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Abdominal pregnancy following gonadotropin treatment
lnamoto and Terao
was l 20 mg/di during operation. A male infant weighing 2380 gm was delivered. The Apgar score was 9 at the time of birth. The placenta weighed 490 gm. The baby obviously had congenital afibrinogenemia with a fibrinogen level of 55 mg/di in the umbilical vein. After the cesarean section, 6 to l 2 gm/wk of fibrinogen was given to maintain a plasma fibrinogen level of 60 to 120 mg/di for 2 weeks. The amount of lochia was normal, and the patient was discharged from our hospital on June 5.
Comment There is no sex-related difference in the incidence of congenital afibrinogenemia as it is an inherited autosomal recessive trait and has been reported in more than I 00 cases. According to my investigation, there have been 73 cases in female subjects. Five of the women were reported to be married. Among these five, there were two pregnancies that resulted in abortion during the second' and third' months of pregnancy, respectively. On the other hand, many articles have reported on cases of pregnancy in patients with congenital hypofibrinogenemia, and almost all had normal deliveries if the plasma fibrinogen level was >60 mg/di. Because of the three pregnancies in this patient and
December I, 1985 Am J Obstet Gynecol
in the patients with congenital afibrinogenemia or hypofibrinogenemia reported on so far, fibrinogen may not be necessary for implantation. This is suggested by the fact that in the cases reported by Matsuno et al.' and Dube et al.' the patients became pregnant despite congenital afibrinogenemia. However, fibrinogen may be required to maintain the placenta and fetus. It appears that a plasma fibrinogen level >60 mg/di is needed to maintain implantation of the placenta and fetus especially because of the bleeding that occurred during pregnancy in this case. Dube et al.' stated in their report that their case was the first of congenital afibrinogenemia and pregnancy in the world. The case reported here is the first of congenital afibrinogenemia and a successful delivery in the world. REFERENCES I. Matsuno K, Mori K, Amikawa H, et al. A case of congenital afibrinogenemia with abortion, intracranial hemorrhage, and peritonitis . .Jpn.J Clin Hematol 1977;18:1438. 2. Dube B, Agarwal SP, Gupta ~1\1, Chawla SC. Congenital deficiency of fibrinogen in two sisters. A clinical and haematological study. Acta Haematol 1970;43:120.
Abdominal pregnancy following gonadotropin treatment F. 0. Saracoglu, M.D., E. Goksin, M.D., and T. Durukan, M.D. Ankara, Turkey An abdominal pregnancy after treatment with human menopausal and chorionic gonadotropins is reported. The role of induction of ovulation with human menopausal and chorionic gonadotropins as a cause of ectopic pregnancy has not been delineated. However, it appears that ultrasonography has become one of the most important aids in the diagnosis of abdominal pregnancy. (AM J OssTET GvNECOL 1985;153:804-5.)
Key words: Abdominal pregnancy, gonadotropin treatment, abruptio placentae, ultrasonography Abdominal pregnancy is one of the rare but serious problems in obstetrics. Several cases of abdominal pregnancy have been reported and the current diagnostic and management techniques have been discussed in the literature, but, to our knowledge, this is the first case which occurred after induction of ovulation with human menopausal and chorionic gonadotropins and was
From the Department of ObJtetrics and GJ•nerology, Harette/Je Universi~y School of Medicine. Received for publirationjamuiry 2, 1985; revised March 12. 1985: accepted May 20, 1985. Reprint requests: Dr. F. 0. Saracoglu, Gazi Mmtafa Kema/ Buh•ari, No. 120119, Maltepe, Ankara, Turkey.
complicated with nearly total abruptio placentae. This is also the third English-literature report of an abdominal pregnancy diagnosed by ultrasonography at less than 15 weeks' gestation.'
Case report A 34-year-old woman, gravida I, para 0, was seen in the obstetric department of Hacettepe University Medical Center because of acute pain in the lower abdomen. She had failed to ovulate after clomiphene therapy, but conceived after ovulation had been induced with human menopausal and chorionic gonadotropins in the first cycle. She was 13 weeks pregnant by estimated gestational age at this time.
Gonadotropin treatment and abdominal pregnancy
Volume 153 1'umber 7
805
Comment
Fig. I. Scan of the fetal head (Vtx), trunk (govde), and placenta (pl)
outside of the uterus
(u),
in the abdominal ca\'ity.
The abdomen was tender to palpation. Pelvic examination revealed that the cervix was soft and closed; the uterus was anteverted and slightly enlarged. A soft mass behind the uterus was palpated. Laboratory tests produced findings that were within normal limits. The patient's blood pressure was I 00/80 mm Hg, and the pulse rate was 112 bpm. A urine test for pregnancy was positive. L'ltrasonographic examination of the patient demonstrated that the placenta and fetus were placed outside of the uterus, in the abdominal cavity (Fig. I). Fetal heart movements were not seen. An exploratory laparotomy was performed after abdominal pregnancy had been diagnosed. When the peritoneal cavity was entered, the placenta was noticed to be implanted over the broad ligament and on the sigmoid colon, and nearly 90% of the placenta was separated. The cul-de-sac was full of blood. An intact amniotic sac and a dead fetus, 11 cm in length, were noted in the abdominal cavity. The placenta and fetus were removed and bleeding was controlled. The fallopian tubes and uterus were entirely explored and no rupture site was noted. Except for minimal tubal adhesions, there was no tubal blockage or evidence of pelvic inflammatory disease. The appearance in this case was that of a primary abdominal pregnancy. Ten days after the operation, the patient was discharged from the hospital in good condition.
