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Broad Ligament Pregnancy

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Chapter
Broad Ligament Pregnancy
SteliosFiorentzis, TheodorosMargetousakis,
ChrysostomosGeorgellis, PantelisKotridis,
DimitraOikonomopoulou, AlexandrosKaramperis,
GeorgiaKaramperi-Sotiropoulou and DionysiosKaravyrakis
Abstract
An ectopic pregnancy implanted between the leaves of the broad ligament is a
challenge to diagnose and manage. It can be found in almost any week of pregnancy,
and it can present with a great spectrum of symptoms. This makes it necessary
for the clinician to keep a high level of alertness and suspicion for this uncom-
mon diagnosis and to be prepared when treating any ectopic pregnancy with poor
response to medical treatment. The broad ligament surrounds a number of ana-
tomical structures, structures necessary to be preserved when removing the ectopic
pregnancy. This can be a challenge for the surgeon, especially when the patient
presents with severe symptoms and the pregnancy is advanced. In these cases, even
hysterectomies have been reported, a severe operation especially when the patient
is young and without having completed her family planning. Finally, in the last
three decades with the increasing widespread of laparoscopy and the added experi-
ence, there is a growing effort to manage these ectopic pregnancies with minimally
invasive procedures, offering the patient a faster recovery, minimum blood loss, and
lower surgical morbidity.
Keywords: broad ligament, ectopic pregnancy, abdominal pain, laparotomy,
laparoscopy, hysterectomy
1. Introduction
One of the rarest places of an ectopic pregnancy to be implanted is between the
leaves of the broad ligament. Loschge in 1816 made the first known report of a broad
ligament pregnancy [1], while Champion etal. in 1938 published a large series of 62
cases [2]. Kennedy in 1925, after recording one broad ligament pregnancy among 613
ectopic cases, calculated the incidence of intraligamentary pregnancy as 1 for every
183,900 pregnancies [3]. Even today when the medical literature is so extended and
continuing, the exact incidence of this rare type of ectopic pregnancy is difficult
to be exactly calculated. The extensive use of assisted reproductive technology has
made even more difficult tracking every case. The rarity of ectopic pregnancies in
the broad ligament makes it challenging for the clinician to diagnose, and it needs a
high index of suspicion. In most of cases the diagnosis is done during an operation
for treatment of a presumed ruptured tubal pregnancy. Despite the fact that most
cases are diagnosed in the first trimester of pregnancy, there are a few cases reported
that the diagnosis was not made until the third trimester and the final outcome was a
Non-tubal Ectopic Pregnancy
2
live birth. The rarity of these cases also makes it impossible to find extensive series of
patients so as to determine the best treatment, making the clinician rely on previous
case reports and the methods used in other treated cases.
2. Anatomy
The broad ligament of the uterus is a double-layer fold of peritoneum (anterior
and posterior leaves) extending from each side of the uterus to the lateral pelvic walls
and the pelvic floor. It covers the lateral uterine corpus and the upper cervix as well.
The structures within the broad ligament (uterine tubes, ovarian artery, uterine
artery, ovarian ligament, round ligament of the uterus, suspensory ligament of the
ovary, ovary) are considered retroperitoneal. The broad ligament itself is composed of
visceral and parietal peritonea that contain smooth muscle and connective tissue [4, 5].
3. Pathophysiology
The way the trophoblast can be implanted retroperitoneally is still not clear.
Broad ligament pregnancies are classified as abdominal ectopic pregnancies and can
be further classified as primary or secondary. Many of them are considered to have
started as a tubal or ovarian pregnancy, which later ruptured intraperitoneally and
was implanted again in another location [6]. Studdiford in 1942 [7] suggested three
criteria, later modified by Friedrich and Rankin [8], for the diagnosis of a primary
peritoneal pregnancy, (i) normal tube and ovaries with no evidence of recent or
remote surgery, (ii) absence of any uteroperitoneal fistula, and (iii) the presence
of a pregnancy related exclusively to the peritoneal surface and young enough to
eliminate the possibility of secondary implantation following a primary nidation in
the tube.
Sotus in 1977, in a case report of a retroperitoneal ectopic pregnancy, hypothe-
sized that an ectopic trophoblast could invade and penetrate the peritoneum, which
soon thereafter covered the gestational tissues [9].
Another possible way for retroperitoneal implantation is during the embryo
transfer in IVF, with uterine perforation and direct retroperitoneal placement. The
arguments against this proposal are based on the softness and the flexibility of the
catheters used for embryo transfer [7]. Another argument against this mechanism
that has been reported is a broad ligament pregnancy after an ultrasound-guided
embryo transfer [11].
The above proposals cannot explain how a broad ligament pregnancy can occur
in a patient with bilateral salpingectomy. The possibility of a microscopic fistulous
tract through which the transferred embryos entered the abdominal cavity has also
been proposed by Fisch etal. in 1996 [10]. Apantaku etal., also in 1996, proposed
the possibility of recanalization of a fallopian tube stump in a patient with bilateral
salpingectomy [11].
Fisch etal. made another proposal trying to explain a reported broad ligament preg-
nancy. They suggested that the spermatozoa could enter the abdominal cavity through
a cornual fistulous tract and fertilize an oocyte already migrated there. This proposal
was made when trying to explain a broad ligament pregnancy to a patient with bilateral
salpingectomy who had intercourse the day after follicular aspiration [10].
Finally it has to be mentioned that Deshpande etal. in 1999 reported a twin
pregnancy in the broad ligament to a patient who underwent invitro fertilization
[12], while in 2001, Phupong etal. reported a twin pregnancy in the broad ligament
after spontaneous conception [13].
