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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Successful laparoscopic management of a primary omental pregnancy: Case report and review of literature Yasuhito Tanase, Shozo Yoshida, Naoto Furukawa & Hiroshi Kobayashi Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan
Keywords Abdominal pregnancy; laparoscopic surgery; primary omental pregnancy Correspondence Yasuhito Tanase, Department of Obstetrics and Gynecology, Nara Medical University, Shijyo- tyou 840, Kashihara, Nara 634-8522, Japan. Tel: +81 744 22 3051 Fax: +81 744 23 6557 Email: [email protected] Received: 14 April 2013; revised 24 June 2013; accepted 7 July 2013 DOI:10.1111/ases.12056
Abstract A 32-year-old gravid 1, parity 0 woman was referred to our hospital with suspicion of ectopic pregnancy 31 days after her previous menstrual period. She had a 5-month history of secondary infertility reported increasing lower abdominal pain. Her serum human chronic gonadotropin level was 8160 mIU/mL. Her medical history was significant for a myomectomy and an enucleation of left ovarian cyst. On suspicion of an ectopic pregnancy, laparoscopic exploration was performed. Dense pelvic adhesion was seen. After dissection of the adhesion, we could not find the blastocyst in her pelvis. Early pregnancy tissue implanted in the omentum was identified and was excised laparoscopically. The postoperative course was uneventful. When no ectopia is found in the fallopian tubes during laparoscopy or laparotomy for ectopic pregnancy, all peritoneal surfaces and the omentum must be carefully inspected during surgery.
Introduction Abdominal pregnancy is rare, accounting for 1 in 10 000 live births. Omental pregnancy is an extremely rare form of abdominal pregnancy. The early preoperative diagnosis is complex, but omental pregnancy has a risk of sudden life-threatening intra-abdominal bleeding. Herein, we discuss a rare case of primary omental pregnancy for which wesuccessfully performed laparoscopic partial omentectomy.
Case Presentation A 32-year-old gravida 1, para 0 woman presented to our institution (Nara Medical University, Nara, Japan) with a 5-month history of secondary infertility. The patient’s menstrual cycle was regular, with a length of 28 days. Obstetrical history included one miscarriage approximately 5 months before presentation. Medical history was significant for myomectomy and enucleation of a left ovarian endometriotic cyst; however, family history was unremarkable. Chief complaints were lower abdominal pain and amenorrhea. It had been 31 days since the
beginning of her last menstrual period, and her pregnancy test was positive, with a serum human chronic gonadotropin level of 8160 mIU/mL. The patient’s vital signs were stable. However, there was mild tenderness in her pelvis. The uterus was soft with a normal size but restricted mobility. Bilateral adnexa were not palpable. There was no vaginal bleeding. Pelvic ultrasound revealed a 2-cm hyperechoic mass in the right adnexa. However, transvaginal ultrasonography did not reveal a gestational sac in the uterus. Free fluid could be seen in the pelvis. A preoperative diagnosis of ruptured right tubal pregnancy was made. Laparoscopic exploration was performed via a 12-mm port through an intraumbilical incision after insufflation using a Veress needle. Three additional 5-mm ports were inserted in the left and right lower quadrants and suprapubic region. Part of the omentum was adhered to the pelvic wall. Dense adhesions and approximately 300-mL dark blood were found in the pelvis. Both ovaries and fallopian tubes were adhered to each ovarian fossa. In addition, the uterus was adhered to the small intestine. The dense pelvic adhesions were dissected, but a diagnosis of pelvic ectopic pregnancy could not be made.
Asian J Endosc Surg 6 (2013) 327–329 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
327
Primary omental pregnancy
Y Tanase et al.
Discussion
Figure 1 A 3-cm cystic mass was detected in the omentum, which was covered with a massive blood clot.
Figure 2 Chorionic villi and trophoblastic proliferation in the omental fat (hematoxylin & eosin, 40×).
