G. Obajimi and O. Awolude
Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Nigeria
Abstract
A 30 year-old P0+1 lady who was referred to the gynaecology clinic on account of inability to conceive for 8 years duration and progressive abdominal distension of 2 years duration. She had a history of severe cyclical dysmenorrhoea warranting occasional hospitalization. An abdomino-pelvic ultrasound revealed marked intra-abdominal collection. The uterus and ovaries appeared normal. She subsequently had laparoscopy and drainage of 6 litres of endometriotic ascites. Both fallopian tubes were diseased. She was followed up on an out-patient basis with sub-cutaneous goserelin injections and referred for assisted reproduction.
Keywords: Endometriosis, Ascites, Infertility, Laparoscopy
Correspondence:
Dr. G. Obajimi
Dept. of Obstetrics and Gynaecology,
College of Medicine,
University of Ibadan,
Nigeria.
Email:gbolahanobajimi@gmail.com
CASE
A 30 year-old P0+1 lady who was referred to the gynaecology clinic, whose complaints were inability to conceive for 8 years duration and progressive abdominal distension of 2 years duration. She had a history of severe, chronic cyclical dysmenorrhoea warranting occasional hospitalization. There was no history suggestive of weight loss, nausea, vomiting or change in bowel habit. However, she experienced early satiety and occasional bloating. She attained menarche at 14 years and menstruated for 5 days in a regular 30 days cycle. Her sexual debut was at 17 years. She had been on combined oral contraceptive pills (microgynon) in the preceding 12 months. She was the 2nd wife of a polygamous union. The other two wives had two children each. There was a history of voluntary termination of pregnancy about 8 years earlier.
Clinical examination revealed a healthy young lady with a distended abdomen. Fluid thrill was positive. Digital rectal examination was essentially normal. Vaginal
examination was difficult and unremarkable due to the distension, limiting access to the uterus and adnexae. Her vital signs were normal. Laboratory investigations revealed a packed cell volume of 38%, white blood cell count of 14,600/mm3, (Polymorphonuclear neutrophils were 90%, lymphocytes were 7% and monocytes 3%). Liver function tests, Electrolytes & Urea were within normal limits. Her Carcinoma antigen -125 was markedly elevated at 118u/ml (Reference <35). A chest X-ray was performed to exclude possible pleural effusion and was essentially normal.
Abdominopelvic ultrasound revealed marked abdominal collection with normal looking uterus and ovaries. There were no pelvic masses and other abdominal organs were unremarkable. A diagnosis of massive ascites probably due to an intra-abdominal malignancy was made in a patient with background history of infertility. In view of her stable clinical condition and reassuring abdomino-pelvic ultrasound, a decision was taken to further evaluate the peritoneal cavity. She subsequently had laparoscopy and drainage of 6 litres of endometriotic ascites. Findings were massive chocolatey ascites, dense pelvic adhesions, multiple endometriotic deposits along the anterior abdominal wall, pelvic side wall, large bowel, ovaries, uterus and the Pouch of Douglas. The ascitic fluid was sent for cytology and she was commenced on medical management for endometriosis with subcutaneous goserelin injection (zoladex) 10.8mg every 13 weeks for 6 months.
Cytology revealed sheets of epithelial cells and fragments of loosely arranged spindled stroma. There was no atypia. She was followed up at the gynaecology clinic for 12 months and she demonstrated sustained clinical improvement and was referred for assisted conception in view of the tubal disease.