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DOI: http://dx.doi.org/10.5772/intechopen.88986
4. Symptoms
There is a wide range of symptoms which can lead a patient to seek help and find
out that she is pregnant with an ectopic pregnancy. Most of the symptoms are the
same as for every other ectopic pregnancy, with abdominal pain and vaginal bleed-
ing to be the most prominent. The abdominal pain can be severe and of sudden
onset [14] or intermittent and associated with other symptoms [15]. The pain can
also be characterized as “mild” or “moderate” [16, 17] or just a “discomfort” [18],
or finally it can be gradually increased in intensity [19]. The location of the pain has
also to be reported to be related with the side of the ectopic pregnancy [19–21]. The
duration of the pain can also vary between different cases, with even an extreme
case of 4months of intermittent pain to have been reported [22]. Finally it is not
unusual for a broad ligament pregnancy to be completely asymptomatic and to be
found during an early routine visit [11, 12].
The vaginal bleeding, if present, can also be of different severities. Cases with
just vaginal spotting [21, 23, 24] have been reported, while in other reported cases,
vaginal bleeding was present and more severe [22, 25–31], leading the patient to
seek medical assistance.
Other symptoms that have been reported in an early broad ligament pregnancy
include nausea [20, 24, 32], chills and fever [20], vomiting [20, 28], and dysuria
[15]. These symptoms can be present alone or accompanying others, with various
severities and to be evaluated as important or of no importance by the patient.
Despite the modern techniques and progress, there are places (more often in the
developing world) where a pregnant woman cannot have access to proper antenatal
care, making possible for an intraligamentary pregnancy to advance. In such a case,
it is possible for the pregnant woman to seek help because of inability to perceive
fetal movement [33, 34] or to be referred to a more specialized hospital due to
severe oligamnion [35, 36] or intrauterine growth retardation [35]. Abdominal pain
and vaginal bleeding are other possible symptoms for an advanced intraligamentary
pregnancy like any other ectopic pregnancy.
It is also possible for a broad ligament pregnancy to have no symptom at all and
to be found during a routine visit. Suchánková etal. reported a case where a patient
with bilateral salpingectomy was referred to hospital from an assisted reproduction
center to solve suspicion of molar intrauterine pregnancy, while the ultrasound
and the following laparoscopy revealed a right broad ligament pregnancy [37].
Apantaku etal. in 2006 presented a case where a broad ligament pregnancy was
discovered during a routine visit of a patient who had an IVF 6weeks earlier [11],
while Deshpande etal. in 1999 presented the first case of a twin broad ligament
pregnancy 7weeks after IVF [12]. Siow etal. in 2004 reported a case of a 10-week
asymptomatic woman who presented for routine antenatal care and was found with
a right adnexal mass and empty uterus. This was also the first published broad liga-
ment pregnancy which was managed laparoscopically [38]. Laparoscopy was also
used to treat another case presented by Cosentino etal. in 2017 of an asymptomatic
woman who presented to be submitted to a noninvasive prenatal diagnosis proce-
dure and was found to have a broad ligament pregnancy [39].
Finally there have been reported cases where the pregnancy went uneventfully
until term. Seckin etal. in 2011 reported a case with a primigravid patient who
was admitted due to breech presentation and oligamnion. Because of the breech
presentation, they decided to proceed with primary cesarean section, where an
unruptured gestational sac was found between the layers of the broad ligament with
both adnexa being normal [36]. In another case report by Schramm in 1982, a case
of a patient who presented with pains every 4–5minutes for 1hour was described.
Another three mild contractions the next 90minutes were recorded, and after that
Non-tubal Ectopic Pregnancy
4
it was difficult to identify the fetal lie and a definite uterine outline. Emergency
laparotomy was carried out, and the placenta was found to be attached to the ante-
rior layer of the broad ligament [40]. The above cases were with favorable result;
both mother and child survived through gestation and birth. Rakotomahenina etal.
in 2014 reported a post-term pregnancy in the right broad ligament. The patient was
not followed up during gestation and presented to the hospital at the 44th week.
The fetus was dead in transversal position and was extracted from the right broad
ligament by laparotomy [41]. This case showed that a broad ligament pregnancy can
reach term without any serious symptoms.
From the above it can be concluded that a broad ligament pregnancy can present
with a variety of symptoms or no symptom at all. When preparing for an opera-
tive solution for an ectopic pregnancy, the clinician must be prepared for this rare
presentation, and it needs a high level of suspicion. When conservative manage-
ment with methotrexate is chosen for an ectopic pregnancy and does not have the
expected results, broad ligament pregnancy should also be part of the differential
diagnosis.
5. Diagnosis
The diagnosis of an ectopic pregnancy located in the broad ligament is difficult
to be established preoperatively. In most cases the broad ligament diagnosis is done
during the operation for a misdiagnosed tubal pregnancy, which can be either by
laparotomy or laparoscopy. In this case the pregnancy can be found laterally to the
uterus, medial to the pelvic side walls, superior to the pelvic floor, and inferior to
the fallopian tube [42].