After further exploration of the abdominal cavity, we found a massive blood clot adhered to the distal omentum. We irrigated and evacuated this clot and confirmed a 3-cm blastocyst entrapped in the omentum surrounding the massive coagulum (Figure 1). With an ultrasonic knife, laparoscopic partial omentectomy was performed. There were villous-like tissues within the cyst. Microscopically, degenerated villous trophoblasts in the omental cyst were consistent with ectopic pregnancy, particularly omental pregnancy. Neovascular generation and invasive changes in the omentum were seen (Figure 2). Therefore, a diagnosis of primary omental pregnancy was made. The patient’s postoperative course was uneventful. Serum human chronic gonadotropin levels returned to normal range by postoperative day 17.
328
Primary abdominal pregnancy is defined as implantation of a fertilized egg in the peritoneum. In 1942, Studdiford established criteria for the diagnosis of primary abdominal pregnancy (1). These criteria were modified by Friedrich and Rankin in 1968 and later accepted as those of primary abdominal pregnancy (2). The criteria are as follows: (i) presence of any pregnancy that is less than 12-weeks histological gestational age and in which trophoblastic attachments are solely related to the peritoneal surface; (ii) grossly normal tubes and ovaries; and (iii) the absence of uteroperitoneal fistula. In addition, Berghella and Wolf recommended that histological evidence of neovascularization or growth of a trophoblast into the supporting tissue be shown (3). In the pathological sections of the patient in our study, neovascularization with extensive villous formation and trophoblastic proliferation into the omental tissue were observed. Based to these criteria, we diagnosed our case as a primary abdominal pregnancy, specifically an omental pregnancy. Simultaneously, we laparoscopically evaluated an omental pregnancy, a rare form of abdominal pregnancy, and removed it safely without any complications. Most abdominal pregnancies are considered as the secondary type, a condition in which the embryo or fetus continues to grow in the abdominal cavity after its disruption from the fallopian tube (the site of primary development) (4). The most probable cause of secondary abdominal pregnancy is the displacement of ectopic pregnancy tissue into the abdominal cavity during salpingostomy. However, it can also be caused by salpingectomy, after which more than half of reported cases of omental pregnancy occur (5). It should be noted that with secondary abdominal pregnancy, the trophoblast can be implanted at multiple sites in the abdomen. Hence, all peritoneal surfaces and the omentum must be carefully inspected during surgery. The diagnosis of abdominal pregnancy is complex. Ultrasonography coupled with clinical evaluation has a diagnostic success rate of approximately 50%. MRI can also be used to confirm the diagnosis of abdominal pregnancy, and its advantages have been reported (6). Takeda et al. reported the utility of diffusion-weighted MRI for localization of an ectopic pregnancy (7). Nevertheless, an early diagnosis of abdominal pregnancy is difficult. Because a delayed diagnosis of abdominal pregnancy poses a serious threat to the survival of the mother, it is important to bear in mind that pregnancy can exist in unusual locations. The mortality of abdominal pregnancy is said to be seven times higher than that of ectopic pregnancies at other sites (4).
Asian J Endosc Surg 6 (2013) 327–329 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Primary omental pregnancy
Y Tanase et al.
Risk factors for abdominal pregnancy are the same as for ectopic pregnancy and include previous pelvic surgical history and pelvic post-inflammatory status, particularly ingestion of progesterone pills and subsequent ovulation induction. In this case, the patient’s medical history was significant for myomectomy and enucleation of a left ovarian endometriotic cyst, and it was considered the cause of the abdominal pregnancy. Most reported omental pregnancies have been treated by laparotomy, which is considered as the gold standard in the management of omental pregnancy. However, several cases that were successfully treated by laparoscopy have been reported (8,9), and the number of reports recommending early laparoscopy for hemodynamically stable patients is increasing. In this study, we have reported the successful treatment of a rare case of primary omental pregnancy by laparoscopy. On surgical exploration, a hemorrhagic mass adherent to the omentum and a blood clot were the most consistent findings. However, it is important to remember that an omental pregnancy can easily be overlooked, even by skillful surgeons, during laparoscopic exploration.
