Hysterotomy for retained placenta with imminent uterine rupture in a preterm angular pregnancy

Abstract

Sir, A 26-year-old primigravida was wheeled into labor ward at 30 weeks in preterm labor. She had no record of her poorly supervised antenatal period. Soon after she was admitted she delivered a preterm asphyxiated female child. Methylergometrine 0.2 mg was administered intramuscularly at delivery of anterior shoulder. An abnormal lateral bulge was noted at uterine fundus after the delivery owing to the skinny body build of the patient. There was no evidence of placental separation even after 30 minutes and a diagnosis of retained placenta was made. Manual removal was attempted in the operation theatre but failed despite all measures as the placenta remained beyond reach and the cervical os did not yield. Even sharp curettage was attempted but it could not reach placental edge and vaginal bleeding became brisk. Laparotomy was done. Upon exteriorizing uterus a 10 × 10 cm sacculation (Figure 1) in the left cornual region of the uterus was noted. The myometrium overlying the bulge was thinned out to be a mere membrane, with placenta and venous sinuses readily visible underneath and uterine rupture seemed imminent. A coronal incision was done into the myometrium overlying the placenta, which resulted in spontaneous, prompt and complete extrusion of the placental tissue. Exploration of the endometrial cavity revealed no retained placental fragments and a normal cavity. The myometrial incision was sutured in three layers. Postoperative period was uneventful and the patient was discharged on the 5th postoperative day. The lateral sacculation of the uterus at left cornual region with characteristic lateral displacement of left round ligament. Not many obstetricians are aware of the rare clinical entity of angular pregnancy or they often confuse it with interstitial or cornual pregnancy, as it is rarely discussed in textbooks. Angular pregnancy refers to implantation of the embryo just medial to the uterotubal junction, in the lateral angle of the uterine cavity (1), whereas interstitial pregnancy refers to the implantation in the intramural portion of the fallopian tube and is a true ectopic pregnancy (2). The critical differential feature is that the fertilized ovum of an interstitial pregnancy essentially develops in the uterine wall, whereas in an angular pregnancy it develops toward the uterine cavity and that might probably be the reason for a more favorable outcome of a majority of angular pregnancies. Nevertheless angular pregnancy is a potentially dangerous clinical entity and may lead to complications during pregnancy like persistent uterine pain and bleeding, spontaneous abortion, ruptured uterus (3) and rarely retained placenta. On a PubMed search we found only one similar case of angular pregnancy complicated by retained placenta requiring hysterotomy, making it a very rare complication of angular pregnancy. Despite being accurately described earlier, angular pregnancy is yet to be widely acknowledged as a separate clinical entity.