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Ectopic Pregnancy in an Inguinal Herniorrhaphy Scar
August 2004, Vol. 11, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
Ectopic Pregnancy in an Inguinal Herniorrhaphy Scar Nari Kay, M.D., and Ching-Chung Liang, M.D.
Abstract
(J Am Assoc Gynecol Laparosc 2004, 11(3):433–435)
An ectopic pregnancy may occur in unusual sites. In the following case, an ectopic pregnancy was discovered in the first trimester within an inguinal herniorrhaphy scar from an inguinal herniorrhaphy performed about 20 years previously. Early diagnosis of the ectopic pregnancy by sonography enabled laparoscopic management and preservation of the woman’s fertility.
hospital on postoperative day 3. Serum β-hCG level was 3102 mIU/dL 2 days after surgery. On a follow-up visit 1 week after surgery, the serum β-hCG level had decreased to 192 mIU/dL, and no ultrasound evidence of persistent ectopic pregnancy was observed. Two weeks after surgery, a urine pregnancy test had a negative result.
The implantation of a pregnancy within the site of a surgical scar is a rare form of ectopic pregnancy. Such a condition is most often located within the uterine scar of a previous cesarean delivery.1 A pregnancy implanted in a surgical scar outside the uterus is an even more unusual occurrence that is difficult to diagnose. Only a few cases of ectopic pregnancy in hernia sac areas have been reported.2,3 We describe a case of an ectopic pregnancy embedded in the inguinal sac of a previous herniorrhaphy scar. To the best of our knowledge, this is the first case report of a pregnancy in a herniorrhaphy scar. The patient’s fertility was preserved through a successful conservative laparoscopic removal of the ectopic pregnancy.
Discussion To our knowledge based on a MEDLINE search from 1966 to 2002, this is the first reported case of an ectopic pregnancy occurring in a herniorrhaphy scar that was managed by laparoscopy and confirmed histologically. A few reported cases in the literature describe ectopic pregnancies in a hernial sac area.2,3 A pregnancy that develops in a previous surgical scar is the rarest of all ectopic pregnancies and must be distinguished from other types of ectopic pregnancies. We hypothesize that the ectopic pregnancy within the previous herniorrhaphy scar resulted from reimplantation of a tubal abortion as a form of a secondary abdominal pregnancy. Although the diagnosis of abdominal pregnancy is challenging, the possibility of primary abdominal pregnancy cannot be ruled out. The mortality rate of abdominal pregnancy is seven times higher than that of nonabdominal ectopic pregnancies.4 One of the more serious problems in laparoscopic treatment is the control of bleeding. When an abdominal pregnancy has advanced and the villi have invaded broadly and deeply, laparotomy becomes necessary. Because the laparoscopic approach is direct and simple, medical therapy may be of limited value in the treatment of early abdominal pregnancy.5 Due to the rarity of ectopic implantation in an inguinal herniorrhaphy area, it is nearly impossible to diagnose a surgical scar ectopic pregnancy preoperatively or even intraoperatively. Our case emphasizes the need for careful ultrasound assessment and
Case Report A 35-year-old woman (gravida 6, para 2) came to our department after 8 weeks of amenorrhea without abnormal vaginal bleeding or abdominal pain. She had no risk factors for ectopic pregnancy. She had undergone a right inguinal herniorrhaphy more than two decades previously. Physical examination revealed a mild right lower abdominal tenderness on deep palpation but no mass over the inguinal area could be palpated. Laboratory data revealed a quantitative serum β-human chorionic gonadotropin (hCG) level of 8537 mIU/dL. A transvaginal ultrasound revealed a right adnexal heteroechogenic mass (Figure 1) located next to the right ovary with minimal fluid in the pelvis and no intrauterine gestational sac. However, a 3-cm bulging mass arising from the right round ligament was seen in the inguinal canal area, and the right ovary and tubal fimbria were embedded in the mass (Figure 2). Operative laparoscopy was performed to excise the mass, later confirmed as chorionic villi. Bleeding was controlled with bipolar cautery. After an uneventful postoperative recovery, the patient was discharged from the
From the Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan (both authors). Corresponding author Ching-Chung Liang, M.D., Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, 5 Fu-Hsing Street, Kwei-Shan, Tao-Yuan, Taiwan, R.O.C 10591. Submitted November 3, 2003. Accepted for publication April 2, 2004. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2004, Vol. 11 No. 3 © 2004 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
433
Inguinal Herniorrhaphy and Ectopic Pregnancy Kay and Liang
FIGURE 1. Transvaginal ultrasound image showing an adnexal mass next to the right ovary. Diagnostic laparoscopy revealed bilateral fallopian tubes and a normal-appearing left ovary.
