Concurrent Ruptured Ectopic Pregnancy and Appendicitis by cqe15118



Concurrent Ruptured Ectopic Pregnancy and
Nguyen Hien, MD, Khanh Le, MD, Connie Le, MD, and Hanh Nguyen, BS

The acute abdomen in pregnancy is a surgical               genic material in the uterine cavity consistent with
emergency requiring timely diagnosis and therapy           possible retained products of conception and ad-
to avoid potentially high maternal and fetal mor-          nexa within normal limits. The findings were dis-
bidity and mortality. Ectopic pregnancy and appen-         cussed with a radiologist, who stated that the ap-
dicitis are 2 causes of acute abdomen in pregnancy.        pendix could not be visualized because of the
We present a case of concurrent ruptured ectopic           surrounding echogenic material. In addition, the
pregnancy and appendicitis, and we review possible         concerns about possible ectopic pregnancy were
mechanisms that may underlie the pathogenesis of           articulated with the radiologist, who noted no ad-
the simultaneous existence of these conditions in a        nexal mass or free pelvic fluid suggestive of ectopic
patient.                                                   pregnancy. The initial impression was incomplete
                                                           abortion, for which dilation and curettage was per-
Case Report                                                formed. The patient was discharged from the hos-
A 30-year-old woman, gravida 3, para 2, presented          pital with instructions to follow up immediately if
to the emergency department with a 2-day history           she experienced fever, recurrent or worsening ab-
of dull, bilateral, lower quadrant abdominal pain          dominal pain, vomiting, or other systemic com-
radiating to the back. The patient had experienced         plaints.
vaginal spotting for 3 days and heavy bleeding for 1          The patient returned to the emergency depart-
day. The last reported menstrual period was 6              ment 1 week later with persistent right lower quad-
weeks before presentation. She denied fevers,              rant abdominal pain that had worsened severely
chills, vomiting, constipation, and diarrhea. Past         over the preceding 24 hours. There were associated
medical, obstetric, gynecological, and surgical his-       fever, chills, vomiting, and anorexia, but no vaginal
tories were remarkable only for 2 uncomplicated            bleeding. The patient’s vital signs included a tem-
live births, and no history of sexually transmitted        perature of 101.6°F, blood pressure of 90/60 mm
diseases or pelvic inflammatory disease.                    Hg, heart rate of 108 beats/min, and respiratory
   The patient’s vital signs included a temperature        rate of 20 breaths/min. The physical examination
of 98°F, blood pressure of 110/60 mm Hg, pulse of          was significant for rebound tenderness in the right
85 beats/min, and respiratory rate of 14 breaths/          lower quadrant and was positive for McBurney
min. Physical examination revealed a closed cervix,        point tenderness and psoas signs. Pelvic examina-
no cervical notion tenderness, and mild right ad-          tion revealed closed cervix without cervical motion
nexal tenderness. Serum level of -human chori-             tenderness and moderate right adnexal fullness and
onic gonadotropin ( hCG) was 20,000 IU/mL, and             tenderness. hCG was 500 IU/mL, and complete
complete blood cell count revealed 8.6 leukocytes/
                                                           blood cell count was significant for a leukocyte
mm3, hematocrit of 0.33, and platelet count of
                                                           count of 18,0000/mm3 with 89% polymorphonu-
220,000. A transvaginal sonogram revealed echo-
                                                           clear leukocytes and 10% bands, hematocrit of
                                                           0.30, and a platelet count of 350,000. Cervical and
   Submitted, revised, 29 October 2004.                    urine cultures were negative for infection. Trans-
   From the Department of Family Practice, George Wash-    vaginal sonogram revealed a right complex mass
ington University, Washington DC (NH, CL), the Depart-
ment of Family Practice, Howard University Hospital,       measuring 3       4 cm, minimal free fluid in the
Washington DC (KL), and Virginia Commonwealth Uni-         adnexa, and an empty sac. The findings were dis-
versity, School of Medicine, Richmond (HN). Address cor-
respondence to Dr. Nguyen Hien, 3808 Daniel’s Run          cussed with the radiologist, who stated that the
Court, Fairfax, VA 22030 (e-mail:       appendix could not be well visualized. Preoperative                                 Concurrent Ruptured Ectopic Pregnancy and Appendicitis   63
diagnosis of acute abdomen was made, and the           umented. Because of the potential for high mater-
patient was taken emergently to laparotomy, which      nal-fetal morbidity and mortality associated with
revealed a ruptured right fallopian tube, 500 mL of    either condition, the practitioner must be vigilant
surrounding organized blood clot, adhesions ex-        for these differential diagnoses in patients present-
tending from omentum to ascending colon, and a         ing with acute abdomen in pregnancy.