Ultrasound, transvaginal or abdominal, is the method of choice to identify the
location of an ectopic pregnancy. If finding the site of an ectopic pregnancy is dif-
ficult, the easiest way to rule out an ectopic pregnancy is to identify an intrauterine
one [43], something almost 100% possible in a gestation greater than 5,5weeks [44,
45]. An empty uterus with positive pregnancy test and the presence of a gestational
sac or mass outside the uterus gives high suspicion for ectopic pregnancy [46]. A
broad ligament pregnancy can grow significantly before giving any symptoms [47],
in which the size can lead to distorted anatomy and increased difficulty in making
an accurate diagnosis [48]. Phupong etal. in 2003 based on an empty uterus, a mass
with a single viable fetus in a gestational sac located just beside the right side of the
lower part of the uterus, and the clinical findings and their experience in a previ-
ous managed case, they reported a correct preoperative diagnosis by transvaginal
ultrasound [31]. These two findings (empty uterus and an ectopic pregnancy mass
just beside the lower part of the uterus when using transvaginal ultrasound) are
two suggested ultrasonographic clues which can make the clinician suspect a broad
ligament pregnancy [31]. Also in 2001 Sharma etal. reported that they managed
to diagnose preoperatively a broad ligament pregnancy based on the anterior place
with peritoneal reflection of the placenta combined with free fluid in the abdominal
cavity and a bulky with thick endometrium uterus [28]. Allibone etal. in 1981 [49]
suggested six criteria in order to assist the identification of an abdominal preg-
nancy: (a) demonstration of a fetus in a gestational sac outside the uterus, or the
depiction of an abdominal or pelvic mass, identifiable as the uterus, separate from
the fetus [49, 50], (b) failure to see a uterine wall between the fetus or products of
conception and the urinary bladder, (c) recognition of a close approximation of
fetal parts to the maternal abdominal wall, or gestational products like the placenta,
both features alerting the sonographer to the absence of enveloping uterine walls,
(d) demonstration of eccentric position and/or abnormal attitude of the fetus, (e)
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Broad Ligament Pregnancy
DOI: http://dx.doi.org/10.5772/intechopen.88986
localization of the placenta outside the confines of the uterine cavity, (f) visual-
ization of the placenta immediately adjacent to the fetal chest and head with no
intervening amniotic fluid [51]
Magnetic resonance imaging (MRI) can offer great help to the diagnosis of an
ectopic pregnancy, especially when then location is unknown. MRI can also offer
valuable information for the preoperative planning so as to avoid cutting in the
placenta and reduce the bleeding during surgery [52, 53]. MRI can also highlight
the involvement of pelvic structures and organs in an ectopic pregnancy, providing
more helpful data to the preoperative planning [46]. Finally, it is also important to
remember the contraindication of some contrast agents in pregnancy, which has to
be considered when the life of the mother is at risk. In any case an informed consent
should be obtained by the patient [54].
Angiogram is another tool which can prove its usefulness preoperatively, in
order to reveal the location of the placental vessels, while embolization and pre- or
postoperative can be used to control hemorrhage. Embolization could also be
used for difficult-to-reach vessels intraoperatively [49, 55], although the location
of a broad ligament pregnancy and the fact that such a pregnancy as often as not
presents with acute abdomen limit the possible use of the above techniques.
6. Management
The rarity of this type of ectopic pregnancy makes it impossible to have prospec-
tive trials so as to conclude the best possible treatment. The reported cases that
already can be found in the international medical literature can propose different
management options [56], taking into consideration the different means every
managing clinician can use.
Broad ligament pregnancies are difficult to be diagnosed before the time of
surgical management. Therefore, methotrexate cannot be considered the first-line
treatment for these conditions but may have been initiated if diagnosed incor-
rectly as tubal pregnancies [22, 57]. Despite that, Direkvand-Moghadam etal. in
2015 reported a case where they treated a left broad ligament pregnancy with a
single dose of methotrexate in a patient with left abdominal pain, 33days since last
menstrual period, β-hcg=212IU.L, and no abnormal sonographic findings. The
maximum level of β-hcg was 659IU.L, the forty sixth day after the last menstrual
period, and returned to normal 3weeks after the injection [21].
The way a patient with broad ligament pregnancy presents (abdominal pain in
the first trimester) makes it very difficult to follow conservative treatment in order
to achieve a favorable result such a live birth. Cachón López et al. in 1989 reported
such a case of an 18-year-old woman diagnosed with a 30.4week abdominal preg-
nancy. The diagnosis was established by clinical and imaging tests. They decided
to keep the patient under close surveillance for 2weeks and to induce fetal lung
maturation. At 32.4weeks of gestation, a laparotomy was performed giving birth
to a 1.100gr baby. The placenta was found on the surface of the anterior leaf of the
broad ligament and was removed together with the right salpinx [58].
Laparoscopic management of a broad ligament pregnancy is not impossible, and
it has many advantages as shown by the laparoscopic management of abdominal
pregnancies in other unusual sites. These advantages include the faster recovery of
the patient, the lower surgical morbidity, and the better control of the blood loss
[38]. It can be considered when the size is small [23, 59] and the patient stable. The
presence of proficient laparoscopists and the option to convert to laparotomy at
any time are also crucial [38]. Olsen in 1997 reported the first case of a successful
laparoscopic management of a broad ligament pregnancy [23], while in 2004 Siow
Non-tubal Ectopic Pregnancy
6
etal. reported a successful laparoscopic management of a pregnancy presenting
with a 6.5cm mass. Siow etal. injected vasopressin into the broad ligament before
starting the excision, the pregnancy was removed, and the surgery was completed
uncomplicated [38]. Since then there has been an increase in the reports of broad
ligament pregnancies which were managed with laparoscopy [11, 17, 24, 25, 30,
60–62], while Mo etal. in 2018, in the case they reported, managed laparoscopically
a broad ligament pregnancy with a hemoperitoneum of about 2800ml. In most
cases coagulation was used to control the breeding. Cheung etal. in 2014 reported
that they needed to use three 1-0 Biosyn stitches in order to close the implantation
site inside the broad ligament, so as to control the bleeding [17], while Kar in 2012
used superficial infiltration of Pitressin (vasopressin) so as to control the hemor-
rhage from the base [62]. Finally in a case report by Yang etal. in 2017, they used
absorbable hemostatic cellulose which was inserted into the retroperitoneal space in
order to prevent bleeding [63].
Despite the extensive use of laparoscopy and the willingness to treat an ectopic
pregnancy with more conservative ways, explorative laparotomy is still the way
most cases are treated. The presentation to the hospital—most common with
abdominal pain—of a missed broad ligament pregnancy plays an important role to
this. Laparotomies have been reported in order to treat a wide spectrum of broad
ligament pregnancies, starting with 5weeks of amenorrhea [60], till broad ligament
pregnancies at term [15, 36] which were admitted for an emergency cesarian sec-
tion. Finally a case of a post-term broad ligament pregnancy has been reported [41].