FIGURE 2. Laparoscopic view of ectopic pregnancy (black arrow) that was implanted in the previous herniorrhaphy area. The gestational tissue was expelled from the incision site (white arrow). U = uterus, R = round ligament, T = tube, E = ectopic gestation.
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August 2004, Vol. 11, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
a detailed medical history of every patient with a suspected ectopic pregnancy. Whenever a pregnancy is not visualized in the uterus or Fallopian tubes, unusual sites such as the cervix, cornua, ovaries, and pouch of Douglas should be examined. Based upon our experience, clinicians should be aware of the possibility of an ectopic pregnancy implanting in a previous surgical scar particularly when the patient has a history of previous abdominal surgery.
2. D’souza CR, Richard HI: Ectopic pregnancy in a hernial sac: A case report. The Canadian Journal of Surgery 1970, 13:166–7. 3. Polak L, Witek R, Bader O, et al: Case of ectopic pregnancy disclosed during inguinal herniotomy. Wiadomosci Lekarskie 1974, 27:1521–3. 4. Atrash HK, Friede A, Hogue CJ: Abdominal pregnancy in the United States: Frequency and maternal mortality. Obstet Gynecol 1987, 69(3 pt 1):333–7.
References
5. Toshiyuki T, Tasuku H, Hiroki Y, et al: Laparoscopic management of early primary abdominal pregnancy. Obstet Gynecol 1997, 90:687–8.
1. Donald L, Fylstra MD: Ectopic pregnancy within a cesarean scar: A review. Obstet Gynecol Surv 2002, 57:537–43.
435
The Journal of the American Association of Gynecologic Laparoscopists
Ectopic Pregnancy in an Inguinal Herniorrhaphy Scar Nari Kay, M.D., and Ching-Chung Liang, M.D.
Abstract
(J Am Assoc Gynecol Laparosc 2004, 11(3):433–435)
An ectopic pregnancy may occur in unusual sites. In the following case, an ectopic pregnancy was discovered in the first trimester within an inguinal herniorrhaphy scar from an inguinal herniorrhaphy performed about 20 years previously. Early diagnosis of the ectopic pregnancy by sonography enabled laparoscopic management and preservation of the woman’s fertility.
hospital on postoperative day 3. Serum β-hCG level was 3102 mIU/dL 2 days after surgery. On a follow-up visit 1 week after surgery, the serum β-hCG level had decreased to 192 mIU/dL, and no ultrasound evidence of persistent ectopic pregnancy was observed. Two weeks after surgery, a urine pregnancy test had a negative result.
The implantation of a pregnancy within the site of a surgical scar is a rare form of ectopic pregnancy. Such a condition is most often located within the uterine scar of a previous cesarean delivery.1 A pregnancy implanted in a surgical scar outside the uterus is an even more unusual occurrence that is difficult to diagnose. Only a few cases of ectopic pregnancy in hernia sac areas have been reported.2,3 We describe a case of an ectopic pregnancy embedded in the inguinal sac of a previous herniorrhaphy scar. To the best of our knowledge, this is the first case report of a pregnancy in a herniorrhaphy scar. The patient’s fertility was preserved through a successful conservative laparoscopic removal of the ectopic pregnancy.
