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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 22  |  Issue : 1  |  Page : 36-38

First trimester tubal ectopic pregnancy


1 Department of Anatomy, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
2 Department of Radiology, Crystal Specialist Hospital, Lagos, Nigeria
3 Department of Physiology, College of Medicine, University of Lagos, Lagos, Nigeria
4 Department of Anatomy, Faculty of Basic Medical Sciences, Bowen University, Iwo, Nigeria

Date of Web Publication3-Dec-2014

Correspondence Address:
Dr. Victor Ukwenya
Department of Anatomy, College of Medicine, Ekiti State University, Ado-Ekiti
Nigeria
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DOI: 10.4103/1115-1474.146148

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  Abstract 

About 1% of pregnancies is in an ectopic location with implantation not occurring inside of the womb, and of these 98% occurs in the Fallopian tubes. However, implantation can also occur in the cervix, ovaries, and abdomen. Ultrasound scan was performed on a 19-year-old nulliparous female at the Ultrasound Unit of Crystal Specialist Hospital, Lagos, Nigeria. The patient had complained of abdominal pain and vaginal bleeding. Transabdominal scan revealed an empty uterus and extra-uterine embryo implanted in the right adnexa. The fetal pole had a crown-rump-length (CRL) of 13 mm and the gestational age (GA) was 7 weeks 4 days; expected date of delivery (EDD) was 04/03/14. Ectopic pregnancies are usually associated with maternal morbidity and mortality resulting from complications. This case highlights the importance of ultrasound sonography in obstetrics and its adjunct purpose in the preoperative diagnosis and management of ectopic pregnancy.

Keywords: Ectopic pregnancy; extra-uterine; fallopian tube; first trimester; obstetrics; ultrasound scan; ultrasound


How to cite this article:
Ukwenya V, Adams A, Quadri K K, James A. First trimester tubal ectopic pregnancy. West Afr J Radiol 2015;22:36-8

How to cite this URL:
Ukwenya V, Adams A, Quadri K K, James A. First trimester tubal ectopic pregnancy. West Afr J Radiol [serial online] 2015 [cited 2022 Jan 22];22:36-8. Available from: https://www.wajradiology.org/text.asp?2015/22/1/36/146148


  Introduction Top


An ectopic pregnancy, or eccyesis, is described as a complication of pregnancy in which the embryo implants outside the uterine cavity. [1] About 1% of pregnancies is in an ectopic location with implantation not occurring inside of the womb, and of these 98% occurs in the Fallopian tubes. However, implantation can also occur in the cervix, ovaries, and abdomen. The vast majority of ectopic pregnancies implant in the Fallopian tube. [2],[3]

Reports show that pregnancies can grow in the fimbrial end (5% of all ectopic pregnancies), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial parts of the tube (2%). [4],[5] Mortality of a tubal pregnancy at the isthmus or intrauterine portion of the tube (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage. Tubal ectopic pregnancy has been hypothesised to be caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur. [6]

Ectopic pregnancies are difficult to diagnose; misdiagnoses could have a fatal outcome. Ten percent of all ectopic pregnancies at Ile-Ife, Nigeria over a 15-year period (1985-1999) were misdiagnosed initially at presentation. [7] There were five maternal deaths among the 38 misdiagnosed cases compared to two maternal deaths among the 342 initially correctly diagnosed cases. [7] This paper reports an unusual case of early diagnosis of tubal ectopic pregnancy through transabdominal ultrasound scan.


  Case Report Top


Ultrasound scan was performed on a 19-year-old nulliparous female patient who complained of amenorrhea, abdominal pain, bleeding, and cramps along with slightly distended lower abdomen. Siemens Ultrasound machine (Sonoline 450 SL, made in Germany) with a 3.5 MHz probe was used. The patient admitted to a family history of ectopic pregnancy. The present conception was her first. A transabdominal scan was performed for a panoramic view of abdominal and pelvic structures.

Longitudinal scan revealed the empty uterus in an anteverted position posterior to the urinary bladder, which was recognized as a pear-shaped structure. The uterus measured 68 mm by 50 mm. In the extreme lateral right adnexa (tubo-ovarian area), and indenting the posterior wall of the bladder was a viable fetal pole in an extrauterine gestational sac of diameter 20 mm [Figure 1]. The crown-rump-length (CRL) was 13 mm and gestational age (GA) was 7 weeks 4 days; expected date of delivery (EDD) was 04/03/14. There was no free fluid in the recto-uterine pouch.
Figure 1: Longitudinal pelvic scan of an ectopic pregnancy in a young adult female. GS = gestational sac; FP = fetal pole; UT= uterus; UB= urinary bladder

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  Discussion Top


Ectopic pregnancies are among the leading cause of mortality in women, especially in the Sub-Saharan region, [8],[9] ; a case fatality of 37 per 1000 has been reported for Lagos, Nigeria. [10] They are also usually associated with life-threatening complications that necessitate the importance of early diagnosis. Detection of an adnexal mass separate from the ovaries is diagnostic of ectopic pregnancy. [11] Ectopic pregnancies are often diagnosed by high resolution vaginal ultrasonography [12] or vaginal ultrasound combined with a discriminatory serum level of beta subunit human chorionic gonadotropin (hCG) of 1000 IU/I. [11] The absence of intrauterine sac with hCG levels above 6500 IU/I secondary to complaints of abdominal pain, second degree amenorrhea and irregular vaginal bleeding has been cited to be indicative of ectopic pregnancy. [13],[14]