In the published medical literature, different outcomes for women who under-
went laparotomy or laparoscopy for a broad ligament pregnancy can also be found.
There have been reported cases where the size of the pregnancy made it possible to
be removed without any damage to the surrounding organs [1012, 14, 15, 17, 19–26,
33, 36–38, 41, 60–62, 64–66], where in other cases salpingectomy [18, 27, 31, 32, 40,
56, 58, 67], oophorectomy [30], or salpingo-oophorectomy [28, 34, 35, 39] was nec-
essary to be performed due to the damage these organs presented. There have also
been reported cases where the need for hysterectomy presented [20, 29, 40, 68],
and finally in a report by Wolfe and Neigus in 1953, among three cases reported, the
two patients died [20]. The above show that a broad ligament pregnancy can be a
life-threatening situation or a cause of a serious disability, especially when exci-
sion of ovaries or the uterus is a necessity in order to save the patient. It also makes
it necessary to inform the patient before the operation of the possible outcomes,
especially when the suspicion of a broad ligament pregnancy is present.
Finally, the fact that a missed broad ligament pregnancy can present from an
early week of amenorrhea or it can reach term and post-term, with a great range
of symptoms (from none to very acute) makes the broad ligament pregnancy part
of the differential diagnosis of nearly every pregnant woman presenting to the
emergency room, no matter in which week of pregnancy she is. In the case that a
broad ligament pregnancy is considered to be a possibility, it is important for the
managing surgeon to gather the best available team. Because of the complexity of
these cases, this team cannot be limited to gynecologists but should also include—if
possible—general surgeons, urologists, and interventional radiologists. Each one of
them can play an important role to the management of a broad ligament pregnancy
depending on the size of the pregnancy and the damage to the surrounding organs.
7. Conclusions
An ectopic pregnancy located between the leaves of the broad ligament is a rare
but possibly life-threatening presentation of an ectopic pregnancy. The fact that it
7
Broad Ligament Pregnancy
DOI: http://dx.doi.org/10.5772/intechopen.88986
can be easily missed is it can cause worrying symptoms in any week of pregnancy,
or it can go uneventful till term makes it a possibility in differential diagnosis of
almost every pregnant woman presenting to the emergencies. The diagnosis preop-
eratively is also difficult to be established. MRI can play an important role if there
is ultrasound suspicion for a broad ligament pregnancy. It must also be mentioned
that, although there is growing need to manage ectopic pregnancies with minimal
invasive techniques, methotrexate cannot be considered a first-line treatment for
this type of ectopic pregnancy. On the other hand, there are numerous reports, and
becoming more often every year, of broad ligament pregnancies managed laparo-
scopically. Finally, every gynecologist or surgeon who must operate a woman with a
suspicion of a broad ligament pregnancy must provide the patient the best informa-
tion for possible excision of organs crucial to reproduction.
Author details
SteliosFiorentzis1, TheodorosMargetousakis2, ChrysostomosGeorgellis3,
PantelisKotridis4, DimitraOikonomopoulou5, AlexandrosKaramperis6,
GeorgiaKaramperi-Sotiropoulou7 and DionysiosKaravyrakis1*
1 Department of Obstetrics and Gynecology, General Hospital of Sitia, Greece
2 Department of General Surgery, General Hospital of Sitia, Greece
3 Department of Urology, University Hospital of Alexandroupolis, Greece
4 Department of Obstetrics and Gynecology, General Hospital of Kalymnos, Greece
5 Department of Obstetrics and Gynecology, Alexandra Hospital, Athens, Greece
6 Department of Obstetrics and Gynecology, Elefsina General Hospital, Greece
7 Health Center Kalyvion, Saronikos, Greece
*Address all correspondence to: dkaravyrakis@gmail.com
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
8
Non-tubal Ectopic Pregnancy
[1] Loschge. Beschreibung einer
merkwuerdigen schwangerschaft
innerhalb des breiten mutterbandes. Arch
Fuer Medizinische Erfahrung. 1818;2:218
[2] Champion PK, Tessitore NJ.
Intraligamentary pregnancy. American
Journal of Obstetrics and Gynecology.
1938;36(2):281-293. Available from:
https://linkinghub.elsevier.com/
retrieve/pii/S0002937838910002
[3] Kennedy WT.Intraligamentous
pregnancy. American Journal
of Obstetrics and Gynecology.
1925;10(6):858-862. Available from:
https://linkinghub.elsevier.com/
retrieve/pii/S0002937825904632
[4] Bajowa Edozien GY.Sexual offenses,
adult: Normal anogenital anatomy
and variants. In: Encyclopedia of
Forensic and Legal Medicine [Internet].
2nd ed. Cambridge, Massachusetts:
Elsevier; 2016. pp.286-311. Available
from: https://linkinghub.elsevier.com/
retrieve/pii/B9780128000342000744
[5] Chiva LM, Magrina J.Abdominal
and pelvic anatomy. In: Principles
of Gynecologic Oncology Surgery
[Internet]. Philadelphia: Elsevier;
2018. pp.3-49. Available from: https://
linkinghub.elsevier.com/retrieve/pii/
B978032342878100002X
[6] Ouassour S, Filali AA, Raiss M,
Bezad R, Tazi Z, Alami MH, etal.
Retroperitoneal ectopic pregnancy:
Diagnosis and therapeutic
challenges. Case Reports in Surgery.
2017;2017:9871865. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/29201485
[7] Studdiford WE.Primary peritoneal
pregnancy. American Journal
of Obstetrics and Gynecology.
1942;44(3):487-491. Available from:
https://linkinghub.elsevier.com/
retrieve/pii/S0002937842904885
[8] Friedrich EG, Rankin CA.Primary
pelvic peritoneal pregnancy. Obstetrics
and Gynecology. 1968;31(5):649-653.
