Obstetrics and Gynecological Imaging Lee et al.

Retroperitoneal Ectopic Pregnancy

Case Report
Retroperitoneal Ectopic Pregnancy
Jung Whee Lee1, Kyung Myung Sohn, Hyun Seok Jung
he terms ectopic pregnancy and extrauterine pregnancy refer to a gestation anywhere outside the endometrial cavity of the uterus. The fallopian tubes are by far the most common sites of such pregnancy, whereas the ovary and abdominal cavity are less frequently involved [1]. The retroperitoneal space is an exceptional location. We describe a rare case of retroperitoneal pregnancy.

Case Report A 21-year-old woman, gravida 0, para 00 00, was admitted via the emergency department with the main complaint of left flank pain. The patients medical and gynecologic history was unremarkable. Physical examination showed mild tenderness on the left flank area. The patient had a 6-week history of amenorrhea, and the results of the urine test were positive for pregnancy. Abdominal sonography revealed a large mass below the left kidney with mild dilatation of the left renal pelvis and proximal ureter (Fig. 1A). The mass contained a gestational sac and embryo (Fig. 1B). Cardiac activity and gross motion of the embryo were also noted on real-time gray-scale sonography. There was neither an intrauterine gestational sac nor an adnexal mass. The patient was brought to the operating room with the diagnosis of retroperitoneal ectopic pregnancy. Careful inspection in the
Received April 23, 2004; accepted after revision July 22, 2004.
1All authors:

field of operation revealed that the uterus, fallopian tubes, and other pelvic organs were normal with no evidence of pelvic adhesion. The posterior peritoneum was also intact. There was no free fluid in the peritoneum and retroperitoneum. A retroperitoneal mass of approximately 5 cm was found in the left paraaortic region below the left kidney. The base of the gestational sac was not completely removed because of the adhesion around this mass lesion. Grossly, products of conception together with a placenta were noted, and an embryo with gestational sac and chorionic villi was identified histologically. The embryo was grossly normal without abnormal development. The patient did well after surgery. Discussion Ectopic pregnancy occurs when the fertilized ovum becomes implanted in tissue other than the endometrium. Most ectopic pregnancies are located in the ampullary segment of the fallopian tube. However, they may also occur within the interstitial portion of the fallopian tube, in the uterine cervical canal, between the leaves of the broad ligament, within the ovarian cortex, or on the peritoneal surface (abdominal pregnancy) [1]. In very rare cases, the abdominal pregnancy may be retroperitoneal. The incidence of abdominal pregnancy has been variously reported as between

Lee JW, Sohn KM, Jung HS

one per 3,372 births and one per 7,931 births [2]. Abdominal pregnancies are classified as either primary or secondary. Most abdominal pregnancies probably originate as tubal or ovarian pregnancies that rupture into the peritoneal cavity, where they implant for a second time (hence, the term secondary abdominal pregnancy) [2]. Only a very small fraction of the reported cases meet the three criteria for primary abdominal pregnancy established in 1942 by Studdiford: normal tubes and ovaries, absence of uteroperitoneal fistula, and pregnancy related exclusively to the peritoneal surface and diagnosed early enough to exclude the possibility of secondary implantation after primary nidation elsewhere [3]. Our case meets these criteria apart from the fact that implantation occurred in the retroperitoneal space rather than in the peritoneal surface. Reported sites of primary abdominal pregnancy are the pouch of Douglas, posterior uterine wall, uterine fundus, liver, spleen, lesser sac, and diaphragm [2]. Ectopic pregnancy, a known complication of in vitro fertilizationembryo transfer (IVFET), has increased in frequency due to the nationwide proliferation of IVFET programs. As ectopic pregnancies become more common, so too do reports of unusual implantation sites including the retroperitoneum [4]. Two mechanisms may account for the retroperito-

Department of Radiology, Our Lady of Mercy Hospital, The Catholic University of Korea, 665 Bupyeong-dong, Bupyeong-gu, Incheon 403-720, South Korea. Address correspondence to J. W. Lee.

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Retroperitoneal Ectopic Pregnancy

A
Fig. 1.21-year-old woman with retroperitoneal pregnancy. LK = left kidney. A, Abdominal sonogram of left flank area shows echogenic mass (M) compressing left proximal ureter (arrow) and causing mild dilatation of left renal pelvis. B, Sonogram shows mass has thick echogenic wall and internal cystic portion with embryo (arrow).

neal location of an ectopic pregnancy in IVF ET patients: spontaneous retrograde migration of the embryo after intrauterine transfer and uterine perforation with unintended retroperitoneal or intraabdominal embryo placement at the time of transfer [4]. However, our patient had not undergone IVFET, and there was no evidence of tubal rupture or uterine perforation found at surgery. There have been very few reports of retroperitoneal ectopic pregnancy in the absence of IVFET [57], and it is difficult to explain how these rare implantations occur. However, several theories have been proposed. Dissemination of cells or tissue fragments through vascular channels, as in the case of trophoblastic diseases, typically terminates in pulmonary tissue, whereas dissemination of endometrial cancers through lymphatic channels leads to metastases in the periaortic and portal hepatic nodes [8]. Hall et al. [9] sug-

gested that the fertilized ovum reaches the retroperitoneal space via the lymphatic system because they found lymphatic tissue together with the ectopic mass. Another explanation is that the embryo implants on the posterior peritoneal surface in the first instance and reaches a retroperitoneal position by subsequent trophoblastic invasion through the peritoneum [4]. In summary, we have presented a rare case of retroperitoneal pregnancy. Retroperitoneal location probably involved trophoblastic invasion after primary abdominal pregnancy or a lymphatic route. References
1. Thomas GS. Early pregnancy loss and ectopic pregnancy. In: Jonathan SB, ed. Novaks gynecology, 13th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002:507542 2. Martin JN, Sessums JK, Martin RW, et al. Ab-

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dominal pregnancy: current concepts of management. Obstet Gynecol 1988;71:549557 Studdiford WF. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942;44:487 Ferland RJ, Chadwick DA, OBrien JA, Granai CO III. An ectopic pregnancy in the upper retroperitoneum following in vitro fertilization and embryo transfer. Obstet Gynecol 1991;78:544546 Lazarov L. A rare case of a retroperitoneally situated extrauterine pregnancy [in Bulgarian]. Akush Ginekol (Sofia) 1993;32:4041 Terrier JP, Garcia S, Hardwigsen J, DErcole C, Andrac-Meyer Charpin C. Retroperitoneal ectopic pregnancy: report of a case. Ann Pathol 1998;18:201202 Sotus PC. Retroperitoneal ectopic pregnancy: a case report. JAMA 1977;238:13631364 Yabushita H, Shimazu M, Yamada H, et al. Occult lymph node metastases detected by cytokeratin immunohistochemistry predict recurrence in node-negative endometrial cancer. Gynecol Oncol 2001;80:139144 Hall JS, Harris M, Levy RC, Walrond ER. Retroperitoneal ectopic pregnancy. J Obstet Gynaecol Br Commonw 1973;80:9294

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