Chronic ectopic pregnancy presenting as a suspected tubo-ovarian abscess: a diagnostic dilemma
An ectopic pregnancy (EP) occurs when the gestational sac is implanted outside of the endometrial cavity. An absolute majority of cases of ectopic pregnancies are implanted in the fallopian tube and present clinically with symptoms of amenorrhoea, lower abdominal pain and vaginal bleeding. Chronic EP (CEP) is a variant of EP, which is difficult to diagnose with variable and non-specific clinical signs and symptoms and there remains no universal agreement about the definition of CEP. Often it is a retrospective diagnosis considering the clinical presentation and intra operative findings. Serum B-HCG, which is a reliable marker in monitoring as well as establishing a diagnosis of EP, tends to remain low or negative in CEP due to sparse chorionic villi, adding further challenges to making the diagnosis. CEP often develops when the trophoblastic tissue gradually invades through the implantation site leading to repeated rupture at the site and continued minor bleeding that over time can develop into a haematocele and appear as a pelvic mass. However, the final diagnosis of CEP is often made at histology with findings of haemorrhage and blood clots, disintegration of the tubal wall, multiple minor ruptures, and areas of dense fibrosis and necrosis embedded within degenerated and/or avital chorionic villi.
CASE PRESENTATION
A para 2+2 presented to the gynaecology assessment unit with a 4-day history of severe lower abdominal pain associated with mild PV bleeding, which was presumed to be normal periods. She had had a spontaneous miscarriage 4weeks prior and her serum B-HCG levels had dropped from 700 IU/L to 400IU/L and 3 weeks postmiscarriage urine pregnancy test was negative. She had no history of similar pain, no history of dysmenorrhoea, no bowel or urinary symptoms or previous pelvic inflammatory disease or use of intrauterine contraceptive device.
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