Available from: http://www.ncbi.nlm.
nih.gov/pubmed/5646396
[9] Sotus PC.Retroperitoneal ectopic
pregnancy: A case report. JAMA.
1977;238(13):1363-1364. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/578188
[10] Fisch B, Peled Y, Kaplan B, Zehavi S,
Neri A.Abdominal pregnancy following
invitro fertilization in a patient with
previous bilateral salpingectomy.
Obstetrics and Gynecology. 1996;88(4
Pt 2):642-643. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/8841236
[11] Apantaku O, Rana P, Inglis T.Broad
ligament ectopic pregnancy following
in-vitro fertilisation in a patient with
previous bilateral salpingectomy.
Journal of Obstetrics and Gynaecology.
2006;26(5):474. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/16846888
[12] Deshpande N,Mathers A,
Acharya U.Broad ligament twin
pregnancy following in-vitro
fertilization. Human Reproduction.
1999;14, 3:852-854. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/10221727
[13] Phupong V,Tekasakul P,
Kankaew K.Broad ligament twin
pregnancy. A case report. The
Journal of Reproductive Medicine.
2001;46(2):144-146. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/11255815
[14] Hatada Y.The pedunculated type
of primary peritoneal pregnancy
implanted on the infundibulopelvic
ligament. Obstetrics and Gynecology.
References
9
Broad Ligament Pregnancy
DOI: http://dx.doi.org/10.5772/intechopen.88986
1993;82(4 Pt 2 Suppl):693-695. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/8378016
[15] Dahab AA, Aburass R, Shawkat W,
Babgi R, Essa O, Mujallid RH.Full-term
extrauterine abdominal pregnancy:
A case report. Journal of Medical
Case Reports. 2011;5:531. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/22040324
[16] Badr S, Ghareep A-N, Abdulla LM,
Hassanein R.Ectopic pregnancy
in uncommon implantation sites.
Egyptian Journal of Radiology and
Nuclear Medicine. 2013;44(1):121-
130 Available from: https://
linkinghub.elsevier.com/retrieve/pii/
S0378603X1200099X
[17] Cheung CS, Cheung VYT. Broad
Ligament Ectopic Pregnancy. CRSLS
MIS Case Reports from SLS [Internet].
2014;18(4):1-5. Available from: http://
crsls.sls.org/2014-00102
[18] Khare V, Shrivastava S, Mishra K.An
unusual presentation of live fetus in
broad ligament: A case report. Journal
of Evolution of Medical and Dental
Sciences. 2014;3(01):223-225. Available
from: http://www.jemds.com/data_pdf/
Drveena khare.pdf
[19] AudifredSalomón JR,
Herrera Ortiz A, González
Medrano MG, Estrada Rivera SF.Ectopic
intraligamentary pregnancy.
Ginecología y Obstetricia de México.
2013;81(4):211-214. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/23720935
[20] Wolfe SA, Neigus I.Broad-ligament
pregnancy with report of three early
cases. American Journal of Obstetrics
and Gynecology. 1953;66(1):106-117.
Available from: http://www.ncbi.nlm.
nih.gov/pubmed/13057986
[21] Direkvand-Moghadam A,
Direkvand-Moghadam A.Broad ligament
ectopic pregnancy: A case report. Der
Pharmacia Lettre. 2015;7(10):1-4
[22] Zu M, Zhao GQ , Liu ZQ , Zhang HT,
Chen L, Zhao DH.A case report of a
patient with high β-hCG levels after
operation because of primary broad
ligament pregnancy. Clinical and
Experimental Obstetrics & Gynecology.
2017;44(1):138-142. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/29714884
[23] Olsen ME.Laparoscopic treatment
of intraligamentous pregnancy.
Obstetrics and Gynecology. 1997;89(5
Pt 2):862. Available from: http://www.
ncbi.nlm.nih.gov/pubmed/9166356
[24] Nayar J, Nair SS.Broad ligament
pregnancy—Success story of a
laparoscopically managed case. Journal
of Clinical and Diagnostic Research.
2016;10(7):QD04-QD05. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/27630914
[25] Cormio G, Ceci O, Loverro G,
Bettocchi S.Spontaneous left broad
ligament pregnancy after ipsilateral
salpingo-oophorectomy. Journal
of Minimally Invasive Gynecology.
2006;13(2):84-85. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/16527706
[26] Kutlesic R, Lukic B,Kutlesic M,
Popovic J, Stefanovic M, Vukomanovic P,
etal. Unruptured retroperitoneal
pregnancy implanted in the left broad
ligament: A case report. Vojnosanitetski
Pregled. 2017;74(2):177-183. Available
from: http://www.doiserbia.nb.rs/
Article.aspx?ID=0042-84501600160K
[27] Hameed J, Radhika, Haseena,
Lakshmi S, Jaisree, Ahamed N.A
case of broad ligament pregnancy.
International Journal of Scientific Study.
2014;2(4):77-79
[28] Sharma S,Pathak N,Goraya S,
Mohan P.Broad ligament ectopic
Non-tubal Ectopic Pregnancy
10
pregnancy. Sri Lanka Journalof Obstetrics
and Gynaecology.2012;33(2):60.
Available from: https://sljog.sljol.info/
article/10.4038/sljog.v33i2.4008/
[29] Atalla RK, Murphy PC,
Balachandar C.Combined intrauterine
and broad ligament ectopic pregnancy.
Journal of Obstetrics and Gynaecology.
1997;17(2):203. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/15511824
[30] Cho YK, Henning S, Harkins G.
Broad ligament ectopic pregnancy
after bilateral tubal ligation.
Journal of Minimally Invasive
Gynecology. 2018;25(2):314-315.