The use of this threshold in combination with sonographic detection of an adnexal mass was diagnostic of ectopic pregnancy with a sensitivity of 97%, a specificity of 99%, a positive predictive value of 98% and a negative predictive value of 98%. [11]

Ectopic pregnancy was visualized as an extrauterine gestational sac with a fetal pole in a patient that presented with vaginal bleeding, abdominal cramps, and pain. Typically, the eccyesis was detected in the uterine tube, which is the site of location of most ectopic pregnancies. [2] The preoperative detection of tubal pregnancy in this report is rare and underscores the diagnostic benefit of ultrasonography in obstetrics. Though transvaginal sonography and hCG are the routine tools reported in literature for the diagnosis of ectopic pregnancy; and some authors have advocated the sole use of endovaginal techniques for the diagnosis of ectopic pregnancy, [15] the use of abdominal scan proved very accurate in this case in revealing the ectopic pregnancy in the early stage. This case further highlights the relevance of transabdominal scan, considering the fact that negative endovaginal examinations had been reported in patients with obvious ectopic pregnancies. [15]

The gestational sac diameter (GSD), as opposed to the CRL of the fetal pole, does not appear to reflect the actual GA because it is still very small. This might be due to the constant pressure from the urinary bladder and adjacent anatomical structures like the colon and small intestines.

Ectopic pregnancy is currently deemed to be a major clinical problem and the rate has increased with stimulated ovulation, in vitro fertilization, embryo transfer, and microsurgical techniques. Late diagnosis and misdiagnosis can result in maternal morbidity, mortality as well as high hospital cost. The use of endovaginal examinations combined with transabdominal scans would be helpful in the detection of ectopic pregnancies. For this reason, we strongly advocate the use of ultrasound sonography in the management of early pregnancy.

 
  References Top

1.
Page EW, Villee CA, Villee DB. Human Reproduction, 2 nd ed. Philadelphia: W. B. Saunders Company Ltd; 1976. p. 211.  Back to cited text no. 1
    
2.
Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999;72:207-15.  Back to cited text no. 2
    
3.
Igwegbe AO, Eleje GU, Okpala BC. An appraisal of the management of ectopic pregnancy in a Nigerian tertiary hospital. Ann Med Health Sci Res 2013;3:166-70.  Back to cited text no. 3
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4.
Dilbaz S, Katas B, Demir B, Dilbaz B. Treating cornual ectopic pregnancy with a single methotrexate injection. J Reprod Med 2005;50:141-3.  Back to cited text no. 4
    
5.
Speroff L, Glass RH, Kase NG. Clinical gynecological endocrinology and infertility, 6 th ed. Philadelphia: Lippincott Williams and Wilkins; 1999. p. 1149ff.  Back to cited text no. 5
    
6.
Shaw JL, Dey SK, Critchley HO, Horne AW. Hum Reprod Update 2010;16:432-44.  Back to cited text no. 6
    
7.
Orji EO, Fasubaa OB, Adeyemi B, Dare FO, Onwudiegwu U, Ogunniyi SO. Mortality and morbidity associated with misdiagnosis of ectopic pregnancy in a defined Nigerian population. J Obstet Gynaecol 2002;22:548-50.  Back to cited text no. 7
    
8.
Udigwe GO, Umeononihu OS, Mbachu II. Ectopic Pregnancy: A 5-Year review of cases at Nnamdi Azikiwe University Teaching Hospital (NAUTH) Nnewi. Niger Med J 2010;51:160-3.  Back to cited text no. 8
  Medknow Journal  
9.
Rose IA, Ayodeji, Olalekan OB, Sylvia A. Risk factors for ectopic pregnancy in Lagos, Niger. Acta Obstet Gynecol Scand 2005;84:184-8.  Back to cited text no. 9
    
10.
Ola ER, Imosemi DO, Egwuatu JI, Abudu OO. Ectopic pregnancy in Lagos University, teaching hospital; experience over a five year period. Niger Qt Hosp Med 1999;9:100-3.  Back to cited text no. 10
    
11.
Cacciatore B, Stenman UH, Ylöstalo P. Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum hcG level of 1000 IU/1 (IRP). Br J Obstet Gynaecol 1990;97:904-8.  Back to cited text no. 11
    
12.
Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy? The rational clinical examination systematic review. JAMA 2013;309:1722-9.  Back to cited text no. 12
    
13.
Kadar N, Devore G, Romero R. Discriminatory hCG Zone: Its use in the sonographic evaluation for ectopic pregnancy. Obstet Gynaecol 1981;58:156-61.  Back to cited text no. 13
    
14.
Gharoro EP, Igbafe AA. Ectopic pregnancy revisited in Benin City, Nigeria: Analysis of 152 cases. Acta Obstet Gynecol Scand 2002;81:1139-43.  Back to cited text no. 14
    
15.
Zinn HL, Cohen HL, Zinn DL. Ultrasonographic diagnosis of ectopic pregnancy: Importance of transabdominal imaging. J Ultrasound Med 1997;16:603-7.  Back to cited text no. 15
    


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