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Case Report
Massive Retroperitoneal Hematoma Caused by Retroperitoneal
Ectopic Pregnancy
Jay Goldberg, MD, MSCP; Michael Weinstein,
MD; Kris Kaulback, MD;
Aileen Gariepy, MD; George Bega, MD
A massive retroperitoneal hematoma caused by a retroperitoneal ectopic pregnancy
is managed successfully utilizing multidisciplinary cooperation and transfusion
of blood products.
An ectopic pregnancy is defined as a gestation implanted in a location other
than within the uterine cavity. While these most commonly occur in the fallopian
tube, ectopic pregnancies may rarely occur in the cervix, ovary, or abdominal
cavity. The authors report an unusual case of a retroperitoneal ectopic pregnancy
presenting as a massive retroperitoneal hematoma in a hemodynamically unstable
patient.
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CASE REPORT
A 24-year-old woman (gravida 4, para 1021) presented to the emergency
department at 8 weeks’ gestation by last menstrual period.
She complained of increasing abdominal pain of 1 day’s duration.
She was unaware that she was pregnant. She had no history of prior
surgeries or sexually transmitted infections, and denied any recent
trauma.
On presentation, the patient’s vital signs were initially
stable. She was noted on examination to have significant abdominal
pain with rebound and guarding but no palpable masses. Pelvic examination
revealed a nongravid-sized uterus with no adnexal tenderness, adnexal
enlargement, or cervical motion tenderness.
The patient’s serum human chorionic gonadotropin (hCG) level was 24,872
mIU/mL, and the hemoglobin value was 11.4 g/dL. Transabdominal and transvaginal
ultrasonography showed a nongravid-sized uterus, with no evidence of an
intrauterine gestation. No adnexal mass was identified, but there was a
moderate amount of fluid in the cul-de-sac.
Approximately 2 hours after presentation, the patient became hypotensive
and tachycardic. She was taken to the operating room for exploratory
surgery, with a presumptive diagnosis of a ruptured tubal ectopic
pregnancy.
In the operating room, exploratory laparotomy was performed through a low transverse incision. Approximately 100 mL of blood was suctioned from the pelvis. The uterus, fallopian tubes, ovaries, and broad ligaments appeared normal. Exploration of the upper abdomen revealed a massive, left-sided, retroperitoneal hematoma behind the left colonic mesentery. It was nonpulsatile and nonexpanding, and not bleeding into the peritoneal cavity. Due to continued hypotension and an intraoperative hemoglobin level of 5.5 g/dL, 4 units of packed red blood cells (RBCs) and 3 units of fresh frozen plasma (FFP) were transfused. At that point, it was decided that further exploration of the hematoma was neither necessary nor advisable, and the patientÍs abdomen was closed.
Immediate postoperative computed tomographic arteriography of the abdomen and pelvis was performed, demonstrating a 20-*-15-cm hemorrhagic retroperitoneal mass below the left anterior perirenal space extending down into the upper pelvis (Figures
1 and 2). There was no evidence of psuedoaneurysm or active bleeding. An interventional radiologist was consulted, but the hematoma was not amenable to embolization.
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Figure not available online
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Figure
1. Axial
computed tomographic arteriogram showing a 20-x-15-cm hemorrhagic
retroperitoneal
mass below the left anterior perirenal space extending down
into the upper pelvis.
Courtesy of Jay Goldberg, MD, MSCP. |
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Figure not available online
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Figure
2. Frontal computed tomographic arteriogram showing
a 20-x-15-cm hemorrhagic retroperitoneal mass below the left
anterior perirenal space extending down into the upper pelvis.
Courtesy of Jay Goldberg, MD, MSCP. |
Given the suspicion of an ectopic pregnancy, possibly retroperitoneal in location, a 90-mg intramuscular dose of methotrexate was administered based on her calculated body surface area. The plan was to closely monitor the patient, transfuse additional blood products as needed, and return to the operating room if she became unstable.
