A large amniocele through a fundal uterine defect diagnosed on 2D ultrasound imaging

Abstract

Introduction: Amniocele is herniation of amniotic sac through a uterine myometrial defect. It commonly results from intrauterine procedures such as suction evacuation, dilatation and curettage, manual removal of placenta and other products of conception, etc. Early diagnosis is imperative as that will go a long way to reduce morbidity and mortality. Case Report: A 35-year-old G4P3+0 women was presented to our health facility at 21st week gestation with a week history of lower abdominal pain. Obstetric ultrasound scan done at presentation revealed a fundal myometrial defect with a large amniocele through it, resulting in apparent oligohydramnios. Her first two deliveries were uneventful, but the third was complicated by post-partum hemorrhage due to retained placenta. This necessitated instrumentation and manual removal in the theatre at a secondary Health institution, four years prior to the index pregnancy. No immediate complication was noticed after the procedure. Two weeks after this diagnosis, precisely at 23rd week gestation, she had laparotomy, aimed at reducing the herniated amniotic sac and repairing the defect. This was not possible due to the narrow neck of the defect. She was then closed back and kept on exclusive bed rest and weekly sonographic evaluation of the pregnancy. A scan done at 31st week gestation revealed ruptured herniated amniotic sac into the peritoneal cavity with fetal distress. Estimated ultrasound fetal weight at this time was 1.76 kg. She had emergency cesarean section with delivery of a live very low birth weight baby whose APGAR score was 7 and 8 at 1 and 5 minutes respectively. The baby was admitted into special care baby unit (SCBU) but died 10 hours thereafter. The myometrial defect and uterine incision were repaired in layers. She did well, hemodynamically stable and was discharged on postoperative day-7. Follow-up visits were satisfactory. Conclusion: This case is presented to emphasize the need for training and retraining of physicians and midwives on active management of third stage of labor to forestall the observed pitfalls. It also brings to the fore the utility of gray scale and color Doppler ultrasound in antenatal diagnosis of uterine defect and placenta accreta.