Nusrat H. Khan ( Department of Obstetric and Gynaecology, Dow Medical College and Civil Hospital, Karachi. )
The intrauterine Contraceptive device (I.U.C.D.) is one of the best methods of contraception1 on account of its efficacy and easily reversible effect. Check-ups are required only periodically. Misplacement of I.U.C.D. has been reported as one of the complications of I.U.C.D2,3. The incidence of ectopic pregnancy is higher because I.U.C.D.\\\'s are known to prevent intrauterine pregnancy. Ovarian pregnancy is, however, rare.
A 39 year old woman was admitted on February 23rd, 1989 with acute abdominal pain. General examination was unremarkable. Blood pressure and pulse recordings were within normal limits. On abdominal examination, there was rebound tenderness mainly in the right iliac fossa. Speculum examination revealed a hypertrophied cervix. On per vaginam examination the uterus was found to be bulky. She was para 5+0 last delivery was three years back. There was history of insertion of I.U.C.D. (lippes loop) at a family planning Clinic three years ago and attempt at removal prior to onset of acute abdominal pain. Menstrual history was normal Last menstrual period began on February 2nd, 1989. She was anaemic (Hb 8.8 g/dl). WBC count, IlVS, urine C/S and stools DR were reported as normal. Plain x-ray abdomen indicated that the I.U.C.D was high up in the mid-abdominal cavity. Ultrasound examination showed the I.U.C.D in the wall of the uterus. Uterine Cavity was empty. Symptomatic treatment was given. Menstrual period started on February 28th, 1989. Examination under anaesthesia and diagnostic D&C were done on March 3rd, 1989 to attempt to locate and remove the I.U.C.D. There was no evidence of I.U.C.D in utero. She was discharged home on the following day when pain and bleeding had subsided. Hysterosalpingogram done on March 22nd, 1989 revealed slight dilation of lateral aspect of right fallopian tube. No I.U.C.D noted. Left tube normal. The patient was reviewed again on March 30, 1989 when she complained of persistent vague pain. A mass could now be felt on bimanual examination in the right fornix. Ultrasound was repeated which revealed an extra uterine pregnancy with foetus measuring 2.9 cm on the right side. Diagnostic laparotomy was carried out in emergency. Right salpingo-oophorectomy was done for a right tubo-ovarian mass. Left sided salpingectomy was also done. I.U.C.D. was not found in the abdominal cavity. Post-operative recovery was uneventful. Histopathology of endometrium revealed decidual changes. H istopathology of tubo-ovarian mass confirmed unruptured ovarian ectopic gestation.
Women using an I.U.C.D. have an increased incidence of ectopic pregnancy4-7. In most cases, the presenting symptoms are non- diagnostic and the patient is in a haemodynamically stable condition. The classic triod of pain bleeding and mass occurs in 30% to 40% of ectopic pregnancies and the pelvic symptoms of infection, cyst rupture or torsion, endometriosis and early spontaneous abortion can be very similar to ectopic pregnancy8. Symptoms between four and six weeks gestation present a dilemma. The clinical presentation of this patient was atypical and the diagnosis was difficult. Timely surgical intervention saved the patient from an acute abdominal catastrophe.
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