NHÂN CA THAI NGOÀI TỬ CUNG Ở LÁCH TẠI MEDIC

Bn nữ, 37 tuổi,  trễ kinh 4 tháng nay, không đau bụng , không ra huyết âm đạo bất thường. 10 ngày trước có uống thuốc Bắc để xổ thai (do thấy quickstick nhiều lần dương tính). Đến khám Medic kiểm tra. Trước đó=
 - ngày 2/7/2013 : khám ở bv Từ Dũ : Beta HCG 2554 đv . Siêu âm : Không thấy bất thường
 - ngày 16/7/2013 : khám ở  bv Từ Dũ : Beta HCG 2830 đv
 - ngày 14 /10/2013 : khám ở bv Phụ sản Nhi Bình Dương :beta HCG 4587 đv , siêu âm không thấy bất thường.
Khám ở Medic 21/10/2013 : 1/ siêu âm : tử cung phần phụ bình thường , nội mạc tử cung không dầy , không dịch tự do , các tạng khác không thấy bất thường , ngoại trừ Lách mặt trên giáp cơ hoành có 1 thương tổn dạng xoang nang , kt # 4 x 3 cm , có mạch máu ngoại biên, có nốt vôi .
Kết luận : u lách (cđpb : GEU ở lách ). Xn : beta HCG 4431 đv .
T.V.S [bs J.Thanh Xuân] có cùng ý kiến trên.
MRI kết luận: Nang lách chứa dịch khả năng Hemangioma tuy không điển hình. Hội chẩn vì beta HCG tiếp tục tăng cao hơn 5000 đv nên nghĩ đến chorio lách.

Discussion

An ectopic pregnancy is defined as any pregnancyin which the fertilized ovum implants anywhere other than in the uterine cavity. The estimated incidence of ectopic pregnancies is approximately 20 cases per 1000 pregnancies. 1 The most common site of ectopic implantation is the fallopian tube, accounting for 95.5% of all ectopic gestations.2 Upper abdominal pregnancies are very rare, accounting for 1.3% of ectopic pregnancies. 2 Previous reports have described such pregnancies in the omentum, intestines, liver, spleen, and lesser sac.2–4 The spleen is relatively more favorable for implantation considering the fact that it is a flat organ, rich in blood flow, and easily reached in the human supine position by the fertilized ovum. 4 However, none of the anatomic sites described above, including the spleen, can accommodate placental attachment or a growing embryo; therefore, rupture and a massive hemorrhage may very likely occur if left untreated. 5 Several factors are known to increase the risk of an ectopic pregnancy, including a history of pelvic inflammatory disease, a previous ectopic pregnancy, endometriosis, previous pelvic surgery, reproductive assistance, and uterotubal anomalies.2,5 In our case, the patient had none of the clinically identifiable risk factors for an ectopic pregnancy.

The clinical hallmark of an ectopic pregnancy is abdominal pain and amenorrhea with vaginal bleeding, often occurring 6 to 8 weeks after the last normal menstrual period.5 Nearly all previously reported cases of splenic pregnancies presented with abdominal tenderness or intra-abdominal bleeding. 2–4,6–11 Our patient, however, was clinically asymptomatic, apart from a single episode of postcoital vaginal spotting. A review of previous reports of primary splenic pregnancies by Kalof et al 2 showed that most patients had a sudden onset of left upper quadrant abdominal pain at 6 to 8 weeks’ gestation. The size of the splenic gestation at clinical presentation ranged from 2 to 3.5 cm, suggesting that rupture of the splenic capsule occurs when the ectopic gestation exceeds this size. 2 Interestingly, in our case, the patient was clinically asymptomatic even though the gestational sac was relatively large (3 × 4 cm) in comparison to previous reports.

The absence of an intrauterine gestational sac on transvaginal sonography in conjunction with a β-hCG level of greater than 1500 U/L is thought to be suggestive of an ectopic pregnancy. 5 An ectopic pregnancy is also suspected when the β-hCG level remains elevated and the histological findings of uterine curettage do not include chorionic villi. 5 This case was challenging because transvaginal sonography, curettage, and laparoscopy were not diagnostic, and the high blood level of the β-hCG titer, which kept increasing steadily, was the only suggestive indicator of pregnancy, most probably an unidentified ectopic pregnancy.

Abdominal pregnancies are classified as either primary or secondary; the latter, which are much more common, are associated with displacement of the fertilized ovum from the fallopian tubes or the uterus to a secondary site. 2,12 Primary abdominal pregnancies, which arise from fertilization of an ovum within the peritoneal cavity, with anatomically normal fallopian tubes, ovaries, and uterus, are extremely rare. 2 In this case, intraoperative laparoscopic examination revealed no abnormalities in the fallopian tubes or the uterus and no evidence of pregnancy outside the spleen.

Thereby, we may conclude that the case described is most likely a case of a primary splenic pregnancy.