Omental pregnancy in a woman taking the progestogen‐only pill

Abstract

A 25-year-old, gravida 6, para 4, was referred to the Early Pregnancy Assessment Unit with 6 weeks of amenorrhea and ten days history of progressive non-specific abdominal pain. She was taking the progestogen-only pill (POP), norethisterone 0.35 mg/daily (Micronor, Jassen -Cilag, United Kingdom), and there was no history of missed pills over the past six weeks. Her periods were regular but her last period was lighter and lasted three instead of five days. She had had four full term normal vaginal deliveries with no previous history of pelvic inflammatory diseases. She stopped taking the combined oral contraceptive pill at the age of 22 due to migraine headaches and was advised to take the POP.Ten days earlier, she had presented to the Emergency Department with a history of non-specific lower abdominal pain. She was given antibiotics for a presumptive diagnosis of urinary tract infection. Three days prior to admission, she was seen by her General Practitioner for lower abdominal pain and fainting attack. A mild analgesic was prescribed. Pregnancy test was not carried out on the two previous occasions.On examination, she was hemodynamically stable. There was localized tenderness in the left iliac fossa but there were no signs of peritonism. Bimanual pelvic assessment revealed a slightly tender, normal sized uterus with a closed external cervical os. She had cervical excitation with left adnexa tenderness but no adnexal mass was palpable. There was no vaginal bleeding and the pregnancy test was positive. Ultrasound scan (transabdominal and transvaginal) demonstrated a thickened endometrial lining, no intrauterine gestational sac and the right ovary appeared normal. On the left, two complex masses of mixed echogenicity were noted and these measured 73¿61¿28 mm and 47¿42¿38 mm. The left ovary could not be identified. Free fluid was noted in the pelvis. Her serum b human chorionic gonadotrophin (b-hCG) was 21107 IU/L. The findings and investigations were suggestive of an ectopic pregnancy with a complex ovarian cyst.An exploratory laparotomy was carried out through a transverse suprapubic incision. A 7¿5¿2 cm mass consisting of blood clots and tissue fragments was found attached to the omentum and the posterior aspect of the left broad ligament. The left ovary was enlarged by 4¿4¿4 cm corpus luteum cyst. The uterus, right ovary and right tube were normal. The left tube was normal in caliber with no evidence of enlargement or active bleeding. There was 300 ml of blood and blood clots in the Pouch of Douglas. Active bleeding occurred during separ-

Primary omental pregnancy: Case report

“…Clinical, ultrasonographic, histopathological and surgical findings must be combined to diagnose a case as a primary omental pregnancy. Recent contraceptive usage such as progesterone-only pills and intrauterine devices can be accepted as a risk factor (Mousa and Thong, 2001). Our patient has not been using any contraceptive method.…”

Early Abdominal Ectopic Pregnancies: A Systematic Review of the Literature

“…There were 25 reports from 24 different references of an abdominal pregnancy being primarily implanted on the omentum [42,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115]. The patient’s average age at initial presentation was 27 (range 13–36) with the average gestational age at diagnosis of 7 weeks and 2 days (range 4–16 weeks) and parity of 1.3.…”

“…Culdocentesis was used in 6 patients [93,96,102,103,109] to assist in the diagnosis of a ruptured ectopic pregnancy. A delay in presentation to definitive treatment was noted in 8 patients [94,95,98,101,103,107,111,114] with 2 of the patients having an initial negative laparoscopic examination [95,114]. After a diagnosis of a hemorrhagic corpus luteum in 1 patient [114], MRI was used after the HCG continued to rise following the negative laparoscopy and a dilation and curettage to identify the site of the abdominal ectopic pregnancy.…”

Primary omental ectopic pregnancy

“…Laparotomy was performed as most of the reported cases for omental pregnancies 1–7,9 , 12 except three cases were managed successfully by laparoscopic approach 8,10 , 13 . In this case, laparotomy was finally carried out from initial laparoscopic approach because of suspicious intraoperative findings and the clinical background of the patient.…”

“…Omental pregnancy is a rare form of ectopic pregnancy. Only 15 cases had been reported in the literature 1–14 . Primary omental pregnancy accounted for only four of them 8,10 , 12,13 .…”