- 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.
