally invasive surgeries especially in a young stable patient. We are presenting a case of a 28 year old female with clinical suspicion of right sided tubal ectopic pregnancy. Diagnosis of right broad ligament pregnancy was done during laparoscopy.
Introduction
Ectopic pregnancy means implantation of the fertilized ovum outside the uterine body. Most of the ectopic pregnancies occurs in the fallopian tube. Abdominal pregnancy accounts for 1% of which broad ligament pregnancy is very rare.[1] Here, we are presenting a case of broad ligament ectopic pregnancy, in which laparoscopy played an important role in diagnosis and its subsequent management.
Case Report
A 28 year old female Gravida 2 Para 1 Living 1 presented to emergency ward with complaints of pain in abdomen since 2 days, and one episode of spotting per vaginum. She had 2 months of amenorrhea. Her urine pregnancy test was positive. She had previous vaginal delivery. There was no previous history of surgery or significant medical history. No other significant past history was obtained.
On general examination, she was conscious, afebrile. Her blood pressure was 110/60 mm of Hg, and pulse was 86/min. Mild tenderness in right iliac fossa was present on abdominal examination. Per speculum examination revealed minimal blood discharge through the os. On vaginal examination ill-defined mass in the right fornix was felt with positive cervical motion tenderness. Size of the uterus could not be assessed due to tenderness.
Transvaginal ultrasound (TVS) revealed empty uterus with thickened endometrium. There was an ill-defined mass measuring 3*2 cm on the right side of the uterus suggestive of an unruptured right tubal ectopic pregnancy. There was no free fluid collected in the pouch of douglas. Hematological examination showed hemoglobin level of 8.8 gm/dl and white blood cell count of 12,500/ mm3. Serum β HCG measured 26,198 mIU/ml.
From this clinical and ultrasonographic findings, diagnosis of right ectopic pregnancy was made but the exact location was uncertain. As she was hemodynamically stable, a decision for laparoscopy was taken for definitive diagnosis and management. A 3*2 cm irregular mass in the right broad ligament most probably ectopic pregnancy was found with minimal blood in the POD. Uterus, both the fallopian tube and ovary appeared normal.
Figure 1. Mass seen protruding from the right broad ligament.
Figure 2. Distended tube seen above the mass.
Figure 3. Removal of the mass.
Figure 4. View after removal of the complete mass.
Figure 5. Final view after giving wash.
The Broad ligament was opened and excision of mass was done. Hemostasis was achieved by bipolar cautery and bleeding could be easily controlled. Also, right salpingectomy was done. The tissue was completely removed and sent for histopathological examination. Ureter peristalsis was confirmed again after giving wash and right ureter was visualized. Histopathology report confirmed the tissue as products of conception. Postoperative course was uneventful and she was discharged on 4th postoperative day.
Discussion
Ectopic pregnancy is a type of pregnancy that occurs outside the normal uterine cavity. Fallopian tube is the most common site of ectopic pregnancy and abdominal pregnancy accounts for 1%.[1] It can occur in any part but it is most common in POD and rare in the broad ligament.
Broad ligament ectopic pregnancy is also known as interligamentous pregnancy. In broad ligament pregnancy the fetus or gestation sac develop within the leaves of the broad ligament. The incidence of broad ligament pregnancy is 1 in 189,300 pregnancies.[2] Broad ligament pregnancy is very rare, and maternal mortality rate is as high as 20%.[1] It can be due to primary implantation of the zygote on the broad ligament or followed by secondary implantation in the fallopian tube, ovary or peritoneal surface. In secondary broad ligament pregnancy, ovum first implants in the fallopian tube. Due to fimbrial abortion or rupture of the fallopian tube it gets implanted in the broad ligament.
Risk factors include a history of pelvic inflammatory disease, previous ectopic pregnancy, previous salpingectomy, abdominal tuberculosis, endometriosis and use of assisted reproductive techniques. There was no risk factor in this case.
There are no specific clinical features for this rare form of ectopic pregnancy to enable diagnosis to be made preoperatively. The clinical presentation of broad ligament ectopic pregnancy is highly variable and can range from asymptomatic early ectopic pregnancy to rupture in labor at term. However, dull lower abdominal pain during early pregnancy and vaginal bleeding are common presentations. Pain has been attributed to placental separation, tearing of broad ligament and small peritoneal hemorrhage’s. Vaginal bleeding occurs due to breakdown of decidual cast. They usually present in the first trimester with pain and vaginal bleeding but live birth is also reported in literature.