To our knowledge, this is the first reported case of abdominal pregnancy after induction of ovulation with human menopausal and chorionic gonadotropins. Although we know that the incidence of ectopic pregnancy is slightly increased in patients on therapy for induction of ovulation, this is usually the result of previous pelvic inflammatory disease or tubal problems, such as salpingitis isthmica nodosa, etc.~ We did not find, however, in the present case any evidence of pelvic inflammatory disease or tubal problems, except mild peritubal adhesions. Abruptio placentae is an uncommon problem in abdominal pregnancy, and has not been reported previously with any of the cases. Even with abruptio placentae (90%), the patient did not bleed to death or present in shock. This indicates that symptoms appeared when the abruptio placentae occurred because of intra-abdominal hemorrhage. In our opinion, the etiology for abruptio placentae in this case was not different from that in intrauterine pregnancies complicated by the same problem. Although abdominal pregnancy is a rare condition because of high fetal and maternal mortality rates, early diagnosis and treatment of it are necessary. Ultrasonography is the recent effective and noninvasive technique for diagnosing abdominal pregnancies. The diagnostic criteria of abdominal pregnancy by ultrasonography were previously proposed by Kobayashi et al." These are as follows: (I) identification of uterus, (2) identification of fetal head outside the uterus, (3) identification of the fetal body outside the uterus, (4) identification of an ectopic placenta, and (5) failure to demonstrate a uterine wall between the fetus and the urinary bladder. Retrospective review of the sonograms in the present case satisfies only the first four diagnostic criteria. REFERENCES I. Alexander MC, Horger EO. Early diagnosis of abdominal
pregnancy by ultrasound . .JCU 1983; 11 :45. 2. McBain JC, Evans JH, Pepperell R.J, Robinson HP, Smith MA, Brown.JB. An unexpectedly high rate of ectopic pregnancy following the induction of ovulation with human pituitary and chorionic gonadotrophin. Br J Obstet Gynaecol 1980;87:5. 3. Kobayashi M, Hellman LM, Filisti LP. Ultrasound: an aid in the diagnosis of ectopic pregnancy. A\1 J 0BSTET GY:\ECOI.
1969; 103: 1131.
was l 20 mg/di during operation. A male infant weighing 2380 gm was delivered. The Apgar score was 9 at the time of birth. The placenta weighed 490 gm. The baby obviously had congenital afibrinogenemia with a fibrinogen level of 55 mg/di in the umbilical vein. After the cesarean section, 6 to l 2 gm/wk of fibrinogen was given to maintain a plasma fibrinogen level of 60 to 120 mg/di for 2 weeks. The amount of lochia was normal, and the patient was discharged from our hospital on June 5.
Comment There is no sex-related difference in the incidence of congenital afibrinogenemia as it is an inherited autosomal recessive trait and has been reported in more than I 00 cases. According to my investigation, there have been 73 cases in female subjects. Five of the women were reported to be married. Among these five, there were two pregnancies that resulted in abortion during the second' and third' months of pregnancy, respectively. On the other hand, many articles have reported on cases of pregnancy in patients with congenital hypofibrinogenemia, and almost all had normal deliveries if the plasma fibrinogen level was >60 mg/di. Because of the three pregnancies in this patient and
December I, 1985 Am J Obstet Gynecol
in the patients with congenital afibrinogenemia or hypofibrinogenemia reported on so far, fibrinogen may not be necessary for implantation. This is suggested by the fact that in the cases reported by Matsuno et al.' and Dube et al.' the patients became pregnant despite congenital afibrinogenemia. However, fibrinogen may be required to maintain the placenta and fetus. It appears that a plasma fibrinogen level >60 mg/di is needed to maintain implantation of the placenta and fetus especially because of the bleeding that occurred during pregnancy in this case. Dube et al.' stated in their report that their case was the first of congenital afibrinogenemia and pregnancy in the world. The case reported here is the first of congenital afibrinogenemia and a successful delivery in the world. REFERENCES I. Matsuno K, Mori K, Amikawa H, et al. A case of congenital afibrinogenemia with abortion, intracranial hemorrhage, and peritonitis . .Jpn.J Clin Hematol 1977;18:1438. 2. Dube B, Agarwal SP, Gupta ~1\1, Chawla SC. Congenital deficiency of fibrinogen in two sisters. A clinical and haematological study. Acta Haematol 1970;43:120.
Abdominal pregnancy following gonadotropin treatment F. 0. Saracoglu, M.D., E. Goksin, M.D., and T. Durukan, M.D. Ankara, Turkey An abdominal pregnancy after treatment with human menopausal and chorionic gonadotropins is reported. The role of induction of ovulation with human menopausal and chorionic gonadotropins as a cause of ectopic pregnancy has not been delineated. However, it appears that ultrasonography has become one of the most important aids in the diagnosis of abdominal pregnancy. (AM J OssTET GvNECOL 1985;153:804-5.)