grossly inflamed appendix. Right salpingectomy,
appendectomy, lyses of adhesions, and evacuation       Diagnosis
of blood clot were performed without complica-         The difficulty in diagnosing the acute abdomen
tions.                                                 in pregnancy is in attributable in part to the
   In retrospect, sonographic findings at the initial   normal changes in physiologic and metabolic
visit were probably not accurately interpreted. The    states and anatomic distortions in pregnant pa-
echogenic material visualized on the initial trans-    tients.1,2 The leukocyte count and sedimentation
vaginal sonogram was probably reactive decidua         rate can be artificially elevated in the gravid state
and hemorrhage rather than products of concep-         in the absence of infection. The appendix is char-
tion. Pathologic examination of the resected seg-      acteristically pushed cephalad by the gravid
ment of appendix revealed edema and inflammation        uterus, so that typical signs of appendicitis, such
of the appendix without abscess formation, consis-     as McBurney point tenderness and psoas signs,
tent with early appendicitis. Pathology of the re-     may not be elicited.1,3,4 Although advances in
sected right fallopian tube revealed immature pla-     pelvic sonography by transvaginal and high fre-
cental tissue and villi consistent with ectopic        quency sonogram5 and highly sensitive tests for
pregnancy. Retrospective pathological review of          hCG have facilitated earlier diagnosis of ectopic
the specimen from the initial dilation and curettage   pregnancy before the onset of clinical symptoms,
revealed decidua without chronic villi, which was      differences in operator technique, and obscuring
not consistent with the earlier diagnosis of incom-    bowel and gas may render preoperative diagnosis
plete abortion. After surgery, the patient received    of appendicitis and/or ectopic pregnancy incon-
intravenous cefazolin (Ancef). She was discharged      clusive. A corollary of this is that lack of defini-
from the hospital in stable condition 3 days later     tive findings on sonography (such as free pelvic
with a prescription for oral antibiotics.              fluid, echogenic adnexal mass for ectopic preg-
                                                       nancy, and noncompressible appendix 6 mm
                                                       with free fluid for appendicitis), in the presence
Discussion                                             of high clinical suspicion from a complete history
Epidemiology                                           and physical examination, should not preclude a
Ectopic pregnancy has been rarely reported in con-     differential diagnosis including appendicitis and
junction with appendicitis; there are 22 such cases    ectopic pregnancy in the workup of acute abdo-
in the medical literature since 1960.1 We present a    men in a pregnant patient.1– 4
case in which a patient presented simultaneously           Our patient did not present with vaginal bleed-
with appendicitis and ipsilateral ruptured ectopic     ing at the latter visit, when she was diagnosed with
pregnancy. Abdominal pain that occurs during           ruptured ectopic pregnancy. This demonstrates
pregnancy is challenging to work up because of the     that ectopic pregnancy and appendicitis may not
broad range of differential diagnoses and distor-      always present with classic historical, physical ex-
tions of anatomic relationships by the gravid          amination, laboratory, and radiographic features,
uterus. Common gynecologic causes include ovar-        particularly in pregnancy. Diagnoses of appendici-
ian torsion, degenerating leiomyomata, ruptured        tis and ectopic pregnancy were entertained preop-
corpus luteum, pelvic inflammatory disease, and         eratively, but neither could be excluded by history,
tubo-ovarian abscess. As the most common cause of      physical, laboratory, and radiology examinations.
surgical pain in pregnant patients, appendicitis is    Because of the uncertainty in diagnosis, emergency
estimated to occur at an incidence of 1 per 1500       exploratory laparotomy was pursued, leading to the
pregnancies.1 Ectopic pregnancies occur at a fre-      surprising finding of concurrent ruptured ectopic
quency of approximately 16 per 1000 patients.          pregnancy and appendicitis. Therefore, in patients
However, only 22 previous cases of simultaneous        with acute abdomen in pregnancy in whom there is
ectopic pregnancy and appendicitis have been doc-      diagnostic uncertainty, a surgical approach through

64 JABFP January–February 2005       Vol. 18 No. 1                            
laparoscopy or laparotomy can be invaluable for         ectopic pregnancy and appendicitis have indicated a
diagnosis and therapy.1,2,6                             predilection for right tubal ectopic pregnancy
                                                        (75%) versus left tubal ectopic pregnancy (16%).1
Etiologic Inter-Relationships                           These observations are consistent with the possi-
The risk of ectopic pregnancy increases with pre-       bility for adjacent inflammation in right-sided ec-
vious ectopic pregnancy and conditions leading          topic pregnancy and appendicitis as a possible un-
to tubal damage and infertility such as pelvic          derlying pathogenic mechanism. Most of the cases
inflammatory disease, prior tubal surgery, and           above were characterized by the onset of symptoms
smoking.7 It is interesting that in vitro fertiliza-    in less than 1 week and the emergence of concur-
tion for tubal infertility has been reported in         rent ectopic pregnancy and appendicitis. Our case
