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An abdominal pregnancy 10 years after treatment for pelvic tuberculosis
An abdominal pregnancy 10 years after treatment for pelvic tuberculosis Tekin Durukan, MD: Biilent Urman, MD: Rakan Yarali, MD: Unser Arikan, MD,b and Omer Beykal, MDc Ankara, Turkey An abdominal pregnacy after treatment for female genital tuberculosis is presented. Early treatment after the diagnosis of female genital tuberculosis may restore fertility in the rare patient. Chemotherapy is the cornerstone of therapy. Ectopic pregnancies are common and should be ruled out to avoid catastrophic results. (AM J OBSTET GVNECOl 1990;163:594-5.)
Key words: Pelvic tuberculosis, abdominal pregnancy Intrauterine pregnancy is rare after genital tuberculosis. It may occur occasionally if the disease is diagnosed and treated in its very early stage. Ectopic pregnancies have been reported after antituberculous therapy and after reconstructive surgery for occlusions of the oviducts because of this condition.' An abdominal pregnancy after treatment for female genital tuberculosis is presented and discussed. Case report A 38-year-old woman who had been infertile for 10 years reported to the emergency department complaining of abdominal pain, nausea, and vomiting. She stated that she was 13 weeks pregnant according to her last menstrual period. The result of a urine pregnancy test was positive, and the patient complained of lower abdominal pain and vaginal bleeding for the past week. During an infertility workup 8 years ago hysterosalpingography revealed a bilateral tubal block and signs compatible with female genital tuberculosis. Biopsy from the endometrium was reported as granulomatous endometritis. She received multiple-agent antituberculous therapy (isoniazid 300 mg/day; ethambutol 1000 mg/day; and rifampin 600 mg/day) for 12 months. Physical examination disclosed an abdomen that was mildly distended with rebound tenderness in lower quadrants. A left-sided tender mass was palpated bimanually. Ultrasonographic examination of the pelvis revealed an empty.uterus and a gestational sac occupied by a From the Department of Obstetrics and Gynecology: the Department of Patlwlogy, b and the Department of Radiology,' Faculty ofMedicine, University of Hacettepe. Received for publication September 25, 1989; revised February 14, 1990; accepted March 1,1990. Reprint requests: Tekin Durukan, MD, University of Hacettepe, Faculty of Medicine, Department of Obstetrics and Gynecology, SihhiyeAnkara, Turkey. 6/1/20574
594
13-week embryo with positive cardiac activity adjacent to the uterus in the pouch of Douglas (Fig. 1). A presumptive evidence of ovarian or abdominal pregnancy was made. At laparotomy it was seen that the sac and the embryo measuring 12 x 10 x 10 cm occupied the pouch of Douglas with the placenta attached to the posterior leaf of the broad ligament and partially to the Douglas peritoneum. The placenta was partially separated and there was approximately 300 ml of blood filling the Douglas pouch. The tubes were intact with no evidence of utero peritoneal fistula, and the ovaries on both sides were normal with a leaking corpus luteum occupying the left ovary. A left salpingo-oophorectomy was performed, removing the placenta totally with partial dissection of the Douglas peritoneum; the bleeding sites were cauterized. The pathologic examination revealed a normal tube with calcifications in the muscularis layer. There were no chorial elements in the ovary and the sac showed no evidence of ovarian tissue. A diagnosis of abdominal pregnancy was made. Comment Primary abdominal pregnancy is rare and represents 1.6% of all ectopic pregnancies. Criteria first set by Studdiford should be met to make the diagnosis. 2 The outcome of pregnancy is usually fetal death or placental separation with intraperitoneal bleeding. Ultrasonography is useful in diagnosis of the condition, especially if the uterus is empty and both ovaries are visible. Recurrent abdominal pain in an infertile woman should alert the clinician to the probability of abdominal pregnancy in addition to more likely diagnoses, such as recurrent pelvic inflammatory disease, including female genital tuberculosis, tubal ectopic pregnancy, and threatened abortion. Prompt termination is necessary once the diagnosis is made. Female genital tuberculosis should be treated medically after the diagnosis. Operation should not be the
Abdominal pregnancy after pelvic tuberculosis
Volume 163 Number 2
595
Fig. 1. Pelvic ultrasonogram of the patient reveals an empty uterus and a gestational sac localized in the pouch of Douglas.
initial mode of therapy because of the possibility of activating latent disease; however, if use of the antituberculous drugs are not successful and symptoms or tuboovarian masses remain after 1 year, operation should be considered with use of an additional drug not used in initial treatment. Hysterosalpingogram can be diagnostic if the typical signs are seen. Endometrium is involved in 50% of cases. Early diagnosis and therapy may restore fertility, although ectopic pregnancies and abortions are more common than successful intrauterine pregnancies. In a 31-year study of 1436 cases of female genital tuberculosis, only four pregnancies (two localized ectopically to the tubes) have been reported.'