Approximately 20 hours later, the patient's hemoglobin values had dropped from 9.6 to 6.8 g/dL
and she again became hypotensive, so she was returned to the operating room for exploration of the retroperitoneal hematoma. A midline skin incision was made extending above the umbilicus. There was a significant amount of intra-abdominal blood arising from a small hole in the very tense retroperitoneal hematoma. The hematoma was opened with cautery, and approximately 2 L of clotted blood were removed. Bright red blood was oozing from a quarter-sized vascular area in the most superior portion of the hematoma cavity. Clips were applied to the vascular structures, resulting in hemostasis. No products of conception were grossly visible at the time of surgery. In total, from admission to completion of the second surgery, the patient received 12 units of packed RBCs and 8 units of FFP. Pathologic evaluation of the evacuated clotted blood revealed chorionic villi (Figure
3), confirming the suspected diagnosis of retroperitoneal ectopic pregnancy leading to a hematoma.
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Figure not available online
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Figure
3. Microscopic image (200x) of degenerating chorionic
villi identified in the evacuated retroperitoneal blood clot.
Courtesy of Jay Goldberg, MD, MSCP. |
Two days after evacuation of the retroperitoneal hematoma, the patientÍs serum hCG level had decreased from 24,872 to 6,000 mIU/mL. Two days later, it had declined to 3,200 mIU/mL.
Her postoperative course was complicated by intermittent fever and a mild ileus. These resolved without specific interventions. The patient was discharged 8 days after her initial presentation, without further complication. Her hCG level was followed serially as an outpatient until it fell to less than
10 mIU/mL 3 weeks later.
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DISCUSSION
The management of retroperitoneal hemorrhage is based on hemodynamic
parameters and secondary clinical findings. The majority of retroperitoneal
hemorrhage is from venous sources and thus can be managed with
expeditious correction of coagulopathy, volume replacement, and
close monitoring. Patients who continue to bleed despite these
efforts often have an arterial etiology and may benefit
from angiography with embolization or stenting. Surgery to control
bleeding in the retroperitoneum can be quite challenging, and is
usually reserved for patients who do not respond to initial volume
replacement or who have failed angiography. Rarely, a decompressive
operation may be indicated when retroperitoneal bleeding causes
femoral or lumbar plexus neuropathies or abdominal compartment
syndrome.
Spontaneous retroperitoneal hematomas are uncommon. The majority
of retroperitoneal hematomas are secondary to anticoagulation therapy.
Other etiologies include neoplasm, arterial aneurysm, pseudoaneurysm
rupture, and trauma.
Very few cases of retroperitoneal ectopic pregnancy have been
reported.1-3 Following in vitro fertilization-embryo transfer (IVF-ET),
a retroperitoneal ectopic pregnancy was hypothesized to have occurred
via uterine perforation, with retroperitoneal placement of the
transferred embryo.1 Reports in the absence of IVF-ET have theorized
that retroperitoneal implantation may have occurred via vascular
routes, lymphatic channels, or transperitoneal trophoblastic invasion.2,3
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CONCLUSION
This case is of interest because of the unusual presentation and
successful management of a hemodynamically unstable patient with a massive
retroperitoneal hematoma due to retroperitoneal implantation of an ectopic
pregnancy. While rare, successful outcome of this life-threatening condition
is predicated on multidisciplinary cooperation, clinical vigilance, and
potentially massive transfusion of blood products.
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Jay Goldberg, MD, MSCP, is director, Division of General Obstetrics and Gynecology; Michael
Weinstein, MD, is assistant professor of surgery; Kris
Kaulback, MD, is associate professor of surgery; Aileen
Gariepy, MD, is instructor of obstetrics and gynecology; and George
Bega, MD, is director, 3D/4D Ultrasound Imaging Program. All are at Jefferson Medical College, Philadelphia, Penn.
References
- Ferland RJ, Chadwick DA, OÍBrien JA, Granai CO 3rd. An ectopic pregnancy in the upper retroperitoneum following in vitro fertilization and embryo transfer. Obstet
Gynecol. 1991;78(3 pt 2):544-546.
- Lee JW, Sohn KM, Jung HS. Retroperitoneal ectopic pregnancy. AJR
Am J Roentgenol. 2005;184(5):
1600-1601.
- Sotus PC. Retroperitoneal ectopic pregnancy: a case report. JAMA. 1977;238(13):1363-1364.
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