Ampullary Localization of Unruptured Ectopic Pregnancy of Eighteen Weeks about a Case

Ectopic pregnancy is therefore implanted out of the normal implantation site of the uterine cavity. It is a surgical emergency that can compromise the vital prognosis and fertility of patients when the diagnosis is made at the stage of rupturing. Its incidence has doubled or even tripled in the world in the last two decades. Although it still remains the leading cause of maternal mortality in the first trimester by tubal rupturing accounting for 13% of maternal deaths this increase is closely linked to several factors such as sexually transmitted infections, history of salpingitis, tubal surgery, abortions, inert or progesterone associated IUD use and smoking. Tubal location is by far the most common (96 to 99% of cases). The clinical signs are therefore relatively late and the rupture of the tube is preceded by a fissure syndrome. We report a rare case of unruptured ampullary pregnancy that has evolved to 18 weeks.

Keywords: Ectopic; Advanced Pregnancy; Amplular Localization

Ectopic pregnancy or extrauterine pregnancy is defined as implantation and subsequent development of the zygote at a site other than normal intrauterine cavity [1]. It is a surgical emergency that can compromise the vital prognosis and fertility of patients when the diagnosis is made at the stage of breaking. Although it still remains the leading cause of maternal mortality in the first trimester by tubal breaking accounting for 13% of maternal deaths this increase is closely linked to several factors such as sexually transmitted infections, history of salpingitis, tubal surgery, abortions, IUD use and smoking [2-4]. Tubal location is by far the most common (96 to 99% of cases). The whole fallopian tube may be interested. The bulb, especially the isthmo-ampullary junction is the preferred location anatomically, this segment is wide and extensible [5]. Ultrasonography and serial estimates of serum human chorionic gonadotropin (hCG) are used to detect or rule out ectopic pregnancy in women with vaginal bleeding or abdominal pain with delay of menstruation [6].

The clinical diagnosis of USG but is not always easy to find [7]. The clinical signs are therefore relatively late and the rupture of the tube is preceded by a fissure syndrome. We report a rare case of unruptured ampullary pregnancy that has evolved to 18 weeks.

Mrs K, 27 years old, mother of a living child (vaginal delivery for a pregnancy completed 6 years ago), the history of the disease began with 18 weeks of late menstruation associated with metrorrhagia of average abundance and pelvic pain. She had no risk factors for ectopic pregnancy. On examination, the patient was 15/15 conscious, hemodynamically and respiratory stable. The abdominal examination revealed slight pelvic area sensitivity associated with a left iliac mass of about 20 cm. Bimanual pelvic examination revealed a left lateral uterine mass approximately 18x20 cm, felt separately from the uterus with reduced mobility.

The initial hemoglobin was 11.8 g /dl. The quantitative beta-hCG: 76000 miu / ml. The ultrasound revealed a left gestational sac with an 18-week gestational age fetus without fetal cardiac activity and showed an enlarged uterus with an empty uterine cavity. Both Ovaries were normal (Figure 1). The patient was taken for emergency laparotomy after duly obtaining informed consent. Laparotomy revealed a left infundibula tubal pregnancy measuring approximately 18 cm long, so a left salpingectomy was performed. On exploration: the right fallopian tube and the ovary were normal (Figure 2). The histological examination of the piece showed a fallopian tube with ectopic gestation in the fetus corresponding approximately to 18 weeks of gestation. The patient's post-operative course was uneventful.

Advanced Ampullary localization of ectopic pregnancy is rare. the doubling time of serum beta-hcg and the transvaginal ultrasound make it possible to identify precocious ectopic pregnancy. the absence of transvaginal ultrasound in the first trimester leads to the late diagnosis of ectopic pregnancy. However, despite transvaginal ultrasound performed during the first trimester, an ectopic pregnancy may be missed because of inexperienced radiologists or the presence of a heterotopic pregnancy Mert Gol et al. reported a case of ectopic tubal rupture of 17 weeks [8]. One case of late ectopic pregnancy was reported in a 1989 publication: it is an ampullary pregnancy whose diagnosis was established only at laparotomy [9]. More recently, R.Mhaskar published a case of right-sided ampullary ectopic pregnancy conducted up to 16 weeks with a live fetus treated with salpingectomy [8]. We believe that transvaginal ultrasound by a radiologist Experiment with a first-trimester serum beta-HCG doubling time is the best diagnostic modality for the early diagnosis of ectopic pregnancy [8].

Ectopic pregnancy is defined as the implantation of a pregnancy outside the uterus. This definition excludes interstitial, cervical and cornual pregnancies. It is a surgical emergency that can compromise the vital prognosis and fertility of patients when the diagnosis is made at the stage of breaking. All segments of the trunk may be interested. The bulb, especially the isthmo-ampullary junction is the preferred location anatomically, this segment is wide and extensible. Ultrasonography and serial estimates of serum human chorionic gonadotropin (hCG) are used to detect or rule out ectopic pregnancy in women with vaginal bleeding or abdominal pain with rule delay. The presence of a lateral, uterine, sensitive, poorly limited mass is an important element in the diagnosis of the USG but is not always easy to find, while the painful wheelbase of the cul de sac is often present. The clinical signs are the refore relatively late and the rupture of the tube is preceded by a fissure syndrome. We report a rare case of unruptured ampullary pregnancy that has evolved to 18 weeks.