**. Gupta AS
(* Third Year Resident, ** Professor. Department of Obstetrics and Gynecology, Seth GS
Medical College & KEM
Hospital, . Mumbai, India
A 22 year old nulligravida presented with pelvic pain for 2 months. There was no menstrual irregularity. There was a left adnexal mass on pelvic examination. Provisional diagnosis of pelvic inflammatory disease with probability of genital tuberculosis was made. The patient was started on antibiotics. Ultrasonography (USG) was suggestive of pyosalphinx. Serum β-hCG was negative. Laparoscopy showed dense pelvic adhesions. Laproscopic adhesiolysis was done. A friable looking mass of 3 cm x 3 cm was seen on the left fallopian tube and was excised. Histopathology confirmed the diagnosis of a chronic ectopic. This case highlights that the differential diagnosis of a chronic ectopic should always be kept in mind while treating a patient with an adnexal mass.
The entity of a chronic ectopic gestation has not been properly defined in the gynecological textbooks [1,2] . It is formed due to repeated hemorrhages in the gestational sac leading to disintegration and formation of a pelvic mass.[3, 4, 5] A chronic ectopic pregnancy is often mild symptomatically and has a protracted course.[5,6] Its clinical presentation can often be confused for pelvic inflammatory disease, endometriosis or uterine leiomyoma.
A 22 year old patient, nulligravida, presented with complaints of pelvic pain for the past 2 months. She did not complain of any fever, menstrual irregularity or vaginal discharge. There was no other major medical or surgical illness in the past except for a history of hypersensitivity to ciprofloxacin. On examination, her general condition was fair and vital parameters were stable, with a pulse rate of 84/min and blood pressure of 110/70 mm Hg. There was no pallor or icterus. Cardiovascular system and respiratory system were within normal limits. The abdomen was soft with tenderness in the left iliac fossa. On per speculum examination, cervix and vagina were healthy. There was no vaginal discharge. On bimanual examination uterus was normal in size, anteverted and mobile. There was a left sided tense, cystic and tender adnexal mass of around 4 cm in size. Right sided adnexa was free.
Figure 1. Ultrasound Image of the adnexal mass. The cursor defines the adnexal mass which was suspected to be a pyosalpinx.
In her investigations, Hb was 13.2 gm%. White cell count was 8,700/mm3 and her liver and renal function tests were within normal limits. Serum β-hCG level was <1.2 mIU/ml. Pelvic USG was suggestive of a heterogeneous mass visualized above the left ovary of 4.4 x 3.1 cm with cystic changes, suggestive of a pyosalphinx. Endometrial thickness was normal. The patient was started on parenteral broad spectrum antibiotics and posted for a diagnostic and operative laparoscopy. On laparoscopy pelvis was obliterated with a thick curtain of omentum. After Adhesiolysis the uterus was visualized. It was normal in size. Right fallopian tube and ovary were normal. Multiple adhesions between the tube and the cul-de-sac were released to visualize the left adnexa. On the left side one 3x3 cm friable looking mass was seen at the end of the tube The left ovary was normal. An intra operative diagnosis of chronic ectopic pregnancy was made. Left sided salphingectomy was done. Histopathology showed presence of non-viable villi which was consistent with the diagnosis of a chronic ectopic pregnancy of the left Fallopian tube.
A chronic ectopic pregnancy is not a very rare entity and hence should be kept in the differential diagnosis of any complex adnexal mass. It classically has very mild symptoms and a protracted course.[5,6] USG can be useful in diagnosing a chronic ectopic pregnancy but is not specific. USG picture can mimic that of pelvic inflammatory disease, endometriosis or uterine leiomyoma. Serum β-hCG levels also tend to be negative. A clinical suspicion is all that can help in obtaining a pre-operative diagnosis.
In this case, the serum β-hCG levels were negative and the USG was suggestive of a pyosalphinx. The main complaint of the patient was pain in abdomen. This can be correlated to her intraoperative finding of multiple adhesions. It remains a matter of debate whether the treatment of this patient should have been limited to adhesiolysis, since it would take care of her chief complaint. Whether a salphingectomy is actually required for a chronic ectopic pregnancy or the mass can be treated expectantly, like that of an unruptured ectopic mass on medical management, requires further study. An unruptured ectopic mass on medical management is monitored solely with the fall in serum β-hCG levels, and left alone once the β-hCG levels are normal. Since the β-hCG levels are normal for most of the chronic ectopic pregnancy, applying the same principal is not possible. It can be argued that a surgical intervention should remain restricted to solving the chief complaint and may not involve salpingectomy in all the cases, especially in the younger women who are desirous of childbearing. Twin possibilities of spontaneous recanalisation of the tube and restoration of its function or persistence of the pathology causing the ectopic implantation persists. When operative laparoscopy is done in symptomatic patients it makes for good clinical practice to excise the lesion and obtain a tissue diagnosis as occasionally neoplastic or inflammatory lesions like tuberculosis may be diagnosed.
We can conclude that the differential diagnosis of chronic ectopic pregnancy should be kept in mind while dealing with a case of adnexal mass.
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- Nacharaju M, Vellanki V S, Gillellamudi S B, Kotha VK and Alluri A. A Rare Case of Chronic Ectopic Pregnancy Presenting as Large Hematosalpinx. Clinical Medicine Insights Reproductive Health 2014; 8: 1–4.
- Manson F. Ectopic pregnancy with negative serum hCG level. http://sonoworld. com/fetus/page.aspx?id=1712. Updated March 28, 2006. Accessed date: 27/08/2014.
Chronic Ectopic Pregnancy Masquerading
as a Pyosalphinx. JPGO Volume 1 Issue 11. Available from: http://www.jpgo.org/2014/11/chronic-ectopic-pregnancy-masquerading.html Gupta AS.