A 29-year-old pregnant woman (gravida 2, para 1) with a gestational age of 12 weeks by last menstrual period presented to the Department of Obstetrics and Gynecology for evaluation of possible bicornuate uterus, potential ectopic pregnancy, and dermoid cyst detected during routine ultrasonography. Her medical history was notable for 2 cesarean deliveries. The patient had no complaints of pain or discomfort but did report vaginal discharge with slight fetal movement. The patient’s β-human chorionic gonadotropin level was measured, and results were pending. An osteopathic structural examination was performed on the thoracic and lumbar spine in addition to the sacrum, which revealed that T1-9 was neutral, rotated right, sidebent left; T10-12, flexed, rotated right, sidebent right; L1-5, neutral, sidebent right, rotated left; and sacrum with a positive seated flexion test on the left and rotated to the right on a right oblique axis.
Results of a pelvic transvaginal sonogram revealed the presence of a gestational sac and positive fetal heart tones with an uncertain location, either within the left fallopian tube proximal to the uterus or to the left of the uterine fundus. A magnetic resonance image of the pelvis without contrast showed a 4.6-cm eccentrically located gestational sac to the left of the uterine fundus surrounded by an asymmetric, thin myometrial mantle consistent with an ectopic pregnancy of the cornua (
Figure).
Because of the size of the gestational sac, the potential location in the cornua, and the thinness of the uterine wall as evidenced by the magnetic resonance image, a diagnostic laparoscopy was ordered. At this time, this approach was preferred over open laparotomy because the patient was in stable condition without complaints of pain.
On the same day the patient presented to the Department of Obstetrics and Gynecology, she underwent laparoscopy. In the operating room, incisions were made in the abdomen, the abdomen was insufflated, and a camera was inserted to view the pelvic contents. The contents visualized were consistent with the MR image of a large ectopic pregnancy located in the left cornua of the uterus with a thin wall and a dermoid cyst. Because of the risk of rupture of the ectopic pregnancy and subsequent compromise to maternal health, the decision was made to convert to open laparotomy.
The slight manipulation of the uterus during the open procedure caused rupture of the uterine wall where the fetus was implanted with resultant spontaneous expulsion of the fetus. The remaining fetal tissue was evacuated and sent to the pathology department for testing. The dermoid cyst was removed from the overlying ovarian tissues using sharp and blunt dissection. The patient tolerated the remainder of the procedure well, and the rest of the hospital course was uneventful.