In this case, she presented with severe abdominal pain with guarding and rigidity and no vaginal bleeding, raising the possible differential diagnosis of ruptured ectopic pregnancy, torsion of ovarian cyst or any surgical cause of acute abdomen. As her urine pregnancy test was positive, so the provisional diagnosis of ectopic pregnancy was made.
Ultrasound is usually the preferred investigation. Ectopic pregnancy can be diagnosed with the help of high resolution transvaginal sonography combined with serum Beta HCG with sensitivity of 93% and a specificity of 99%.[3] Broad ligament pregnancy is very rarely diagnosed prior to surgery. Definitive diagnosis is usually intraoperative.
Conservative management or medical management is not recommended for broad ligament ectopic if the diagnosis is certain. Usually exploratory laparotomy is considered as the choice of surgical management as the patients are unstable. Our patient was managed laparoscopically as she was stable and it was a small broad ligament pregnancy. Laparoscopy played important role not only in diagnosis but also in management of the case in the same setting. Laparoscopy also has advantages of lower morbidity, mortality, less blood loss, and faster recovery.
Broad ligament ectopic pregnancy is also known as interligamentous pregnancy. In broad ligament pregnancy the fetus or gestation sac develop within the leaves of the broad ligament. The incidence of broad ligament pregnancy is 1 in 189,300 pregnancies.[2] Broad ligament pregnancy is very rare, and maternal mortality rate is as high as 20%.[1] It can be due to primary implantation of the zygote on the broad ligament or followed by secondary implantation in the fallopian tube, ovary or peritoneal surface. In secondary broad ligament pregnancy, ovum first implants in the fallopian tube. Due to fimbrial abortion or rupture of the fallopian tube it gets implanted in the broad ligament.
Risk factors include a history of pelvic inflammatory disease, previous ectopic pregnancy, previous salpingectomy, abdominal tuberculosis, endometriosis and use of assisted reproductive techniques. There was no risk factor in this case.
There are no specific clinical features for this rare form of ectopic pregnancy to enable diagnosis to be made preoperatively. The clinical presentation of broad ligament ectopic pregnancy is highly variable and can range from asymptomatic early ectopic pregnancy to rupture in labor at term. However, dull lower abdominal pain during early pregnancy and vaginal bleeding are common presentations. Pain has been attributed to placental separation, tearing of broad ligament and small peritoneal hemorrhage’s. Vaginal bleeding occurs due to breakdown of decidual cast. They usually present in the first trimester with pain and vaginal bleeding but live birth is also reported in literature.
In this case, she presented with severe abdominal pain with guarding and rigidity and no vaginal bleeding, raising the possible differential diagnosis of ruptured ectopic pregnancy, torsion of ovarian cyst or any surgical cause of acute abdomen. As her urine pregnancy test was positive, so the provisional diagnosis of ectopic pregnancy was made.
Ultrasound is usually the preferred investigation. Ectopic pregnancy can be diagnosed with the help of high resolution transvaginal sonography combined with serum Beta HCG with sensitivity of 93% and a specificity of 99%.[3] Broad ligament pregnancy is very rarely diagnosed prior to surgery. Definitive diagnosis is usually intraoperative.
Conservative management or medical management is not recommended for broad ligament ectopic if the diagnosis is certain. Usually exploratory laparotomy is considered as the choice of surgical management as the patients are unstable. Our patient was managed laparoscopically as she was stable and it was a small broad ligament pregnancy. Laparoscopy played important role not only in diagnosis but also in management of the case in the same setting. Laparoscopy also has advantages of lower morbidity, mortality, less blood loss, and faster recovery.
Conclusion
Being a rare condition, diagnosis of it is challenging. One needs a high index of suspicion for such a rare diagnosis. Laparoscopy should be considered for diagnosis and management whenever in doubt in appropriately selected patient.
References
- Sharma S, Pathak N, Goraya SPS, Mohan P. Broad ligament ectopic pregnancy. Sri Lanka J Obstet Gynaecol 2011;33:60–2.
- Sheethal CH, Powar A. Full term viable secondary broad ligament pregnancy – A rare case. Case Rep Womens Health. 2016;13:4-5
- Nayar J, Nair SS. Broad Ligament Pregnancy - Success Story of a Laparoscopically Managed Case. J Clin Diagn Res. 2016;10(7):QD04-5.
Citation
Shah NH, Mourya S, Paranjpe S. Broad Ligament Ectopic Pregnancy Diagnosed And Managed Laparoscopically. JPGO 2019. Volume 6 No.1. Available from: https://www.jpgo.org/2019/01/broad-ligament-ectopic-pregnancy.html