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Ureteral obstruction in chronic ectopic pregnancy
Ureteral obstruction in chronic ectopic pregnancy PRAPHAT UMA
HOVADHANAKUL, EACHEMPATI,
DENIS St. Louis,
M.D. M.D.
CAVANAGH,
M.D.
Missouri
A caxe of ureteral presented.
obstruction
in association
with
URETERAL OBSTRUCTION has been reported to occur in association with lesions in the pelvic cavity such as tuboovarian abscesses,2 pelvic inflammatory disease , 4, 11~12 appendiceal abscesses,5* ‘9 0p lo ovarian cysts,12 lymphocysts,6p I4 endometriosis,121 I3 uterine leiomyomas and malignant disease of uterus and ovary,la pelvic extragenital tumors,l sigmoid diverticulitis,0 and ovarian vein syndrome.3 A case of ureteral obstruction in association with a chronic ectopic pregnancy is presented. The patient, a 29-year-old Caucasian Ivoman, gravida 4, para 4, was admitted on July 13, 1970, complaining of pain in the right lower quadrant of the abdomen of 6 weeks’ duration. One month prior to admission, she had cramping pain over a 12 hour 1jeriod and had noticed some abdomina1 disrention. Since then, she had a tendency to t:onstipation. She had no urinary symptoms. Her last menstrual period was given as June 28, 1970, but there was some doubt as to whether this was a “normal flow.” Her history was otherwise noncontributory. On examination no costovertebral angle tenderness was elicited. On abdominal examination, an ill-defined, cystic, nontender mass of about 10 cm. in diameter was palpable in the right lower quadrant. Pelvic examination revealed the uterus deviated to the left by the irregu-
From the Department Obstetrics, of Medicine.
St.
Louis
of Gynecology University School
a chronic
ectopic
pregnancy is
lar adnexal mass extending above the pelvic brim on the right. The left adnexa was not palpable. A diagnosis of an ovarian tumor with a possible torsion of its pedicle was made. Hemoglobin was 12.3 Gm. per cent, with hematocrit 37 per cent, and white blood count was 7,750 per cubic millimeter, with a normal differential count. An x-ray of the chest was within normal limits. A urine culture revealed no pathogenic bacteria. The pregnancy test was negative. An intravenous urogram showed obstructive uropathy on the right side with an associated pelvic soft tissue mass (Fig. 1) . At exploratory celiotomy, the small intestines were found to be adherent anteriorly over the cystic intraligamcntous mass. During release of the adhesions, the “cyst” wall was ruptured, extruding clots of altered blood. On closer inspection, thr mass was found to be a hematosalpinx involving the right tube. The right ovary was medial to the tube, and the uterus was of normal size. The left tube and ovary appeared normal. In view of the extensive destruction of the tube and the adherence of the ovary, :t right salpingo-oophorectomy was then performed. In view of the obstructive uropathy found on the intravenous urogram, the right ureter was traced retroperitoneally to the pelvic brim. At this point a dilated ovarian vein was found to be compressing the right ureter. The ovarian vein was ligated with 2-O silk at two places, one inch apart. ‘lhe patient had an uneventful recovery and was discharged on the seventh postoperative day.
and
311
312
Hovadhanakul,
Eachempati,
and
Cavanagh
June
Amer. J. Obstet.
1, 191 Gymr
Fig. 1. Intravenous urogram taken before the operation, revealing obstructive uropathy on the right with an associated pelvic soft tissue mass.
Fig. 2. Intravenous urogram taken 26 days right salpingo-oophorectomy and ovarian ligation, revealing marked improvement.
Examination of the specimen revealed the presence of a large cystic mass measuring 10 by 5 by 3 cm., with an adherent ovary of normal size but pale with gray convolutions. The cystic mass was covered with a ragged, dark-gray, thickened serosa. The lumen was filled with adherent clotted blood. The tube showed organizing hemorrhage with chronic inflammatory infiltration and scattered fibrotic villi. No trophoblastic activity was evident, and findings were generally suggestive of a “chronic ectopic pregnancy.” Excretory urography repeated 26 days after operation showed the right ureter to be much less dilated than was noted in the preoperative film (Fig. 2 ) .
