O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 3 | 24 rupture of tubo-ovarain complex or ovarian malignancy. Laboratory studies revealed a slightly elevated WBC count of 12.9 109/L, normal hemoglobin of 12.0 gm/dL, with marked thrombocytosis of 837x 109/L. She had elevated CRP of 124 mg/L. Electrolyte panel was normal except raised urea of 14.5mmol/L and creatinine of 100 umol/L that was attributed to dehydration. e liver function tests showed low albumin of 21g/L, normal bilirubin, elevated AST of 75U/L, ALT of 72U/L, ALP of 161U/L and GGT of 135U/L. e Ca-125, CEA, Ca19-9, alpha-fetoprotein and bHCG were normal except LDH, which was moderately increased to 339 U/L. Ultrasound of the pelvis and abdomen showed large amount of uid in the peritoneal cavity with echogenic speckles. e patient underwent exploratory laparotomy. e abdomen was opened by a midline vertical incision. About 2000 mililitres of non foul smelling yellowish turbid uid was found in the peritoneal cavity. In addition, there were 500-700 grams of so sticky spherical pellets, all of similar size measuring around 2mm x 2mm attached to the peritoneal surface of bowels as well as oating in the peritoneal cavity. It was a frozen abdomen where small and large bowel and pelvic organs were adherent to each other. A er suctioning the uid and spherical pellets a thorough washout was performed and the abdomen was closed with the intent of follow-up with microbiology and histology report of those pellet like structures. Figure 1 Peritoneal cavity filled with fluid and spherical pellets Figure 2 Peritoneal cavity with severe chemical peritonitis e microbiology of peritoneal uid revealed no bacterial or fungal growth. Auramine O stains as well as PCR were negative for TB. Cytology revealed no malignant cells. Histology of the spherical pellets revealed that they were comprised of anucleate keratinous material. Additionally, some squamous epithelial cells were observed and there was representation of hair sha s as well. Besides, there were numerous neutrophils and coccal bacterial colonies which were in keeping with acute peritonitis. Considering the histology report a diagnosis of spontaneously ruptured teratoma with keratin granuloma peritonealis was made. Abdominopelvic ultrasound, CT scan and MRI were performed a er 4 weeks of laparotomy which revealed features consistent with ruptured matured ovarian teratoma. Figure 3 Transabdominal ultrasound: A heterogeneous mass in the le adnexa with solid component that has lobulated margins. Part of the solid component is hyper-echoic with posterior acoustic shadowing signifying calci cation (tooth component) within the mass. Figure 4 CT abdomen and pelvis: coronal view Figure 5 Noncontrast CT pelvis: Axial view. A heterogeneous mass in le adnexa with solid component that consists of so tissue, fatty components, and calci cations. ere is hypoattenuating fatty uid in antedependent pockets along the anterior abdominal wall. ickened and enhancing anterior peritoneal lining. O&G Forum 2021; 31: 23 - 27 CASE REPORT