Speakers - 2027

Title: Beyond the usual suspects: Unveiling a case of chronic ectopic pregnancy

Abstract

Chronic Ectopic Pregnancy (CEP) is a rare and challenging diagnosis, with few cases reported in literature accounting for approximately 6% of all ectopic gestations. Often it presents with similar symptoms to an Acute Ectopic Pregnancy, namely amenorrhea, lower abdominal pain and vaginal bleeding. However, because of the protracted nature of symptoms and often negative B-HCG as a result of inactive trophoblasts in women with CEP, it often poses a diagnostic dilemma. This case report highlights a rare instance of chronic ectopic pregnancy, emphasizing the importance of early detection, careful differential diagnosis, and tailored treatment to avoid complications such as rupture, hemorrhage, or long-term fertility issues. This is a rare case of CEP in a 29-year-old woman who presented to our emergency department, with the chief complaint of vaginal spotting for 1 month. The menstrual history reported the presence of amenorrhea, with a history of a positive urine pregnancy test, however, at the time of consultation in our emergency department, the urine pregnancy test was already negative.

Introduction: Chronic ectopic pregnancy (CEP) is a variant of ectopic pregnancy (EP) characterized by low or absent serum human chorionic gonadotropin (hCG) levels, resistance to methotrexate (MTX), and an adnexal mass with fibrosis, necrosis, and blood clots due to repeated and gradual fallopian tube wall disintegration. CEP may complicate the course of patients with EP and is difficult to diagnose. Chronic ectopic pregnancy (CEP) is a rare and intriguing clinical entity that presents unique challenges in diagnosis and management. Typically, ectopic pregnancies are diagnosed early in their course, with most cases presenting acutely due to symptoms such as pelvic pain, vaginal bleeding, or the life-threatening rupture of a fallopian tube. However, chronic ectopic pregnancies develop slowly over time, often remaining asymptomatic or producing mild, nonspecific symptoms, which delays diagnosis and can lead to significant morbidity if not recognized promptly. Ectopic pregnancies occur when a fertilized egg implants outside the uterine cavity, most commonly in the fallopian tube. However, in rare cases, ectopic pregnancies can also occur in the ovaries, cervix, or abdominal cavity. A chronic ectopic pregnancy is characterized by the persistence of the pregnancy over weeks or months without resolution, with the possibility of the pregnancy becoming surrounded by fibrous tissue or blood clots, which may prevent immediate rupture or other acute manifestations. The condition poses diagnostic difficulties because the symptoms can be vague, often resembling other gynecological or gastrointestinal disorders. Chronic ectopic pregnancies are frequently misdiagnosed as pelvic inflammatory disease (PID), ovarian cysts, or even appendicitis due to their nonspecific and overlapping clinical symptoms, such as lower abdominal pain, vaginal bleeding, and adnexal tenderness. This diagnostic challenge underscores the importance of maintaining a high index of suspicion and utilizing appropriate imaging and serial β-hCG measurements to ensure accurate diagnosis and timely intervention. Management of CEP depends on factors like the size, location, and stability of the pregnancy. Early detection can facilitate medical management with methotrexate or surgical intervention, which is crucial to preventing life-threatening complications, including hemorrhage or long-term fertility issues. This background underscores the importance of vigilance in diagnosing chronic ectopic pregnancy to mitigate risks to maternal health.

Case Report: This is a case of a 29 years old, Gravida 4 Para 2 (2012), married, who presented at the IWNH emergency room with one month history of vaginal spotting, associated with intermittent hypogastric cramping. She had no known comorbidities nor previous tubal surgeries done. She denies history of a prior tubal pregnancy nor any history of previous tubal infection. She denied any heredofamilial diseases. She is a non-alcoholic beverage drinker, non-smoker and denies history of illicit drug use. She is a Gravida 4 Para 2 (2012), with 2 previous pregnancies carried to term delivered by normal spontaneous vaginal delivery, and 1 abortion with completion curettage done. For this pregnancy, her last menstrual period was las August 4, 2024 with an age of gestation of 19 and 3 days by amenorrhea. She is expected to deliver on May 11, 2025. A transvaginal sonogram was done two weeks before admission revealing thin endometrium, normal-sized anteverted uterus in the light of a positive pregnancy test and the presence of left adnexal mass ectopic (tubal) pregnancy. Patient was lost to follow-up and opted to seek consult at our emergency department. Clinical examination revealed an awake, conscious and coherent patient. She is not in cardiorespiratory distress, noted to be hypertensive at 150/100 mmHg and tachycardic at 110 bpm. Abdominal examination revealed a flat, soft abdomen, with tenderness at the hypogastric area. Pelvic examination revealed a grossly normal external genitalia. Speculum examination showed a midline cervix with scanty bleeding per os. Bimanual examination revealed an introitus that admitted 2 fingers with ease, a closed cervix, the corpus is not enlarged absence, of palpable adnexal mass nor tenderness, and fullness in the posterior cul-de-sac. A battery of ancillary tests were requested. The complete blood count and platelet counts were normal. Her urine pregnancy test was negative and the serum beta-hCG level was low at 5.15 mIU/ml. An urgent transvaginal ultrasonography performed in our institution noted: normal cervix, normal sized retroverted uterus, thickened endometrium, normal ovaries. Right adnexal mass, considered a chronic ectopic pregnancy. Inferolateral to the uterus and inferior to the right ovary is a heterogenous mass measuring 12.42 x 9.52 x 8.88 cm (vol 549.12 cm3), absent vascularity, adherent to the posterior portion of the uterus. Left adnexal mass, consider hydrosalpinx, inferomedial to the left ovary is an anechoic tubulocystic structure measuring 3.54x3.13x2.3cm with incomplete septations, negative sliding sign, negative free fluid at the culde-sac. Hence the impression of Gravida 4 Para 2 (2012) Chronic Ectopic Pregnancy, Left. The patient was then admitted and appraised to undergo exploratory laparotomy, bilateral salpingectomy. Intraoperatively, there was minimal hemoperitoneum with no noted adhesions. The fimbria of the right fallopian tube was cystically dilated to approximately 12 x 10 cm. It was densely adherent to the posterior surface of the corpus. She underwent adhesiolysis and right salpingectomy revealing a tan-yellow cystic mass measuring 12x10x8 cm., On cut section, the internal capsule is hemorrhagic and the mass contained blood clots approximately 500 cc in volume. The Left fallopian tube was edematous but normal in length. A contralateral salpingectomy was done as the patient was nondesirous of future pregnancies. Both ovaries were grossly normal. The patient had an uneventful recovery from the surgery. She was discharged from the hospital day two post-op with no complications. A repeat serum bhCG level, done a week after surgery, was undetectable.