report could be found in a rather extensive review of the literature. This may be due to the fact that it is unusual for a ruptured ectopic pregnancy to be sealed off without significant clinical manifestations. In reviewing the records of the Department of Gynecology and Obstetrics, St. Louis University Group of Hospitals, from 1950 through 1969, there were 102,339 deliveries and 387 ectopic pregnancies, and this was the only case seen which was complicated by obstructive uropathy. The ureteric obstruction in this case may have been primarily associated with the development of the ovarian vein syndrome. On the other hand, it seems more likely that the obstruction was a pressure effect of the pelvic mass in association with periureteral fibrosis, with the ovarian vein syndrome being a secondary effect. Relief of the obstruction by removal of the pelvic mass and ligation of the ovarian vein is
Comment
The occurrence of ureteric obstruction in association with a chronic ectopic pregnancy is apparently rare, and, indeed, no previous
after vein
Volwne 110 Nulnber J
Ureteral
demonstrated in the postoperative excretory urogram. Ureteric obstruction in association with benign tumors such as ovarian cysts and leiomyomas of the uterus has been reported to be relieved promptly on removal of the mass (75 per cent), and only 40 per cent were in association with conditions such as appendicitis, diverticulitis, or endometriosisl” If the obstruction to the ureter
obstruction
in chronic
ectopic
pregnancy
313
had not been released in this case, the patient may have developed signs of pvelonephritis at a later date, Also, as in cases of periureteral endometriosis or inflammatory diseases,it may ultimately result in a nonfunctioning kidney or hypertensive irropathy. Thus, early recognition of the problem with prompt intervention is essential.
REFERENCES I.
2.
Cavanagh, D., Egan, R. L., Dolan, P. A., and Rutledge, F.: Obstet. Gynec. Survey 20: 70, 1965. Cox, B. S., DeVere, R. D., and Thomas, D. J.: J. Obstet. Gynaec. Brit. Comm. 76: 1117, i96i3.
7. .
4. 5. 6.
Dykhuizen, Obstet. Everett, OBSTET. Goodwin, J. Surg. Griffith, 103: 43,
R. F., and Roberts, J. A.: Surg. Gvnec. 130: 443. 1970. II. S., and Scott, R. B.: AMER. J. G~KEC. 44: 1010, 1942. W. E., and Turner, R. D., Amer. 94: 232, 1957. D. I’., and Carlton, C. E.: J. Ural. 1970,
7. 8. 9. 10. 11. 12. 13.
Henson, A. 182: Hersch, 1963.
S. W., and Rumley, R. J.: J. .4. M. 80, 1962. R. A.: Gastroenterology 45: 269,
Hoffman, H. L.: Lancet 1:
788, 1932. Hughes, J.: Southern Med. J. 45: 1044, 1952. Klempner, E.: AMER. J. OBSTET. GYNEC. 64: 1232, 1952. Leventhal, M. L., and Solomon, E. M.: AMER. J. OBSTET. GYNEC. 52: 692. 1946. Rutledge, F., Dodd, G. D., Jr., and Kasilag. F. B., Jr.: AMER. J. OBSTET. GYXF,C. 77: 1165, 1959.
HOVADHANAKUL, EACHEMPATI,
DENIS St. Louis,
M.D. M.D.
CAVANAGH,
M.D.
Missouri
A caxe of ureteral presented.
obstruction
in association
with
URETERAL OBSTRUCTION has been reported to occur in association with lesions in the pelvic cavity such as tuboovarian abscesses,2 pelvic inflammatory disease , 4, 11~12 appendiceal abscesses,5* ‘9 0p lo ovarian cysts,12 lymphocysts,6p I4 endometriosis,121 I3 uterine leiomyomas and malignant disease of uterus and ovary,la pelvic extragenital tumors,l sigmoid diverticulitis,0 and ovarian vein syndrome.3 A case of ureteral obstruction in association with a chronic ectopic pregnancy is presented. The patient, a 29-year-old Caucasian Ivoman, gravida 4, para 4, was admitted on July 13, 1970, complaining of pain in the right lower quadrant of the abdomen of 6 weeks’ duration. One month prior to admission, she had cramping pain over a 12 hour 1jeriod and had noticed some abdomina1 disrention. Since then, she had a tendency to t:onstipation. She had no urinary symptoms. Her last menstrual period was given as June 28, 1970, but there was some doubt as to whether this was a “normal flow.” Her history was otherwise noncontributory. On examination no costovertebral angle tenderness was elicited. On abdominal examination, an ill-defined, cystic, nontender mass of about 10 cm. in diameter was palpable in the right lower quadrant. Pelvic examination revealed the uterus deviated to the left by the irregu-
From the Department Obstetrics, of Medicine.
St.
Louis
of Gynecology University School
a chronic
ectopic
pregnancy is
lar adnexal mass extending above the pelvic brim on the right. The left adnexa was not palpable. A diagnosis of an ovarian tumor with a possible torsion of its pedicle was made. Hemoglobin was 12.3 Gm. per cent, with hematocrit 37 per cent, and white blood count was 7,750 per cubic millimeter, with a normal differential count. An x-ray of the chest was within normal limits. A urine culture revealed no pathogenic bacteria. The pregnancy test was negative. An intravenous urogram showed obstructive uropathy on the right side with an associated pelvic soft tissue mass (Fig. 1) . At exploratory celiotomy, the small intestines were found to be adherent anteriorly over the cystic intraligamcntous mass. During release of the adhesions, the “cyst” wall was ruptured, extruding clots of altered blood. On closer inspection, thr mass was found to be a hematosalpinx involving the right tube. The right ovary was medial to the tube, and the uterus was of normal size. The left tube and ovary appeared normal. In view of the extensive destruction of the tube and the adherence of the ovary, :t right salpingo-oophorectomy was then performed. In view of the obstructive uropathy found on the intravenous urogram, the right ureter was traced retroperitoneally to the pelvic brim. At this point a dilated ovarian vein was found to be compressing the right ureter. The ovarian vein was ligated with 2-O silk at two places, one inch apart. ‘lhe patient had an uneventful recovery and was discharged on the seventh postoperative day.