Acknowledgment The authors have no conflicts of interest to disclose and received no financial support for this report.
References 1. Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942; 44: 487–491. 2. Friedrich EG Jr & Rankin CA Jr. Primary pelvic peritoneal pregnancy. Obstet Gynecol 1968; 31: 649–653. 3. Berghella V & Wolf SC. Does primary omental pregnancy exist? Gynecol Obstet Invest 1996; 42: 133–136. 4. Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: Frequency and maternal mortality. Obstet Gynecol 1987; 69: 333–337. 5. Samuer ST, David AG, Lawerence DT et al. Pelvic trophoblastic implants after laparoscopic removal of a tubal pregnancy. Obstet Gynecol 1989; 74: 514–515. 6. Spanta R, Roffman LE, Grissom TJ et al. Abdominal pregnancy: Magnetic resonance identification with ultrasonographic follow-up of placental involution. Am J Obstet Gynecol 1987; 157: 887–889. 7. Takeda A, Imoto S, Mori M et al. Early abdominal pregnancy complicated by parasitic dermoid cyst: Diagnosis by diffusionweighted magnetic resonance imaging and management by laparoendoscopic single-site surgery. J Minim Invasive Gynecol 2012; 19: 647–650. 8. Hyun-Joo S, Tak K, Seon-Kung L. Successful laparoscopic management of primary omental pregnancy. Arch Gynecol Obstet 2010; 281: 163–165. 9. Horneman A, Holl- Ulrich K, Finas D et al. Laparoscopic management of early primary omental pregnancy. Fertil Steril 2008; 89: e9–e11.
Asian J Endosc Surg 6 (2013) 327–329 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
329
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Successful laparoscopic management of a primary omental pregnancy: Case report and review of literature Yasuhito Tanase, Shozo Yoshida, Naoto Furukawa & Hiroshi Kobayashi Department of Obstetrics and Gynecology, Nara Medical University, Nara, Japan
Keywords Abdominal pregnancy; laparoscopic surgery; primary omental pregnancy Correspondence Yasuhito Tanase, Department of Obstetrics and Gynecology, Nara Medical University, Shijyo- tyou 840, Kashihara, Nara 634-8522, Japan. Tel: +81 744 22 3051 Fax: +81 744 23 6557 Email: [email protected] Received: 14 April 2013; revised 24 June 2013; accepted 7 July 2013 DOI:10.1111/ases.12056
Abstract A 32-year-old gravid 1, parity 0 woman was referred to our hospital with suspicion of ectopic pregnancy 31 days after her previous menstrual period. She had a 5-month history of secondary infertility reported increasing lower abdominal pain. Her serum human chronic gonadotropin level was 8160 mIU/mL. Her medical history was significant for a myomectomy and an enucleation of left ovarian cyst. On suspicion of an ectopic pregnancy, laparoscopic exploration was performed. Dense pelvic adhesion was seen. After dissection of the adhesion, we could not find the blastocyst in her pelvis. Early pregnancy tissue implanted in the omentum was identified and was excised laparoscopically. The postoperative course was uneventful. When no ectopia is found in the fallopian tubes during laparoscopy or laparotomy for ectopic pregnancy, all peritoneal surfaces and the omentum must be carefully inspected during surgery.
Introduction Abdominal pregnancy is rare, accounting for 1 in 10 000 live births. Omental pregnancy is an extremely rare form of abdominal pregnancy. The early preoperative diagnosis is complex, but omental pregnancy has a risk of sudden life-threatening intra-abdominal bleeding. Herein, we discuss a rare case of primary omental pregnancy for which wesuccessfully performed laparoscopic partial omentectomy.
