Unruptured retroperitoneal pregnancy implanted in the left broad ligament: A case report

  • Ranko Miodrag Kutlešić Department of Gynecology and Obstetrics, Clinical Center of Niš, Niš, Serbia; Faculty of Medicine, University of Niš, Niš, Serbia
  • Bojan Lukić Faculty of Medicine, University of Niš, Niš, Serbia
  • Marija S. Kutlešić Center for Anesthesia, Clinical Center of Niš, Niš, Serbia
  • Jasmina Popović Faculty of Medicine, University of Niš, Niš, Serbia
  • Milan Stefanović Faculty of Medicine, University of Niš, Niš, Serbia
  • Predrag Vukomanović Faculty of Medicine, University of Niš, Niš, Serbia
  • Goran Lilić Department of Gynecology and Obstetrics, Clinical Center of Niš, Niš, Serbia
Keywords: pregnancy, ectopic, retroperitoneal space, laparoscopy, intraoperative complications, gynecologic surgical procedures,

Abstract


Introduction. Retroperitoneal ectopic pregnancy is extremely rare, but potentially fatal condition due to possible massive hemorrhage, representing a great challenge to clinicians. Case report. We presented early retroperitoneal pregnancy in a patient with previous caesarean section, diagnosed at the sixth gestational week, located in the left broad ligament, primary treated by laparoscopy, which had to be converted to laparotomy due to massive intraoperative bleeding from the implantation site. Conclusion. High index of suspicion, combined with carefully interpreted clinical and ultrasound findings are crucial for the timely diagnosis of retroperitoneal pregnancy, before the occurrence of severe bleeding. The rising, even plateau of serum β-human chorionic gonadotropin (β-HCG) levels without identification of uterine or ectopic (tubal) pregnancy should cause suspicion on ectopic pregnancy in unusual location.

 

Author Biographies

Ranko Miodrag Kutlešić, Department of Gynecology and Obstetrics, Clinical Center of Niš, Niš, Serbia; Faculty of Medicine, University of Niš, Niš, Serbia

docent

Katedra za ginekologiju i akušerstvo

Medicinski fakultet Univerziteta u Nišu

Klinka za ginekologiju i akušerstvo Niš

 

Bojan Lukić, Faculty of Medicine, University of Niš, Niš, Serbia
specijalista ginekolog akušer
Marija S. Kutlešić, Center for Anesthesia, Clinical Center of Niš, Niš, Serbia
šef Odeljenja za anesteziju Klinike za ginekologiju i akušerstvo Niš
Jasmina Popović, Faculty of Medicine, University of Niš, Niš, Serbia

profesor

Katedra za ginekologiju i akušerstvo

Medicinski fakultet Univerziteta u Nišu

Klinka za ginekologiju i akušerstvo Niš

 

Milan Stefanović, Faculty of Medicine, University of Niš, Niš, Serbia

docent

Katedra za ginekologiju i akušerstvo

Medicinski fakultet Univerziteta u Nišu

Klinka za ginekologiju i akušerstvo Niš

 

Predrag Vukomanović, Faculty of Medicine, University of Niš, Niš, Serbia

docent

Katedra za ginekologiju i akušerstvo

Medicinski fakultet Univerziteta u Nišu

Klinka za ginekologiju i akušerstvo Niš

 

Goran Lilić, Department of Gynecology and Obstetrics, Clinical Center of Niš, Niš, Serbia

specijalista ginekologije i akušerstva

Klinka za ginekologiju i akušerstvo

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Published
2017/06/02
Section
Case report