Case report: Ectopic pregnancy at the level of broad ligament: A case report

Abstract

Introduction

Ectopic pregnancies are a significant clinical concern, with 90 % occurring in the fallopian tubes. However, they can also manifest in other locations, including the cervix, ovary, and abdominal cavity. Abdominal pregnancies, which constitute less than 1 % of ectopic pregnancies, are associated with considerable morbidity and mortality. Among these, pregnancies located in the broad ligament are particularly rare and can sometimes be carried to term.

Case presentation

This case report discusses a 27-year-old patient presenting with a 14-week pregnancy diagnosed in the broad ligament, highlighting the challenges in prenatal diagnosis and the potential complications associated with this condition. The report details the clinical management, including an exploratory laparotomy and subsequent treatment, and underscores the importance of awareness and timely intervention in cases of broad ligament ectopic pregnancies. This case contributes to the limited literature on this uncommon type of ectopic pregnancy and emphasizes the need for further research to improve diagnostic and therapeutic approaches.

Clinical discussion

Ectopic pregnancy of the broad ligament is a relatively rare pathology documented in the literature. Its diagnosis is clinical and paraclinical, especially if ultrasound is performed early. Management is similar to that of an abdominal pregnancy. Maternal prognosis can be difficult if management is less than optimal in terms of surgery, anesthesia, resuscitation and the absence of blood products. This is why first-trimester ultrasound is so important.

Conclusions

This case underscores the importance of awareness and timely intervention in managing broad ligament ectopic pregnancies, and highlighting the need for further research to improve diagnostic and therapeutic approaches.

Highlights

• •Ectopic pregnancies primarily occur in the fallopian tubes, but can also be found in rare locations such as the broad ligament.
• •This case report details a 27-year-old patient with a 14-week ectopic pregnancy diagnosed in the broad ligament, illustrating the challenges in prenatal diagnosis.
• •The case emphasizes the critical need for timely diagnosis and intervention in broad ligament ectopic pregnancies.

1. Introduction

Ninety percent of ectopic pregnancies are situated in the fallopian tube; however, they may also manifest in the cervix, ovary, interstitially, within a Cesarean section scar, intramurally, or abdominally [1]. Abdominal pregnancies, characterized by implantation in the peritoneal cavity outside the uterine or fallopian tubes, constitute under 1 % of ectopic pregnancies, yet are linked to significant mortality and morbidity [2].

Pregnancy within the wide ligament is an exceedingly uncommon form of ectopic pregnancy. It is classified as an abdominal pregnancy and may be carried to term. This location may be secondary to the rupture of an ampullary or infundibular pregnancy. Diagnosis during the prenatal consultation is not always easy. We report a case of pregnancy at 14 weeks amenorrhea.

Rarely can an abdominal ectopic pregnancy occur at the broad ligament level. Because the broad ligament is so close to the fallopian tube, it can be challenging to diagnose by imaging and occurs in about 1 in 300 ectopic pregnancies [3]. Since ectopic pregnancies of the broad ligament are uncommon, there is little information available on how to treat them. Despite the fact that more and more instances are being treated laparoscopically, the majority of case reports represent patients who had laparotomies [4].

This manuscript was prepared following the SCARE guidelines [5].

2. Case report

We report the case of a 27-year-old patient, gravida 2 para 1, no significant medical history, operated on 2 years ago for an ectopic pregnancy in the right fallopian tube at 5 weeks amenorrhea and underwent conservative treatment with salpingotomy. The parturient first consulted a general physician, who confirmed the pregnancy at 07 weeks' amenorrhea by means of a suprapubic ultrasound, erroneously localized as intrauterine, without mentioning an adnexal mass. Afterwards, the patient did not benefit from another ultrasound scan.

The patient presented with moderate to severe abdominal pain, present for about a week. She describes persistent pain in the pelvic region, mainly lateralized to the right, associated with episodes of light bleeding.

Examination reveals an anxious patient with blood pressure of 90/58 mmHg, pulse rate 85/min, diffuse abdominal tenderness, gynecological examination reveals mild bleeding, cervix closed.

Abdominal-pelvic ultrasound confirmed a 14-week pregnancy, with visualization of a pregnancy in the broad ligament with an empty uterus, with presence of embryonic heartbeat. And Presence of ectopic tissue in the broad ligament, surrounded by vascular structures. And a hemoperitoneum of moderate abundance.

Her hemoglobin was 9.4 g/dl, we began with resuscitative measures. We set up two large-bore intravenous lines with 1000 ml of 0.9 % saline, and an exploratory laparotomy was indicated and performed, bearing in mind that laparoscopic approach to etiological treatment has long been contraindicated in this situation. Today, it is no longer formally contraindicated, although it does require appropriate equipment and an operator experienced in performing the hemostatic procedure quickly.

