Critical case of Abdominal pregnancy
Abstract– Abdominal pregnancy with stress induced DKA- a very rare diagnosis , is a kind of ectopic pregnancy that can lead to lead to severe maternal morbidity or mortality. The diagnosis is very difficult to establish in acute settings. cases of rupture ectopic when patient is in shock calls for a prompt diagnosis and intervention and if such patients depict stress symptoms/signs such as Diabetic Ketoacidosis , team work helps to treat such patients successfully.
Case report– we present this case of 30 year old G2P1L1 with 5wks 5days gestation with ruptured abdominal pregnancy with sign &symptoms of DKA who presented in emergency in shock. Her vitals were unstable, urine pregnancy test was positive . urgent ultrasound was done which was suggestive of moderate haemoperitoneum and lesion in left adenexa likely due ruptured ectopic pregnany. Patient was taken up for urgent laparotomy and thereafter shifted to ICU. Patient recovered completely and satisfactorily and was discharged after 5 days.
Conclusion– Abdominal pregnancy is a diagnosis difficult to establish and stress induced by it can have avariable presentation such as DKA in this case. It is necessary to be well informed so that the diagnosis does’nt surprise us . Team work with Intensivist and anaesthetist helps to manage such cases with correct and prudent treatment and successful outcome.
Keywords– Abdominal pregnancy, Diabetic Ketoacidosis, Haemoperitoneum, Laparotomy.
Introduction– An ectopic pregnanacy can be defined as pregnancy implantation outside the endometrial lining of the uterine cavity and it comprises 1 to 2 %of all the first trimester pregnancy. This small percentage accounts for almost 6% of pregnancy related deaths . Nearly 95% of ectopic pregnancies are implanted in various segments of fallopian tube , rest 5% inplant in ovary, peritoneal cavity, cervix ,caesarean scar or heterotopic.
Abdominal pregnancy is a rare kind of ectopic pregnancy with incidence of 1 in 10,000 to 25,000 live birth. Abdominal pregnancy are either primary or secondary, secondary being more common. For the diagnosis of primary abdominal pregnancy, Studdiford’s criteria need to be fulfilled , these include:
(a) Normal bilateral tubes and ovaries,
(b) absence of uteroplacental fistula;
(c) pregnancy related exclusively to the peritoneal surface;
Early enough to eliminate the possibility of secondary implantation following primary location in tube. Secondary abdominal pregnancy refer to pregnancy that originated in the tube or less commonly the ovaries and reimplant in the peritoneum where the embryo or fetus continues to grow. A case of primary abdominal pregnancywith stress induced DKA is described here.On examination abdomen was distended and tender. Her Urine Pregnancy test was positive , her Hb=7.3gm% , Hct 18.6% , S.beta HCG = 1350 , RBS= 486 mg% , urine sugar ++++ , urine ketones ++ . Urgent Ultrasound revealed moderate haemoperitoneum and heterogenous lesion in left adenexa with a normal size uterus . On suspicion of left tubal rupture ectopic , urgent laparotomy was arranged that revealed presence of around 2.5 litre of haemoperitoneum along with product of conception attached to posterior leaf of broad ligament . proper surgical dissection was done , POC’s removed and haemostasis was secured by stitches and application of topical haemostatic agents.Patient was transfused 1 unit PRBC intra op and 3 units PRBC post op in ICU. Blood sugar monitoring was done and sugars were controlled on next day without insulin requirement . her urine ketones were negative by 4 th post op day . Her post op period was uneventful. She made a good recovery and was discharged on 5 th post op day.
The HPE of the tissue revealed products of conception.Discussion- Clinical presentation of a ruptured abdominal pregnancy can be very similar to ruptured tubal pregnancy or to any other ruptured ectopic pregnancy so the diagnosis is difficult to make. It can be often missed at Ultrasound and diagnosed intra op when search is made on finding that both thefallopian tubes are normal. MRI can be a useful tool to diagnose it if time and resources allows and can define the extent of invasion in abdominal/pelvic organs . In this case the patient was clinically unstable,her urine pregnancy test positive and USG suggestive of ruptured ectopic pregnancy , she was urgently taken up for laparotomy , but intra op we found both the tubes and ovaries to be normal. Search was made for any other location of pregnancy , when POC’s were found attached to posterior leaf of broad ligament.
Patient had a history of gestational diabetes mellitus but post delivery her sugars were normal so she was not on any medication for that. Her sugars came down gradually on monitoring in 24hrs without requiring any dose of insulin so it was concluded that high sugars were stress related due to the acute incident.her urine ketones were also negative by 4 th post op day.
Abdominal pregnancy is rare with incidence of 1% of all ectopic pregnancies. Abdominal pregnancy referto a pregnancy that has implanted in the peritoneal cavity, external to uterine cavity and fallopian tube .DKA can be a manifestation due to stress in such acute phenomenon.
Conclusion– Failure or delay to diagnose any ruptured ectopic pregnancy can have grave consequences.With help of tests such as urine pregnancy test, Serum beta HCG , Ultrasonography, diagnosis can be made timely and swift intervention can be done saving the precious time and hence life of the patient.
Gynaecologists need to have a high degree of suspicion and better understanding of clinical presentation of such patients and good interpretation of imaging findings.Ultrasound is the diagnostic procedure of choice but in such rare cases , sometimes diagnosis can be missed , then MRI can be of help. In acute settings prompt intervention and good team work helps a lot. Timely decision of surgery in cases of diagnostic ambiguity can be invaluable.