conjunction with concurrent ectopic pregnancy           of ruptured ectopic pregnancy differs from previ-
and heterotopic pregnancy.2,6 Previous reports          ously reported cases of ectopic pregnancy, most of
have described possible underlying etiologic            which were unruptured.1
inter-relationships between ectopic pregnancy and
appendicitis.1,8,9 It is unknown whether appendici-
tis is coincidentally associated with ectopic preg-
                                                        In conclusion, one must be vigilant for the pos-
nancy or is a possible risk factor for subsequent
                                                        sibility of simultaneous causes of abdominal pain
development of ectopic pregnancy. Some authors
                                                        in the workup of acute abdomen in a female
have contended that appendicitis or history of sur-
                                                        patient, particularly during pregnancy when
gery for appendicitis may induce short- or long-
                                                        characteristic physiologic and anatomic relation-
term adjacent inflammation in the fallopian tubes
                                                        ships may be distorted. There may be mutual
that predisposes to subsequent development of ec-
                                                        etiologic/pathogenic mechanisms that lead to
topic pregnancy.1,7,8,9
                                                        concurrent development of both ectopic preg-
    On the other hand, some authors have con-
                                                        nancy and appendicitis through contiguous in-
tended that ectopic pregnancy may induce con-
                                                        flammatory and infectious processes. It is impor-
tiguous inflammation, leading to periappendici-
                                                        tant that during operations for right tubal ectopic
tis, then appendicitis.1,10 At present, there is no
                                                        pregnancy, one must check the appendix to rule
single unifying theory about the etiology of ap-
                                                        out concurrent appendicitis.
pendicitis, but a combination of luminal obstruc-
tion and/or infection is postulated as the most
probable etiologic factor. The theory of luminal        References
obstruction in the pathogenesis of appendicitis           1. Riggs JC, Schiavello HJ, Fixler R. Concurrent ap-
contends that lymphoid hyperplasia or fecaliths              pendicitis and ectopic pregnancy. A case report. J
cause luminal obstruction. A subsequent increase             Reprod Med 2002;47:510 – 4.
in intraluminal pressure results in ischemia of the       2. Akman MA, Katz E, Damewood MD, Ramzy AI,
                                                             Garcia JE. Perforated appendicitis and ectopic preg-
appendiceal wall. The infection theory in the
                                                             nancy following in-vitro fertilization. Hum Reprod
pathogenesis of appendicitis contends that bac-              1995;10:3325– 6.
terial or viral enteric infections from processes         3. Tracey M, Fletcher HS. Appendicitis in pregnancy.
such as gastroenteritis or colitis adjacent to the           Am Surg 2000;66:555–9.
appendix initially lead to mucosal ulceration of          4. Andersen B, Nielsen TF. Appendicitis in pregnancy:
the appendix and subsequent secondary infection              diagnosis, management and complications. Acta Ob-
from normal colonic flora.10                                  stet Gynecol Scand 1999;78:758 – 62.
    Consistent with the infection theory, we postu-       5. Molander P, Paavonen J, Sjoberg J, Savelli L, Cac-
late that ectopic pregnancy may cause an initial             ciatore B. Transvaginal sonography in the diagnosis
contiguous inflammatory reaction in the adjacent              of acute appendicitis. Ultrasound Obstet Gynecol
                                                             2002;20:496 –501.
appendix. This leads to mucosal sloughing and cre-
                                                          6. Barnett A, Chipchase J, Hewitt J. Simultaneous rup-
ates a portal for infection in the appendix by normal
                                                             turing heterotopic pregnancy and acute appendicitis
colonic bacterial flora. We postulate that ectopic            in an in-vitro fertilization twin pregnancy. Hum Re-
pregnancy may trigger appendicitis through a com-            prod 1999;14:850 –1.
bination of initial inflammation and secondary in-         7. Spandorfer SD, Barnhart KT. Role of previous ec-
fection. Previously reported cases of concurrent             topic pregnancy in altering the presentation of sus-                              Concurrent Ruptured Ectopic Pregnancy and Appendicitis      65
   pected ectopic pregnancy. J Reprod Med 2003;48:           nancy and appendicitis—a case report. Med J Malay-
   133– 6.                                                   sia 1996;51:485–7.
8. Bozoklu S, Bozoklu E, Ciftci A, Coskun T. Ruptured     10. Feldman M, Friedman LS, Sleisenger MH,
   ectopic pregnancy with undetectable -hCG levels            editors. Sleisenger & Fordtran’s gastrointestinal
   coexisting with acute appendicitis. Acta Obstet Gy-        and liver disease: pathophysiology, diagnosis,
   necol Scand 1997;76:181–2.                                 management, 7th ed. Philadelphia: WB Saunders;
9. Chia P, Jeyarajah A. Co-existing tubal ectopic preg-       2002.

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