and
311
312
Hovadhanakul,
Eachempati,
and
Cavanagh
June
Amer. J. Obstet.
1, 191 Gymr
Fig. 1. Intravenous urogram taken before the operation, revealing obstructive uropathy on the right with an associated pelvic soft tissue mass.
Fig. 2. Intravenous urogram taken 26 days right salpingo-oophorectomy and ovarian ligation, revealing marked improvement.
Examination of the specimen revealed the presence of a large cystic mass measuring 10 by 5 by 3 cm., with an adherent ovary of normal size but pale with gray convolutions. The cystic mass was covered with a ragged, dark-gray, thickened serosa. The lumen was filled with adherent clotted blood. The tube showed organizing hemorrhage with chronic inflammatory infiltration and scattered fibrotic villi. No trophoblastic activity was evident, and findings were generally suggestive of a “chronic ectopic pregnancy.” Excretory urography repeated 26 days after operation showed the right ureter to be much less dilated than was noted in the preoperative film (Fig. 2 ) .
report could be found in a rather extensive review of the literature. This may be due to the fact that it is unusual for a ruptured ectopic pregnancy to be sealed off without significant clinical manifestations. In reviewing the records of the Department of Gynecology and Obstetrics, St. Louis University Group of Hospitals, from 1950 through 1969, there were 102,339 deliveries and 387 ectopic pregnancies, and this was the only case seen which was complicated by obstructive uropathy. The ureteric obstruction in this case may have been primarily associated with the development of the ovarian vein syndrome. On the other hand, it seems more likely that the obstruction was a pressure effect of the pelvic mass in association with periureteral fibrosis, with the ovarian vein syndrome being a secondary effect. Relief of the obstruction by removal of the pelvic mass and ligation of the ovarian vein is
Comment
The occurrence of ureteric obstruction in association with a chronic ectopic pregnancy is apparently rare, and, indeed, no previous
after vein
Volwne 110 Nulnber J
Ureteral
demonstrated in the postoperative excretory urogram. Ureteric obstruction in association with benign tumors such as ovarian cysts and leiomyomas of the uterus has been reported to be relieved promptly on removal of the mass (75 per cent), and only 40 per cent were in association with conditions such as appendicitis, diverticulitis, or endometriosisl” If the obstruction to the ureter
obstruction
in chronic
ectopic
pregnancy
313
had not been released in this case, the patient may have developed signs of pvelonephritis at a later date, Also, as in cases of periureteral endometriosis or inflammatory diseases,it may ultimately result in a nonfunctioning kidney or hypertensive irropathy. Thus, early recognition of the problem with prompt intervention is essential.
REFERENCES I.
2.
Cavanagh, D., Egan, R. L., Dolan, P. A., and Rutledge, F.: Obstet. Gynec. Survey 20: 70, 1965. Cox, B. S., DeVere, R. D., and Thomas, D. J.: J. Obstet. Gynaec. Brit. Comm. 76: 1117, i96i3.
7. .
4. 5. 6.
Dykhuizen, Obstet. Everett, OBSTET. Goodwin, J. Surg. Griffith, 103: 43,
R. F., and Roberts, J. A.: Surg. Gvnec. 130: 443. 1970. II. S., and Scott, R. B.: AMER. J. G~KEC. 44: 1010, 1942. W. E., and Turner, R. D., Amer. 94: 232, 1957. D. I’., and Carlton, C. E.: J. Ural. 1970,
7. 8. 9. 10. 11. 12. 13.
Henson, A. 182: Hersch, 1963.
S. W., and Rumley, R. J.: J. .4. M. 80, 1962. R. A.: Gastroenterology 45: 269,
Hoffman, H. L.: Lancet 1:
788, 1932. Hughes, J.: Southern Med. J. 45: 1044, 1952. Klempner, E.: AMER. J. OBSTET. GYNEC. 64: 1232, 1952. Leventhal, M. L., and Solomon, E. M.: AMER. J. OBSTET. GYNEC. 52: 692. 1946. Rutledge, F., Dodd, G. D., Jr., and Kasilag. F. B., Jr.: AMER. J. OBSTET. GYXF,C. 77: 1165, 1959.