Abstract

A nulliparous woman aged 45 years was referred to us with painful swelling in left lower limb. She underwent laparoscopic hysterectomy for menorrhagia 12 days prior to the admission. The laparoscopic surgery was completed in 90 min without blood loss and blood transfusion. The size of the uterus was approximately 12 weeks. Duplex scan of the left lower limb confirmed thrombosis of the left external iliac vein, femoral vein, popliteal vein and tibial veins. On examination the laparoscopic puncture wounds healed well. She was hospitalized for initial anticoagulation with low molecular weight heparin (Enoxapain 1 mg/kg body weight twice daily) and compression bandages. Histological examination of the hysterectomy specimen was noted to be benign (Adenomyosis and cervical Leiomyoma). She responded to anticoagulation therapy and was discharged with an advice to attend the follow up clinic for long term anticoagulation advice for the next 6 months to prevent recurrent thromboembolic episodes.

Abstract

Mrs. S, aged 27 years, G2P1A0, having one alive and healthy child delivered 7 years back by cesarean section, presented to emergency unit of our hospital, with complaints of amenorrhea for one and half months and continuous pain in lower abdomen, giddiness, and bleeding per vaginum since one day. Her general condition was satisfactory, with pulse 100/min, BP 110/70 mmHg, and normal temperature. There was no pallor, and her respiratory system and CVS were normal. On per abdominal examination, there was minimal guarding and tenderness present, and no mass was felt. Per speculum examination revealed minimal bleeding through os. Vaginal examination showed that uterus was of normal size, anteverted, and cervical movements were nontender. Right fornix was clear, but in left fornix illdefined tender mass of 3×3 cm was felt. Mild tenderness was present in left fornix.

Laboratory investigations showed positive urine pregnancy test and serum ß-HCG levels of 1,600 IU/I. Her hemoglobin was 9.3 gm%, white cell count 13,000/mm3, differential count of N81,L17, E1, M1, ESR 25 mm/hour, whereas the results for rest of the routine investigations were within normal limits. Ultrasound showed a large mixed echogenic left adenexal lesion of 6.2×3×5 cm3 size with solid and cystic components, and large amount of free fluid in pouch of Douglas, suggestive of ruptured left ectopic gestation. Uterus was empty and of normal size, shape, and echo texture. Both ovaries were normal in size and shape. Emergency laparotomy was done which revealed ruptured gestational sac implanted on sigmoid colon, 200cc of hemoperitonium was present. Products of conception and clots were removed. Part of the chorionic plate was firmly adherent to the bowel and was left behind to avoid bowel injury. Saline wash was given. Complete hemostasis was achieved. Tubercles were seen on anterior surface of uterus. Previous lower segment caesarean section scar was intact. The abdomen was closed after securing complete hemostasis. The patient withstood the surgery well. On postoperative day 8 ßHCG level was 380 mlU/ml and ultrasound of pelvis was normal. The patient was discharged on postoperative day 10. Follow-up of patient in outpatient department after 7 days of discharge showed ßHCG 34 mlU/ml. She was advised Anti Koch's treatment. Diagnosis of primary abdominal pregnancy was made according to Studdiford's criteria1. Both tubes and ovaries were in normal condition with no evidence of recent or remote injury. No evidence of uteroperitoneal fistula was found. The pregnancy was related exclusively to the peritoneal surface and was early enough to eliminate the possibility that it is a secondary implantation following a primary implantation in the tube.