Available from: https://linkinghub.
elsevier.com/retrieve/pii/
S1553465017302212
[31] Phupong V,Lertkhachonsuk R,
Triratanachat S, Sueblinvong T.
Pregnancy in the broad ligament.
Archives of Gynecology and Obstetrics.
2003;268(3):233-235. Available from:
http://link.springer.com/10.1007/
s00404-002-0352-1
[32] Kobak AJ, Levine L.Interstitial
pregnancy developing into the
broad ligament. American Journal
of Obstetrics and Gynecology.
1952;63(3):684, 6. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/14902990
[33] Gupta A, Mahajan N,
Verma D, Sharma C, Rattan A,
Gupta B.Broad ligament
pregnancy a diagnostic dilemma: A
case report. International Journal
of Reproduction, Contraception,
Obstetrics and Gynecology. 2016:
2478-2480. Available from: http://www.
ijrcog.org/index.php/ijrcog/article/
view/1388
[34] Ade-Ojo IP,Akintayo AA,
Afolayan JM, Aduloju OP,
Olagbuji BN.Intraligamentary extrauterine
pregnancy delivered at term: A case
report and review of literature.
African Journal of Reproductive
Health. 2016;20(1):104-108. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/29553183
[35] Sheethal CH, Powar A.Full term
viable secondary broad ligament
pregnancy—A rare case. Case reports
womens Heal. 2017;13:4-5. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/29593985
[36] Seckin B, Turkcapar FA, Tarhan I,
Yalcin HR.Advanced intraligamentary
pregnancy resulting in a live birth.
Journal of Obstetrics and Gynaecology.
2011;31(3):260-261. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/21417654
[37] Suchánková E, Pavlásek J,
Bydžovská I, Lubušký M.Abdominal
pregnancy at a patient after cesarean
section, bilateral salpingectomy and
embryotransfer. Ceskoslovenská
Gynekologie;82(2):122-125. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/28585844
[38] Siow A, Chern B, Soong Y. Successful
laparoscopic treatment of an abdominal
pregnancy in the broad ligament.
Singapore Medical Journal. 2004;45(2):88-
89. Available from: http://www.ncbi.nlm.
nih.gov/pubmed/14985849
[39] Cosentino F, Rossitto C, Turco LC,
Gueli Alletti S, Vascone C, Di Meglio L,
etal. Laparoscopic management of
abdominal pregnancy.
Journal of Minimally Invasive
Gynecology;24(5):724-725. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/28179200
[40] Schramm M.Advanced
intraligamentary pregnancy: A report of
2 cases. The Australian & New Zealand
Journal of Obstetrics & Gynaecology.
1982;22(4):240-242. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/6963166
11
Broad Ligament Pregnancy
DOI: http://dx.doi.org/10.5772/intechopen.88986
[41] Rakotomahenina H,
Andrianampy HA, Ramamonjinirina P,
Solofomalala GD, Brun J-L.Post-term
pregnancy in the broad ligament.
Gynécologie, Obstétrique &
Fertilité;42(7-8):537-539. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/24927650
[42] Dolinko AV, Vrees RA,
Frishman GN.Non-tubal ectopic
pregnancies: Overview and treatment
via local injection. Journal of Minimally
Invasive Gynecology. 2018;25(2):287-
296. Available from: https://
linkinghub.elsevier.com/retrieve/pii/
S1553465017303953
[43] Gracia C.Diagnosing ectopic
pregnancy: Decision analysis
comparing six strategies. Obstetrics
and Gynecology. 2001;97(3):464-
470 Available from: http://
linkinghub.elsevier.com/retrieve/pii/
S0029784400011595
[44] Goldstein SR,Snyder JR,
Watson C, Danon M.Very early
pregnancy detection with endovaginal
ultrasound. Obstetrics and Gynecology.
1988;72(2):200-204. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/3292977
[45] Timor-Tritsch IE, Yeh MN,
Peisner DB, Lesser KB, Slavik TA.The
use of transvaginal ultrasonography
in the diagnosis of ectopic pregnancy.
American Journal of Obstetrics and
Gynecology. 1989;161(1):157-161.
Available from: http://www.ncbi.nlm.
nih.gov/pubmed/2665494
[46] Agarwal N, Odejinmi F.Early
abdominal ectopic pregnancy:
Challenges, update and review of
current management. The Obstetrician
and Gynaecologist. 2014;16(3):193-
198. Available from: http://doi.wiley.
com/10.1111/tog.12109
[47] Worley KC,Hnat MD,
Cunningham FG. Advanced
extrauterine pregnancy: Diagnostic
and therapeutic challenges. American
Journal of Obstetrics and Gynecology.
2008;198(3):297.e1-297.e7. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/18313451
[48] Mausner Geffen E,Slywotzky C,
Bennett G.Pitfalls and tips in the
diagnosis of ectopic pregnancy.
Abdominal Radiology.
2017;42(5):1524-1542 Available from:
http://link.springer.com/10.1007/
s00261-016-1020-4
[49] Allibone GW, Fagan CJ, Porter SC.
The sonographic features of intra-
abdominal pregnancy. Journal of
Clinical Ultrasound. 1981;9(7):383-387.
Available from: http://www.ncbi.nlm.
nih.gov/pubmed/6792237
[50] Washington L, Thompson HE.
Illustrated manual of ultrasonography
in obstetrics and gynecology. Journal
of Clinical Ultrasound. 1975;3(4):315-
316. Available from: http://doi.wiley.
com/10.1002/jcu.1870030420
[51] Garrett WJ, Ward JP, Kossoff G,
De Leon AH.Ultrasonic and
radiological investigation of abdominal
pregnancy. Australasian Radiology.
1975;19(4):334-337. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/1225294
[52] Malian V, Lee JH.MR imaging
and MR angiography of an abdominal
pregnancy with placental infarction.
American Journal of Roentgenology.
