While a complete uterus is the typical site of gestation, it is not absolutely necessary for fertilization and implantation. Ectopic pregnancies are most commonly found in the fallopian tubes or on peritoneal surfaces in the pelvis, including on the ovaries and omentum [1]. Pregnancy after hysterectomy is extremely rare, with the first case of ectopic pregnancy after hysterectomy reported by Wendler in 1895 [2,3,4]. To the best of our knowledge, there are only 72 cases of post-hysterectomy ectopic pregnancy reported in the world literature [3].
A 32-year-old G3P3002 African woman came from Yifag Kebele, Amhara Region, to Felege Hiwot referral hospital in Bahir Dar, Northwest Ethiopia in July 2016. She presented with abdominal pain and intractable vomiting of 1 day’s duration. She was also unable to pass feces and flatus and had developed progressive abdominal distension. She had a past medical history notable only for chronic gastritis for which she took unspecified medications and a past surgical history notable for a Cesarean hysterectomy after an intrauterine fetal demise during labor. As she had been told that her uterus was removed, she did not use contraception and had no menses. She was admitted to our surgical ward with a diagnosis of small bowel obstruction due to presumed post-operation adhesions and possible incisional hernia. She also had severe anemia and was resuscitated with 2 liters of normal saline and transfused with 2 units of blood. A plan was made to correct the hernia once she was stabilized. After 2 days in our hospital, however, her condition worsened and a consultation was made to Obstetrics and Gynecology for further evaluation.
On physical examination at the time of consultation, she was confused and irritable, with an undetectable blood pressure and a thready pulse of 132. She had labored breathing, pale conjunctiva, and a distended abdomen with a palpable mass below the midline surgical scar. An abdominal examination also revealed a fluid wave and hypoactive bowel sounds. Laboratory testing showed a white blood cell count of 12.9 × 103 with 88.4% neutrophils and hemoglobin of 5.8 g/dl. Urine human chorionic gonadotropin (hCG) was positive. A transabdominal ultrasound showed a normal liver, spleen, pancreas, and kidneys. There was a significant debris-filled intraperitoneal fluid collection, especially on the right side of her abdomen, with a deepest pocket measuring 5 cm. No lymphadenopathy was seen. A singleton, viable pregnancy was identified measuring 13 weeks of gestational age with no gross abnormality and adequate amniotic fluid.
The Obstetrics and Gynecology team diagnosed hypovolemic shock secondary to ruptured ectopic pregnancy, and our patient was taken to the operating room for a laparotomy. Intraoperative findings included 4.5 liters of hemoperitoneum, a cervical stump pregnancy with well-formed fetus and intact gestational sac, and active bleeding from partially