Case Presentation A 32-year-old gravida 1, para 0 woman presented to our institution (Nara Medical University, Nara, Japan) with a 5-month history of secondary infertility. The patient’s menstrual cycle was regular, with a length of 28 days. Obstetrical history included one miscarriage approximately 5 months before presentation. Medical history was significant for myomectomy and enucleation of a left ovarian endometriotic cyst; however, family history was unremarkable. Chief complaints were lower abdominal pain and amenorrhea. It had been 31 days since the
beginning of her last menstrual period, and her pregnancy test was positive, with a serum human chronic gonadotropin level of 8160 mIU/mL. The patient’s vital signs were stable. However, there was mild tenderness in her pelvis. The uterus was soft with a normal size but restricted mobility. Bilateral adnexa were not palpable. There was no vaginal bleeding. Pelvic ultrasound revealed a 2-cm hyperechoic mass in the right adnexa. However, transvaginal ultrasonography did not reveal a gestational sac in the uterus. Free fluid could be seen in the pelvis. A preoperative diagnosis of ruptured right tubal pregnancy was made. Laparoscopic exploration was performed via a 12-mm port through an intraumbilical incision after insufflation using a Veress needle. Three additional 5-mm ports were inserted in the left and right lower quadrants and suprapubic region. Part of the omentum was adhered to the pelvic wall. Dense adhesions and approximately 300-mL dark blood were found in the pelvis. Both ovaries and fallopian tubes were adhered to each ovarian fossa. In addition, the uterus was adhered to the small intestine. The dense pelvic adhesions were dissected, but a diagnosis of pelvic ectopic pregnancy could not be made.
Asian J Endosc Surg 6 (2013) 327–329 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
327
Primary omental pregnancy
Y Tanase et al.
Discussion
Figure 1 A 3-cm cystic mass was detected in the omentum, which was covered with a massive blood clot.
Figure 2 Chorionic villi and trophoblastic proliferation in the omental fat (hematoxylin & eosin, 40×).
After further exploration of the abdominal cavity, we found a massive blood clot adhered to the distal omentum. We irrigated and evacuated this clot and confirmed a 3-cm blastocyst entrapped in the omentum surrounding the massive coagulum (Figure 1). With an ultrasonic knife, laparoscopic partial omentectomy was performed. There were villous-like tissues within the cyst. Microscopically, degenerated villous trophoblasts in the omental cyst were consistent with ectopic pregnancy, particularly omental pregnancy. Neovascular generation and invasive changes in the omentum were seen (Figure 2). Therefore, a diagnosis of primary omental pregnancy was made. The patient’s postoperative course was uneventful. Serum human chronic gonadotropin levels returned to normal range by postoperative day 17.
328
Primary abdominal pregnancy is defined as implantation of a fertilized egg in the peritoneum. In 1942, Studdiford established criteria for the diagnosis of primary abdominal pregnancy (1). These criteria were modified by Friedrich and Rankin in 1968 and later accepted as those of primary abdominal pregnancy (2). The criteria are as follows: (i) presence of any pregnancy that is less than 12-weeks histological gestational age and in which trophoblastic attachments are solely related to the peritoneal surface; (ii) grossly normal tubes and ovaries; and (iii) the absence of uteroperitoneal fistula. In addition, Berghella and Wolf recommended that histological evidence of neovascularization or growth of a trophoblast into the supporting tissue be shown (3). In the pathological sections of the patient in our study, neovascularization with extensive villous formation and trophoblastic proliferation into the omental tissue were observed. Based to these criteria, we diagnosed our case as a primary abdominal pregnancy, specifically an omental pregnancy. Simultaneously, we laparoscopically evaluated an omental pregnancy, a rare form of abdominal pregnancy, and removed it safely without any complications. Most abdominal pregnancies are considered as the secondary type, a