Correspondence

Intraabdominal Pregnancy after Hysterectomy

N Engl J Med 2004; 350:417January 22, 2004

Article

To the Editor:

Wiesenfeld and Guido describe an unusual case of intraabdominal pregnancy occurring within a few weeks of hysterectomy (Oct. 16 issue).1 In postulating a possible mechanism to account for the timing of conception and implantation, they suggest that the patient's estimate of the date of her last menstrual period was incorrect.

I would like to propose that the patient's memory was in fact correct. The occurrence of her last period 6 days before surgery made the duration of gestation at diagnosis 12 weeks and 6 days. The crown–rump length, estimated on the basis of computed tomography (CT), suggested a gestation of 12 weeks and 5 days. Both gestation periods are consistent with the occurrence of ovulation approximately one week after surgery (certainly a possibility, since the ovaries were conserved). With intercourse soon before admission for surgery, it is possible that conception occurred in the peritoneal cavity after the hysterectomy. Perhaps this case really confirms the resilience and persistence of the human spermatozoon.

Kim Hinshaw, M.B., B.S.
Sunderland Royal Hospital, SR4 7TP Sunderland, United Kingdom
kim.hinshaw@lineone.net

1 References

1. 1

   Wiesenfeld HC, Guido RS. Intraabdominal pregnancy after hysterectomy. N Engl J Med 2003;349:1534-1534
   Full Text | Web of Science | Medline

To the Editor:

The CT image of the pelvis described by Drs. Wiesenfeld and Guido has a scale across the bottom. This is commonly a centimeter scale. The visualized portion of the fetus from crown to upper abdomen measures 6.3 cm, according to that scale. The crown–rump length must therefore be greater than 6.3 cm, indicating that the gestational age of the fetus may have been more than 12 weeks and 5 days. Perhaps the date of the last menses was 1 month before surgery rather than the reported 6 days, making the fetus 16 weeks old. Was there an ultrasound study that provided a more accurate crown–rump length?

Bernard B. O'Malley, M.D.
Princeton Radiology Associates, Princeton, NJ 08540

Author/Editor Response

We appreciate the comments of Drs. O'Malley and Hinshaw. The timing of conception in this most interesting case was initially a mystery. Pathological examination of the fetus after its removal, however, confirmed the gestational age as that initially suggested on the basis of CT. Conceptions within the intact female reproductive tract due to fertilization by sperm that are more than two days old rarely occur.1 Although the resilience of human spermatozoa is truly noteworthy, the possibility that conception occurred more than one week after intercourse in the unnatural environment of the peritoneal cavity is extremely remote.

Harold C. Wiesenfeld, M.D.
Richard S. Guido, M.D.
University of Pittsburgh School of Medicine, Pittsburgh, PA 15213-3180

1 References

1. 1

   Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation: effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med 1995;333:1517-1521
   Full Text | Web of Science | Medline