Key words: Abdominal pregnancy, gonadotropin treatment, abruptio placentae, ultrasonography Abdominal pregnancy is one of the rare but serious problems in obstetrics. Several cases of abdominal pregnancy have been reported and the current diagnostic and management techniques have been discussed in the literature, but, to our knowledge, this is the first case which occurred after induction of ovulation with human menopausal and chorionic gonadotropins and was
From the Department of ObJtetrics and GJ•nerology, Harette/Je Universi~y School of Medicine. Received for publirationjamuiry 2, 1985; revised March 12. 1985: accepted May 20, 1985. Reprint requests: Dr. F. 0. Saracoglu, Gazi Mmtafa Kema/ Buh•ari, No. 120119, Maltepe, Ankara, Turkey.
complicated with nearly total abruptio placentae. This is also the third English-literature report of an abdominal pregnancy diagnosed by ultrasonography at less than 15 weeks' gestation.'
Case report A 34-year-old woman, gravida I, para 0, was seen in the obstetric department of Hacettepe University Medical Center because of acute pain in the lower abdomen. She had failed to ovulate after clomiphene therapy, but conceived after ovulation had been induced with human menopausal and chorionic gonadotropins in the first cycle. She was 13 weeks pregnant by estimated gestational age at this time.
Gonadotropin treatment and abdominal pregnancy
Volume 153 1'umber 7
805
Comment
Fig. I. Scan of the fetal head (Vtx), trunk (govde), and placenta (pl)
outside of the uterus
(u),
in the abdominal ca\'ity.
The abdomen was tender to palpation. Pelvic examination revealed that the cervix was soft and closed; the uterus was anteverted and slightly enlarged. A soft mass behind the uterus was palpated. Laboratory tests produced findings that were within normal limits. The patient's blood pressure was I 00/80 mm Hg, and the pulse rate was 112 bpm. A urine test for pregnancy was positive. L'ltrasonographic examination of the patient demonstrated that the placenta and fetus were placed outside of the uterus, in the abdominal cavity (Fig. I). Fetal heart movements were not seen. An exploratory laparotomy was performed after abdominal pregnancy had been diagnosed. When the peritoneal cavity was entered, the placenta was noticed to be implanted over the broad ligament and on the sigmoid colon, and nearly 90% of the placenta was separated. The cul-de-sac was full of blood. An intact amniotic sac and a dead fetus, 11 cm in length, were noted in the abdominal cavity. The placenta and fetus were removed and bleeding was controlled. The fallopian tubes and uterus were entirely explored and no rupture site was noted. Except for minimal tubal adhesions, there was no tubal blockage or evidence of pelvic inflammatory disease. The appearance in this case was that of a primary abdominal pregnancy. Ten days after the operation, the patient was discharged from the hospital in good condition.
To our knowledge, this is the first reported case of abdominal pregnancy after induction of ovulation with human menopausal and chorionic gonadotropins. Although we know that the incidence of ectopic pregnancy is slightly increased in patients on therapy for induction of ovulation, this is usually the result of previous pelvic inflammatory disease or tubal problems, such as salpingitis isthmica nodosa, etc.~ We did not find, however, in the present case any evidence of pelvic inflammatory disease or tubal problems, except mild peritubal adhesions. Abruptio placentae is an uncommon problem in abdominal pregnancy, and has not been reported previously with any of the cases. Even with abruptio placentae (90%), the patient did not bleed to death or present in shock. This indicates that symptoms appeared when the abruptio placentae occurred because of intra-abdominal hemorrhage. In our opinion, the etiology for abruptio placentae in this case was not different from that in intrauterine pregnancies complicated by the same problem. Although abdominal pregnancy is a rare condition because of high fetal and maternal mortality rates, early diagnosis and treatment of it are necessary. Ultrasonography is the recent effective and noninvasive technique for diagnosing abdominal pregnancies. The diagnostic criteria of abdominal pregnancy by ultrasonography were previously proposed by Kobayashi et al." These are as follows: (I) identification of uterus, (2) identification of fetal head outside the uterus, (3) identification of the fetal body outside the uterus, (4) identification of an ectopic placenta, and (5) failure to demonstrate a uterine wall between the fetus and the urinary bladder. Retrospective review of the sonograms in the present case satisfies only the first four diagnostic criteria. REFERENCES I. Alexander MC, Horger EO. Early diagnosis of abdominal
pregnancy by ultrasound . .JCU 1983; 11 :45. 2. McBain JC, Evans JH, Pepperell R.J, Robinson HP, Smith MA, Brown.JB. An unexpectedly high rate of ectopic pregnancy following the induction of ovulation with human pituitary and chorionic gonadotrophin. Br J Obstet Gynaecol 1980;87:5. 3. Kobayashi M, Hellman LM, Filisti LP. Ultrasound: an aid in the diagnosis of ectopic pregnancy. A\1 J 0BSTET GY:\ECOI.
1969; 103: 1131.