condition in which the embryo or fetus continues to grow in the abdominal cavity after its disruption from the fallopian tube (the site of primary development) (4). The most probable cause of secondary abdominal pregnancy is the displacement of ectopic pregnancy tissue into the abdominal cavity during salpingostomy. However, it can also be caused by salpingectomy, after which more than half of reported cases of omental pregnancy occur (5). It should be noted that with secondary abdominal pregnancy, the trophoblast can be implanted at multiple sites in the abdomen. Hence, all peritoneal surfaces and the omentum must be carefully inspected during surgery. The diagnosis of abdominal pregnancy is complex. Ultrasonography coupled with clinical evaluation has a diagnostic success rate of approximately 50%. MRI can also be used to confirm the diagnosis of abdominal pregnancy, and its advantages have been reported (6). Takeda et al. reported the utility of diffusion-weighted MRI for localization of an ectopic pregnancy (7). Nevertheless, an early diagnosis of abdominal pregnancy is difficult. Because a delayed diagnosis of abdominal pregnancy poses a serious threat to the survival of the mother, it is important to bear in mind that pregnancy can exist in unusual locations. The mortality of abdominal pregnancy is said to be seven times higher than that of ectopic pregnancies at other sites (4).
Asian J Endosc Surg 6 (2013) 327–329 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Primary omental pregnancy
Y Tanase et al.
Risk factors for abdominal pregnancy are the same as for ectopic pregnancy and include previous pelvic surgical history and pelvic post-inflammatory status, particularly ingestion of progesterone pills and subsequent ovulation induction. In this case, the patient’s medical history was significant for myomectomy and enucleation of a left ovarian endometriotic cyst, and it was considered the cause of the abdominal pregnancy. Most reported omental pregnancies have been treated by laparotomy, which is considered as the gold standard in the management of omental pregnancy. However, several cases that were successfully treated by laparoscopy have been reported (8,9), and the number of reports recommending early laparoscopy for hemodynamically stable patients is increasing. In this study, we have reported the successful treatment of a rare case of primary omental pregnancy by laparoscopy. On surgical exploration, a hemorrhagic mass adherent to the omentum and a blood clot were the most consistent findings. However, it is important to remember that an omental pregnancy can easily be overlooked, even by skillful surgeons, during laparoscopic exploration.
Acknowledgment The authors have no conflicts of interest to disclose and received no financial support for this report.
References 1. Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942; 44: 487–491. 2. Friedrich EG Jr & Rankin CA Jr. Primary pelvic peritoneal pregnancy. Obstet Gynecol 1968; 31: 649–653. 3. Berghella V & Wolf SC. Does primary omental pregnancy exist? Gynecol Obstet Invest 1996; 42: 133–136. 4. Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: Frequency and maternal mortality. Obstet Gynecol 1987; 69: 333–337. 5. Samuer ST, David AG, Lawerence DT et al. Pelvic trophoblastic implants after laparoscopic removal of a tubal pregnancy. Obstet Gynecol 1989; 74: 514–515. 6. Spanta R, Roffman LE, Grissom TJ et al. Abdominal pregnancy: Magnetic resonance identification with ultrasonographic follow-up of placental involution. Am J Obstet Gynecol 1987; 157: 887–889. 7. Takeda A, Imoto S, Mori M et al. Early abdominal pregnancy complicated by parasitic dermoid cyst: Diagnosis by diffusionweighted magnetic resonance imaging and management by laparoendoscopic single-site surgery. J Minim Invasive Gynecol 2012; 19: 647–650. 8. Hyun-Joo S, Tak K, Seon-Kung L. Successful laparoscopic management of primary omental pregnancy. Arch Gynecol Obstet 2010; 281: 163–165. 9. Horneman A, Holl- Ulrich K, Finas D et al. Laparoscopic management of early primary omental pregnancy. Fertil Steril 2008; 89: e9–e11.
Asian J Endosc Surg 6 (2013) 327–329 © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
329