Discussion To our knowledge based on a MEDLINE search from 1966 to 2002, this is the first reported case of an ectopic pregnancy occurring in a herniorrhaphy scar that was managed by laparoscopy and confirmed histologically. A few reported cases in the literature describe ectopic pregnancies in a hernial sac area.2,3 A pregnancy that develops in a previous surgical scar is the rarest of all ectopic pregnancies and must be distinguished from other types of ectopic pregnancies. We hypothesize that the ectopic pregnancy within the previous herniorrhaphy scar resulted from reimplantation of a tubal abortion as a form of a secondary abdominal pregnancy. Although the diagnosis of abdominal pregnancy is challenging, the possibility of primary abdominal pregnancy cannot be ruled out. The mortality rate of abdominal pregnancy is seven times higher than that of nonabdominal ectopic pregnancies.4 One of the more serious problems in laparoscopic treatment is the control of bleeding. When an abdominal pregnancy has advanced and the villi have invaded broadly and deeply, laparotomy becomes necessary. Because the laparoscopic approach is direct and simple, medical therapy may be of limited value in the treatment of early abdominal pregnancy.5 Due to the rarity of ectopic implantation in an inguinal herniorrhaphy area, it is nearly impossible to diagnose a surgical scar ectopic pregnancy preoperatively or even intraoperatively. Our case emphasizes the need for careful ultrasound assessment and
Case Report A 35-year-old woman (gravida 6, para 2) came to our department after 8 weeks of amenorrhea without abnormal vaginal bleeding or abdominal pain. She had no risk factors for ectopic pregnancy. She had undergone a right inguinal herniorrhaphy more than two decades previously. Physical examination revealed a mild right lower abdominal tenderness on deep palpation but no mass over the inguinal area could be palpated. Laboratory data revealed a quantitative serum β-human chorionic gonadotropin (hCG) level of 8537 mIU/dL. A transvaginal ultrasound revealed a right adnexal heteroechogenic mass (Figure 1) located next to the right ovary with minimal fluid in the pelvis and no intrauterine gestational sac. However, a 3-cm bulging mass arising from the right round ligament was seen in the inguinal canal area, and the right ovary and tubal fimbria were embedded in the mass (Figure 2). Operative laparoscopy was performed to excise the mass, later confirmed as chorionic villi. Bleeding was controlled with bipolar cautery. After an uneventful postoperative recovery, the patient was discharged from the
From the Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan (both authors). Corresponding author Ching-Chung Liang, M.D., Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, 5 Fu-Hsing Street, Kwei-Shan, Tao-Yuan, Taiwan, R.O.C 10591. Submitted November 3, 2003. Accepted for publication April 2, 2004. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, August 2004, Vol. 11 No. 3 © 2004 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
433
Inguinal Herniorrhaphy and Ectopic Pregnancy Kay and Liang
FIGURE 1. Transvaginal ultrasound image showing an adnexal mass next to the right ovary. Diagnostic laparoscopy revealed bilateral fallopian tubes and a normal-appearing left ovary.
FIGURE 2. Laparoscopic view of ectopic pregnancy (black arrow) that was implanted in the previous herniorrhaphy area. The gestational tissue was expelled from the incision site (white arrow). U = uterus, R = round ligament, T = tube, E = ectopic gestation.
434
August 2004, Vol. 11, No. 3
The Journal of the American Association of Gynecologic Laparoscopists
a detailed medical history of every patient with a suspected ectopic pregnancy. Whenever a pregnancy is not visualized in the uterus or Fallopian tubes, unusual sites such as the cervix, cornua, ovaries, and pouch of Douglas should be examined. Based upon our experience, clinicians should be aware of the possibility of an ectopic pregnancy implanting in a previous surgical scar particularly when the patient has a history of previous abdominal surgery.
2. D’souza CR, Richard HI: Ectopic pregnancy in a hernial sac: A case report. The Canadian Journal of Surgery 1970, 13:166–7. 3. Polak L, Witek R, Bader O, et al: Case of ectopic pregnancy disclosed during inguinal herniotomy. Wiadomosci Lekarskie 1974, 27:1521–3. 4. Atrash HK, Friede A, Hogue CJ: Abdominal pregnancy in the United States: Frequency and maternal mortality. Obstet Gynecol 1987, 69(3 pt 1):333–7.
References
5. Toshiyuki T, Tasuku H, Hiroki Y, et al: Laparoscopic management of early primary abdominal pregnancy. Obstet Gynecol 1997, 90:687–8.
1. Donald L, Fylstra MD: Ectopic pregnancy within a cesarean scar: A review. Obstet Gynecol Surv 2002, 57:537–43.
435