2001;177(6):1305-1306. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/11717071
[53] Ghaneie A, Grajo JR,Derr C,
Kumm TR. Unusual ectopic pregnancies.
Journal of Ultrasound in Medicine.
2015;34(6):951-962. Available
from: http://doi.wiley.com/10.7863/
ultra.34.6.951
[54] ACR Committee on Drugs and
Contrast Media. ACR Manual On
Non-tubal Ectopic Pregnancy
12
Contrast Media Version 10.3. 2018.
pp.95-98
[55] Radhakrishnan K.Radiological case:
Intra-abdominal pregnancy. Applied
Radiology. 2015:44-47
[56] Shamaash AH, Abbas AM.
Undiagnosed asymptomatic second
trimester broad ligament ectopic
pregnancy: A case report and mini-
review. Proceedings in Obstetrics and
Gynecology. 2016;7(1):1-8. Available
from: http://ir.uiowa.edu/pog/vol7/iss1/8
[57] Practice Committee of American
Society for Reproductive Medicine.
Medical treatment of ectopic pregnancy:
A committee opinion. Fertility and
Sterility. 2013;100(3):638-644. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/23849842
[58] Cachón López OR, Gasque
López F, Peniche Rodríguez R, Avila
Vergara MA.Abdominal pregnancy. Its
conservative management. A case report
with a live conceptus. Ginecología y
Obstetricia de México. 1989;57:73-75.
Available from: http://www.ncbi.nlm.
nih.gov/pubmed/2487306
[59] Pisarska MD,Casson PR,
Moise KJ, DiMaio DJ, Buster JE,
Carson SA.Heterotopic abdominal
pregnancy treated at laparoscopy.
Fertility and Sterility. 1998;70(1):159-
160. Available from: http://www.ncbi.
nlm.nih.gov/pubmed/9660440
[60] Sassi A, Dimassi K, Ben Slama S,
Triki A, Lahmar A.A broad ligament
pregnancy successfully managed by
laparoscopy. Journal of Obstetrics and
Gynaecology. 2018;38(3):423-424.
Available from: http://www.ncbi.nlm.
nih.gov/pubmed/28903610
[61] Mo X, Tang S, Zhou L-J-G-Y-K,
Li C.Management of ectopic pregnancy
in a broad ligament and recurrent
tubal pregnancy: A case report. Open
Journal of Obstetrics and Gynecology.
2018;08(05):431-436 Available from:
http://www.scirp.org/journal/doi.
aspx?DOI=10.4236/ojog.2018.85049
[62] Kar S.Primary abdominal
pregnancy following intra-uterine
insemination. The Journal of Human
Reproductive Sciences. 2011;4(2):95-99.
Available from: http://www.ncbi.nlm.
nih.gov/pubmed/22064787
[63] Yang M,Cidan L, Zhang D.
Retroperitoneal ectopic pregnancy:
A case report and review of the
literature. BMC Pregnancy and
Childbirth. 2017;17(1):358. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/29037192
[64] Mittal S,Chhabra P, Khanna R.
Advanced abdominal intraligamentary
pregnancy with live birth. International
Journal of Gynaecology and Obstetrics.
1994;46(3):327-328. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/7806005
[65] Paterson WG, Grant KA.Advanced
intraligamentous pregnancy. Report
of a case, review of the literature and a
discussion of the biological implications.
Obstetrical & Gynecological Survey.
1975;30(11):715-726. Available from:
http://www.ncbi.nlm.nih.gov/
pubmed/1187075
[66] Mittal S, Gupta V,Chawla D,
Pundir S.Broad ligament ectopic
pregnancy: A dilemma to diagnose.
International Journal of Reproduction,
Contraception, Obstetrics and
Gynecology. 2017;6(5):2109. Available
from: http://www.ijrcog.org/index.php/
ijrcog/article/view/2566
[67] Naeiji Z, Saleh M,Keshavarz E.
Broad ligament pregnancy: A case
report. International Journal of
Reproduction, Contraception, Obstetrics
and Gynecology. 2015;9:118-122
[68] Singh U, Singh N, Sankhwar P.Full-
term viable broad ligament pregnancy
13
Broad Ligament Pregnancy
DOI: http://dx.doi.org/10.5772/intechopen.88986
surgically managed with favorable
feto-maternal outcome. Journal of
Obstetrics and Gynaecology of India.
2012;62(Suppl 1):23-24. Available
from: http://www.ncbi.nlm.nih.gov/
pubmed/24293863
ResearchGate has not been able to resolve any citations for this publication.
Article
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Broad ligament pregnancy is a rare event and always delays in diagnosis. A pregnant woman in early twenties presented for our center. Routine ultrasonography revealed a first trimester abdominal pregnancy. Broad ligament pregnancy was diagnosed intraoperation and treated with laparoscopic resection successfully. The patient has a history of right tubal pregnancy 2 years ago and terminated with Laparoscopic Salpingostomy. According to the long term followed-up for the patient, we found that she had recurrent right tubal pregnancy 5 months after the broad ligment ectopic pregnancy. She received the salpingectomy laparoscopically. We presented the case to discuss the clinical management of broad ligament ectopic pregnancy and options of surgical treatments of tubal pregnancy to reduce the risk of recurrent.
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Background Retroperitoneal ectopic pregnancy is extremely rare. This unusual location represents a great challenge for clinicians due to the difficulties of diagnosis and high risk of life-threatening complications. Case Report We report the case of a spontaneous early pregnancy of undetermined location in a patient with a history of previous laparoscopic surgery. Diagnosis steps using clinical examination, ultrasound, and magnetic resonance imaging led to the localization of the pregnancy, in the left side of the para-aortic region, in the retroperitoneal space. Conclusion Retroperitoneal ectopic pregnancy is an uncommon entity with rather complex pathogenesis. Clinicians should carefully interpret clinical signs, biological findings, and imaging features and be aware of unusual locations such as the retroperitoneum for ectopic pregnancies. Early diagnosis and appropriate management strategy are conditio sine qua non for successful treatment outcomes.