A patient with a history of female genital tuberculosis should be followed up indefinitely. Their pregnancies should be considered high risk, and ectopic nidation, which may occur even after a long period, should be ruled out to avoid catastrophic results. REFERENCES I. Nogalez-Ortiz F, Tarancon I, Nogales FF. The pathology of female genital tuberculosis: a 31-year study of 1436 cases. Obstet Gynecol 1979;53:422-8. 2. Oelke I, Veridiano NP. Tancer ML. Abdominal pregnancy : review of current management and addition of 10 cases. Obstet Gynecol 1982;60:200-4.
Key words: Pelvic tuberculosis, abdominal pregnancy Intrauterine pregnancy is rare after genital tuberculosis. It may occur occasionally if the disease is diagnosed and treated in its very early stage. Ectopic pregnancies have been reported after antituberculous therapy and after reconstructive surgery for occlusions of the oviducts because of this condition.' An abdominal pregnancy after treatment for female genital tuberculosis is presented and discussed. Case report A 38-year-old woman who had been infertile for 10 years reported to the emergency department complaining of abdominal pain, nausea, and vomiting. She stated that she was 13 weeks pregnant according to her last menstrual period. The result of a urine pregnancy test was positive, and the patient complained of lower abdominal pain and vaginal bleeding for the past week. During an infertility workup 8 years ago hysterosalpingography revealed a bilateral tubal block and signs compatible with female genital tuberculosis. Biopsy from the endometrium was reported as granulomatous endometritis. She received multiple-agent antituberculous therapy (isoniazid 300 mg/day; ethambutol 1000 mg/day; and rifampin 600 mg/day) for 12 months. Physical examination disclosed an abdomen that was mildly distended with rebound tenderness in lower quadrants. A left-sided tender mass was palpated bimanually. Ultrasonographic examination of the pelvis revealed an empty.uterus and a gestational sac occupied by a From the Department of Obstetrics and Gynecology: the Department of Patlwlogy, b and the Department of Radiology,' Faculty ofMedicine, University of Hacettepe. Received for publication September 25, 1989; revised February 14, 1990; accepted March 1,1990. Reprint requests: Tekin Durukan, MD, University of Hacettepe, Faculty of Medicine, Department of Obstetrics and Gynecology, SihhiyeAnkara, Turkey. 6/1/20574
594
13-week embryo with positive cardiac activity adjacent to the uterus in the pouch of Douglas (Fig. 1). A presumptive evidence of ovarian or abdominal pregnancy was made. At laparotomy it was seen that the sac and the embryo measuring 12 x 10 x 10 cm occupied the pouch of Douglas with the placenta attached to the posterior leaf of the broad ligament and partially to the Douglas peritoneum. The placenta was partially separated and there was approximately 300 ml of blood filling the Douglas pouch. The tubes were intact with no evidence of utero peritoneal fistula, and the ovaries on both sides were normal with a leaking corpus luteum occupying the left ovary. A left salpingo-oophorectomy was performed, removing the placenta totally with partial dissection of the Douglas peritoneum; the bleeding sites were cauterized. The pathologic examination revealed a normal tube with calcifications in the muscularis layer. There were no chorial elements in the ovary and the sac showed no evidence of ovarian tissue. A diagnosis of abdominal pregnancy was made. Comment Primary abdominal pregnancy is rare and represents 1.6% of all ectopic pregnancies. Criteria first set by Studdiford should be met to make the diagnosis. 2 The outcome of pregnancy is usually fetal death or placental separation with intraperitoneal bleeding. Ultrasonography is useful in diagnosis of the condition, especially if the uterus is empty and both ovaries are visible. Recurrent abdominal pain in an infertile woman should alert the clinician to the probability of abdominal pregnancy in addition to more likely diagnoses, such as recurrent pelvic inflammatory disease, including female genital tuberculosis, tubal ectopic pregnancy, and threatened abortion. Prompt termination is necessary once the diagnosis is made. Female genital tuberculosis should be treated medically after the diagnosis. Operation should not be the
Abdominal pregnancy after pelvic tuberculosis
Volume 163 Number 2
595
Fig. 1. Pelvic ultrasonogram of the patient reveals an empty uterus and a gestational sac localized in the pouch of Douglas.
initial mode of therapy because of the possibility of activating latent disease; however, if use of the antituberculous drugs are not successful and symptoms or tuboovarian masses remain after 1 year, operation should be considered with use of an additional drug not used in initial treatment. Hysterosalpingogram can be diagnostic if the typical signs are seen. Endometrium is involved in 50% of cases. Early diagnosis and therapy may restore fertility, although ectopic pregnancies and abortions are more common than successful intrauterine pregnancies. In a 31-year study of 1436 cases of female genital tuberculosis, only four pregnancies (two localized ectopically to the tubes) have been reported.'
A patient with a history of female genital tuberculosis should be followed up indefinitely. Their pregnancies should be considered high risk, and ectopic nidation, which may occur even after a long period, should be ruled out to avoid catastrophic results. REFERENCES I. Nogalez-Ortiz F, Tarancon I, Nogales FF. The pathology of female genital tuberculosis: a 31-year study of 1436 cases. Obstet Gynecol 1979;53:422-8. 2. Oelke I, Veridiano NP. Tancer ML. Abdominal pregnancy : review of current management and addition of 10 cases. Obstet Gynecol 1982;60:200-4.