After opening the skin and subcutaneous tissues, we progressively crossed the rectus abdominis muscles and reached the parietal peritoneum. Opening the parietal peritoneum revealed a fissured right latero-uterine mass of the right broad ligament measuring 110 × 80 mm. The right fallopian tube and ovary were not visualized, both being attached to the mass. Only the right tubal membranes were visible, as shown in Fig. 1, Fig. 2. Hemoperitoneum was 600 ml. The contra-lateral adnexa and uterus were macroscopically normal. We performed a total right salpingectomy and oophorectomy with resection of the right broad ligament. The patient received two units of packed red blood cells during the operation. Histopathological analysis was requested.

Fig. 1.

Ectopic pregnancy in the right adnexa, occupying the right broad ligament.

Fig. 2.

Image showing the ectopic pregnancy and a 125 g dead fetus of broad ligament pregnancy.

After the operation, the patient was admitted to the recovery room, where she spent one day before being transferred to the inpatient ward. During post-operative monitoring, pulse and respiratory rate normalized within 06 h. On the 04 th postoperative day, the patient progressed favorably and was discharged from hospital. The postoperative appointment given 15 days after discharge went off without a problem.

3. Discussion

In the category of abdominal ectopic pregnancies, intra-ligamentary pregnancy is an extremely uncommon occurrence, occurring roughly 1 in 300 times. Abdominal pregnancies can occur anywhere in the abdomen, but they are most frequently found in the pouch of Douglas and less frequently in the broad ligament [6].

Ectopic pregnancy in the broad ligament is a challenging type of pregnancy to diagnose by imaging, and can result in significant morbidity due to rupture and peritoneum [7]. Diagnosis of ectopic broad ligament pregnancy can lead to more critical presentations, in the second and third trimesters, and even to live births [8]. Although there have been advances in imaging, broad ligament pregnancies are generally not diagnosed prior to surgery due to the absence of specific features on imaging. The risk factors for broad-ligament pregnancies are similar to those for ectopic pregnancies, and may include tubal anomalies, ectopic pregnancy history, earlier salpingectomies, pelvic infections, endometriosis, adhesions, assisted reproductive technology (ART), and the existence of intrauterine devices (IUDs) [8].

It generally results from a trophoblastic invasion of the tubal pregnancy through the tubal serosa and into the mesosalpinx, with a secondary implantation between the laminae of the broad ligament. In this situation, the pregnancy is a secondary abdominal pregnancy. It can also result from primary implantation in the broad ligament. The abdominal pain reported at the start of such pregnancies is thought to be due to placental separation and minimal hemoperitoneum [9]. This was also the case in our patient, who had reported a first episode of abdominal pain a month earlier. The early appearance of complications such as moderate to severe abdominal pain or vaginal bleeding enables the diagnosis to be made in good time. The resulting intra-abdominal hemorrhage can be recognized by an acute abdomen or shock. Such complications are associated with maternal and perinatal mortality rates of 40 % and 95 % respectively [10].

The diagnosis of a full-term abdominal pregnancy is rarely made prior to surgery, as in the case described by H. Rakotomahenina and al of a full-term pregnancy with fetal death in the right broad ligament discovered during Cesarean section at around 44 weeks' amenorrhea [11].

Magnetic resonance imaging (MRI) provides supplementary diagnostic information to assess the extent of uterine and mesenteric involvement, and can help with surgical planning. Non-contrast MRI using T2-weighted imaging is a sensitive, specific and precise method for evaluating ectopic pregnancy [12].

However, surgery is indicated immediately in the event of acute rupture with hemoperitoneum and hemodynamic repercussions. The laparoscopic approach has long been contraindicated in this situation, but is no longer formally contraindicated. Insufflation of the peritoneal cavity could even have a positive effect on hemodynamic parameters [13]. Conservative or medical management is not recommended for ligamentous ectopic pregnancies, particularly when the diagnosis is uncertain [3].

Although there isn't much information to help manage broad ligament pregnancies, a number of case studies show that laparoscopic removal is a safe and effective treatment [14].

4. Conclusion

While broad ligament pregnancy is an uncommon and unusual form of ectopic pregnancy, it should be considered when an abnormal pregnancy, with early detection, it could be safely and effectively managed by minimally invasive methods. In closing, what this case adds to the literature, in addition to describing a rare condition, is that even when we are confronted with non-tubal types of ectopic pregnancy, like broad ligament pregnancy, the exploratory method of laparotomy still could be safely employed in appropriate case management.

CRediT authorship contribution statement

M B, A B, and H M were responsible for the patient's diagnosis and clinical management. M B wrote the manuscript. S B, M M H, and J K contributed to the analysis, supervision, writing, reviewing, and editing of the manuscript for intellectual content. All authors have read and approved the final manuscript.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethics approval has been obtained to proceed with the current study.

Guarantor

The corresponding author is the guarantor of submission.

Declaration of Generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the authors did not utilize any generative AI or AI-assisted technologies.

Funding

None.

Declaration of competing interest

The authors declare no conflict of interest.

Data availability

Supporting material is available if further analysis is needed.