Shinde S*, Madge H*, Mali K**.
(* Senior Resident, ** Assistant Professor, Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Ectopic pregnancy is a leading cause of maternal morbidity and mortality in early pregnancy. The clinical features of chronic ectopic pregnancy are variable. We present a case of chronic ectopic pregnancy mimicking pyosalpinx which is a diagnostic dilemma.
An ectopic pregnancy is one in which the fertilized ovum gets implanted in a site other than the normal uterine cavity. The incidence of ectopic pregnancy has increased over the last 20 years. It is around 8.1 for 1000 deliveries. It turns chronic with the formation of a pelvic hematocele due to multiple minute hemorrhages into the peritoneal cavity. Amenorrhea, vaginal bleeding and abdominal pain are the classic features of chronic ectopic pregnancy which are seen in at least 50% of the cases. Diagnosis depends mainly on history-taking, clinical physical examination, laboratory investigations (urine pregnancy test, serum beta hCG) and radiological investigations. Although ultrasonography (USG) has high sensitivity, large adnexal mass can be a challenge in arriving at a correct diagnosis. It can be reported falsely as a large hematosalpinx  or abdominopelvic lump mimicking an ovarian tumor. In this case, patient presented with pain in abdomen, spotting per vaginum, negative urine pregnancy test and radiological findings suggestive of a pyosalpinx.
34 year lady P2L2 referred from a private practitioner with symptoms of abdominal pain and spotting per vaginum since 2 months and USG suggestive of left adnexal space occupying lesion of 6.8x4.3 cm. Her menstrual cycles were regular and she gave no history of amenorrhea. There was no history of vaginal discharge, tuberculosis or use of contraceptives. On examination, her pulse was 90/min and blood pressure was 110/60 mm of Hg. She had no pallor. Abdomen was soft with no guarding, tenderness or rigidity. On speculum examination, cervix and vagina looked healthy. On bimanual examination, uterus was of 6wks size, anteverted, deviated to the right and a 3x4 cm cystic mass was felt in the left fornix. The mass was mobile and left forniceal tenderness was present. There was no cervical motion tenderness. The urinary pregnancy test was negative and beta hCG value was low (3.58 mIU/ml). USG was repeated which showed a thick walled convoluted cystic tubular structure with dense echoes within forming a mass of 6.6x5x4 cm in the left adnexa suggestive of left sided pyosalpinx. Endometrial thickness was 9 mm. In view of pyosalpinx, investigations to rule out tuberculous focus (chest x-ray, Mantoux test, sputum AFB) were done and found to be negative. Computed tomography (CT) of the pelvis showed dilated tubular structures with multiple hypodensities with a maximum diameter of 3.1 cm in left adnexa likely to be left sided pyosalpinx [figure 1]. Minimal free fluid was also noted in the pelvis. She was started on oral cefixime, doxycycline and metronidazole followed by intravenous ceftriaxone and metronidazole for 5 days. Despite antibiotics, her symptoms persisted. Hence, consent for exploratory laparotomy with left salpingectomy SOS left salpingo oophorectomy was taken. Intraoperatively, left fallopian tube showed 3x6cm organized congested mass with blood clots and left ovary was normal. Right fallopian tube and ovary were normal [fig.2]. Thus left sided salpingectomy was done. Histopathology of the specimen showed a fallopian tube wall with dense chronic inflammation and focally multinucleated giant cells. One of the sections showed occasional necrotic villi in the lumen amidst hemorrhage. Final diagnosis of chronic ectopic pregnancy with chronic salpingitis was made. Postoperative period was uneventful. Her symptoms were relieved and she was discharged after 7 days.
Figure 1. CT scan pelvis suggesting pyosalpinx.
Figure 2. Left chronic ectopic pregnancy with normal right fallopian tube and ovary.
Chronic ectopic pregnancy is when implantation occurs outside the endometrial cavity, there are multiple recurrent minute hemorrhages into the peritoneal cavity. At times bleeding can be confined to the fallopian tube resulting in hematosalpinx. In other cases, it can also lead to adhesion formation with adjacent structures presenting clinically as an abdominal or pelvic lump. Thus, clinical acumen, laboratory investigations and imaging all can be misleading and the diagnosis can be confused with hematosalpinx, pyosalpinx, ovarian tumor or abdomino pelvic lump. In this case, there was an inability to diagnose an ectopic pregnancy pre operatively as she gave no history of amenorrhea, urine pregnancy test was negative similar to 17.65% of cases of ectopic pregnancies studied by Swami et al, serum beta hCG was normal similar to study conducted by Surampudi and Gundabattula. USG and CT pelvis reported pyosalphinx. Screen for tuberculosis in the view of pyosalphinx was negative. As laparotomy was done for refractory symptoms, the final diagnosis was made aided with histopathology.
The preoperative diagnosis of chronic ectopic pregnancy is often difficult. Laboratory and imaging can be misleading in diagnosing chronic ectopic pregnancy. Laparoscopy or laparotomy followed by histopathology can help in confirming a chronic ectopic pregnancy.
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Shinde S, Madge H, Mali K. Atypical Presentation Of Chronic Ectopic Pregnancy. JPGO 2019. Vol. 6. No. 6. Available from: https://www.jpgo.org/2019/06/atypical-presentation-of-chronic.html