Author
Information
Pandey N*, Gupta AS
(* Third Year
Resident, ** Professor. Department of Obstetrics and Gynecology, Seth GS Medical College & KEM
Hospital , Mumbai , India
Abstract
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.
Introduction
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.[3]
Case Report
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.
Discussion
A chronic ectopic
pregnancy is not a very rare entity and hence should be kept in the
differential diagnosis of any complex adnexal mass.[1] 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.[3] 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.[5] 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.
Conclusion
We can conclude that the
differential diagnosis of chronic ectopic pregnancy should be kept in mind
while dealing with a case of adnexal mass.
References
- Turan C, Ugur M, Dogan M, Ekici E, Vicdan K, Gokmen O. Transvaginal Ultrasonographic findings of Chronic Ectopic Pregnancy. European Journal of Obstetrics & Gynecology and Reproductive Biology.1996 Aug; 67(2):115-119.
- Uğur M, Turan C, Vicdan K, Ekici E, Oğuz O, Gökmen O. Chronic ectopic pregnancy: a clinical analysis of 62 cases. Aust N Z J Obstet Gynaecol. 1996; 36(2): 186–189.
- Bedi DG, Fagan CJ, Nocera RM. Chronic ectopic pregnancy. J Ultrasound Med. 1984 Aug; 3(8):347-52.
- Harada, M., Hiroi, H., Fujiwara, T., Fujimoto, A., Kikuchi, A., Osuga, Y., Momoeda, M., Kugu, K., Yano, T. and Taketani, Y. Case of chronic ectopic pregnancy diagnosed in which the complete shape of the fetus was visible by ultrasonography. Journal of Obstetrics and Gynaecology Research. 2010; 36: 462–465.
- 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.
Citation
Pandey N, Gupta AS.