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Background Retroperitoneal ectopic pregnancy (REP) is an extremely rare type of ectopic pregnancy, with a total of less than 20 cases reported in the English literature. However, failure to recognize REP may result in severe consequences. Case presentationWe report a case of 32-year-old woman with REP. She had amenorrhea, left lower abdominal pain, but no vaginal bleeding. Her urine human chorionic gonadotropin (HCG) test was positive and blood HCG level was 1880 m-international units per milliliter (mIU/mL). Transvaginal ultrasound sonography showed a left adnexal mass. Laparoscopy found an enlarged uterus, normal right uterine tube and ovary, and normal left uterine tube. The left ovary was partly covered by a blood clot, but appeared normal after removing the clot. There was a 10-mm circular peritoneal defect located lateral to the left sacrocervical ligament, anterior to the left ovarian fossa, and next to the lower edge of the left broad ligament. The patient was diagnosed of having REP with the gestational tissues covered by the peritoneum. The REP was removed by laparoscopic surgery. Bleeding was stopped by bipolar coagulation and absorbable hemostatic cellulose. The patient recovered smoothly and was discharged on the next day after surgery. Her blood HCG returned to normal range 29 days after surgery. ConclusionsREP is very rare, but in any suspected case of ectopic pregnancy, caution must be paid to find signs of REP when the common sites of ectopic pregnancy do not have any positive findings.
Article
Objective: Presentation of rare complication following the assisted reproduction at a patient after cesarean section and bilateral salpingectomy. Design: Case report. Settings: Department of Obstetrics and Gynaecology, Regional Hospital Liberec, a. s.; Department of Obstetrics and Gynaecology, Palacky University Hospital, Olomouc. Observation: Pregnant woman, 26-years old, primiparous, with history of cesarean section and bilateral salpingectomy, was referred from the assisted reproduction centre to solve suspicion of molar intrauterine pregnancy. This diagnosis was settled on the basis of ultrasound scan of uterine cavity and high level of human choriogonadotropine. Instrumental revision of uterine cavity was performed, however there was not consequently demonstrated any histological prove of the pregnancy tissue in uterine cavity and decrease of human choriogonadotropine values. The verifying ultrasound examination was made and then the suspicion of ectopic pregnancy on the right side of the uterus was expressed. Laparoscopy diagnosed ectopic pregnancy localized in the right broad ligament. It was treated by exstirpation of the pregnancy tissue. Conclusion: The diagnosis of ectopic pregnancy should be based on personal history, human choriogonadotropine level assessment and pelvic ultrasound examination. Although it's important to evaluate all the components globally, ultrasound examination is in a majority of cases the most important part for setting the right diagnosis.
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Ectopic pregnancies account for 1.5-2% of all pregnancy in the United States. Of these, approximately 10 percent implant in non-tubal locations, including the abdominal cavity, cervix, ovary, interstitial portion of the fallopian tube, broad ligament, the uterine cornua, or within a cesarean section scar. Because these pregnancies tend to present later than typical tubal pregnancies, they have been associated with greater maternal morbidity and mortality. Advances in ultrasound technology have allowed for earlier diagnosis of non-tubal ectopic pregnancies, which in turn has led to the development of novel minimally invasive techniques to manage them. One of these methods involves the local injection of one of several agents directly into the ectopic pregnancy. In this article, we provide a guide to this technique of local injection, including an overview of the potential agents that can be used, as well as review the diagnostic and specific ultrasound criteria, other possible treatment options, and overall outcomes for non-tubal ectopic pregnancies.
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Introduction: A broad ligament pregnancy is an extremely rare condition and diagnosis is frequently missed and finally made during laparotomy. This is a case of a young patient with high serum beta-human chorionic gonadotropin (β-hCG) levels after operation because of broad ligament pregnancy. Case report: A 31-year-old multipara complained of intermittent lower abdominal pain with vaginal bleeding for four months. A color ultrasonography revealed a cystic mass in the left attachment area, indicating an interstitial tubal pregnancy. However, trophoblastic disease could not be excluded. She accepted conservative treatment with methotrexate (MTX) at first, but observation showed that conservative treatment was slow and accompanied with liver function damage. Therefore, exploratory laparotomy was performed. Intraoperative situations and postoperative pathology confirmed broad ligament pregnancy. Her serum p- hCG was sustained at a high level for three months after operation. Her examinations of serum, CT, and ultrasonography could explain this situation. Conclusion: Primary broad ligament pregnancy refers to pregnancy where implantation of the fertilized ovum occurs directly between the two leaves of the broad ligament. The gravid substance was removed, however serum β-hCG could not gradually re- turn to normal levels. This case should be followed-up closely to prevent adverse outcomes.
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Broad ligament ectopic pregnancy is a rare and serious form of extrauterine pregnancy with a high risk of maternal mortality. There are no specific clinical features. Ultrasonography may help in diagnosis but definitive diagnosis is made only during surgery. A 20-year-old woman with previous 2 abortions presented with acute abdomen. She had no history of amenorrhoea but there was history of two episodes of bleeding in the last month at an interval of 14 days, each episode lasting for two-three days. The last episode of bleeding was 10 days back. Her urine pregnancy test was done and it was positive. There was marked abdominal tenderness with guarding and rigidity. Per vaginal examination revealed marked tenderness in the right fornix and cervical motion tenderness, uterus size could not be assessed due to tenderness. It was diagnosed as a case of ruptured ectopic pregnancy. Since she was haemodynamically unstable, emergency laparotomy was done. She had a right sided broad ligament ectopic pregnancy which had ruptured. The tissue was completely removed and haemostatic sutures were taken. High index of clinical suspicion, early diagnosis and prompt surgery is the key to management.