Full term broad ligament pregnancy through a Cesarean scar
An unbooked 30-year-old female, gravida 2, para 1 with no live issues with previous 1 Cesarean section 4 years back due to oligohydramnios (with neonatal death due to extreme low birth weight) was referred to our hospital from a peripheral clinic, with amenorrhea of 9 months and inability to perceive foetal movement for last one week. She also presented to us once before at 34 weeks with an ultrasonography report of a peripheral clinic showing viable fetus with intra-uterine growth retardation and oligohydramnios with estimated foetal weight of 1.65 kg. At that time she was advised admission but she refused to get evaluated and hospitalized due to some domestic problem.\nDuring her present visit her pregnancy was of 39 weeks from her last menstrual period. She was a known case of bronchial asthma and on steroids off and on for the last 18 years. She was having markable steroid induced myopathy and cushingoid features like moon face, truncal obesity, proximal myopathy, abdominal striae. She had no complaints of pain or discomfort in abdomen. Her vital parameters were found within normal limits. Crepitations and rhonchi were heard in both the lung fields. On abdominal examination, uterus was of 28 weeks size, soft, non-tender and clinically liquor was found to be grossly reduced. Foetal heart sound was absent. On per vaginal examination, cervix was found uneffaced, os closed, laterally displaced to left side and high up. Per vaginal findings of a soft mass occupying the whole anterior fornix pushing the cervix posteriorly and to the left, raised a suspicion of some abnormality. Initial ultrasound report only mentioned intrauterine pregnancy with foetal death. Since clinically we suspected some associated abnormality, patient was referred back for review ultrasonographic evaluation and if required MRI abdomen to know the exact nature of pathology. On ultrasonography by a senior specialist, it appeared to be an extra uterine pregnancy with a non-viable fetus lying to the posterolateral aspect of the uterus. To confirm the diagnosis MRI abdomen was done, which found the entire amniotic sac with a fetus and its placenta in the abdominal cavity pushing the empty uterus anteriorly to the left side (). It also revealed a breach in the lower segment of the uterus communicating to the fetal sac (). Her haemoglobin was 9.3 g/dL and other haematological and biochemical parameters including coagulation profile were within normal range.\nShe was taken up for surgery. Her lung condition caused a challenge to the anaesthesiologist which was tackled by a team of anaesthesiologist and physician. Under general anaesthesia the abdomen was opened. Omental adhesions were encountered, which were separated by sharp and blunt dissection. The uterus was found to be about 10 to 12 weeks size lying on the anterior and left inferolateral aspect of the amniotic sac. The sac was found enclosed in the right broad ligament pushing the fallopian tube and the ovary upward and round ligament stretching over it (). A diagnosis of right broad ligament pregnancy was made. Both the tube and ovary on the right side were found to be normal. Anterior wall of the sac was cut open. A macerated female fetus of 1.7 kg was extracted. The fetus appeared to be at term from the presence of features like creases all over the soles, black shiny hair and fully grown nails and nipples (). Placenta was found on the medial aspect of the sac overlying the uterine side, and it could be removed without causing undue haemorrhage. Anterior wall of the lower segment of the uterus was found gaping and opening into the foetal sac in the right broad ligament (). Uterus was lying on left anterior and cervix was on left posterior aspect of the sac. The sac had extended into the uterovesical space anteriorly. Anatomy of lower uterine segment was grossly distorted, papery thin and indistinguishable from amniotic membrane. A thin strip of tissue was holding the cervix attached to the uterus (). Uterus was considered not salvageable. A total abdominal hysterectomy was performed. A drain was placed in the cavity occupied by the fetus. Postoperatively managed by a team of specialists. She was put on IV steroids besides other medication. However she recovered well without any untoward occurrence. Stitches were removed on the 10th postoperative day in view of her prolonged medication with steroids.