Alsammoua S, , Kennedy J.H, Tolhurst J, Liptak P, Alexander-Sefre F
Department of Gynaecology, Glasgow Royal Infirmary, Glasgow, UK.
Corresponding
author: Dr. Samawal Alsammoua, Specialist Trainee in
Obstetrics & Gynaecology, Department of
Gynaecology, Glasgow
Royal Infirmary, 84-106 Castle Street, Glasgow G4
0SF
Email:alsammoua@doctors.org.uk
Abstract:
INTRODUCTION:
This
report describes a unique case of concurrent chronic and acute ectopic
pregnancies in an ipsilateral tube.
CASE HISTORY:
A 33-year-old woman presented with symptoms suggestive of miscarriage that resolved on conservative management, resulting to normal ßhCG level. However, she was readmitted 5 weeks later with vaginal spotting, right iliac fossa pain and slightly elevated ßHCG. A diagnosis of pregnancy of unknown location was made and she was managed conservatively. Four weeks later the patient presented once again with vaginal bleeding and a positive pregnancy test. Her serum ßhCG level was elevated and her pelvic ultrasound scan showed an adnexal mass. The patient therefore underwent laparoscopic salpingectomy. Histopathological examination showed two ectopic pregnancies within the same tube; an older (chronic) ectopic positioned within proximal end of the tube and a more recent one at the distal end.
CONCLUSION: This case highlights the difficulty in diagnosing chronic ectopic pregnancy and the increased risk of recurrence after conservative management.
Key Words: Concurrent, ipsilateral, chronic ectopic pregnancy
Case report:
A 33-year-old primigravida presented with 5 weeks history of continuous vaginal spotting and right iliac fossa pain after a possible but unconfirmed miscarriage. She had been amenorrheic for almost 10 weeks and had an episode of heavy vaginal bleeding, which was diagnosed as a miscarriage 5 weeks prior to this presentation. She was not using any contraception after stopping oral contraceptive pills a year earlier. The patient did not have any risk factors for ectopic pregnancy such as previous pelvic/ tubal surgery or pelvic inflammatory disease.
Investigations included a pelvic ultrasound scan (USS) which revealed an empty uterus, no signs of retained products of conception and a small 1.9x1.6x1.3cm mass medial to right ovary. ßhCG was 34 U/L. The decision was made for an expectant management that included serial ßhCG levels and ultrasound scans. ßhCG levels remained low gradually decreased and eventually became < 3 U/L four weeks after the initial presentation. Abdominal pain and vaginal spotting were minimal and there was no change on the USS findings therefore the patient was discharged home.
The patient presented again 5 weeks later with a positive home pregnancy test and complaining of vaginal spotting. USS showed a right adnexal mass (1.3x1.5x1.6 cm) and some free fluid in pelvis. ßhCG was highly elevated at 9661 U/L. A diagnosis of ectopic pregnancy was therefore made and the patient underwent diagnostic laparoscopy that revealed a right tubal pregnancy. Right salpingectomy was performed uneventfully and the patient had an uncomplicated recovery. She was discharged home two days later.
Histopathological examination of the removed tube showed “two separate lesions manifesting two ectopic pregnancies; an older (chronic) one positioned proximally and more recent one at the distal end. Sections of the 6 mm lesion towards the uterine proximal end of the fallopian tube showed characteristic features of chronic ectopic pregnancy: a fibrinous nodule with evidence of fresh and old haemorrhage. Within this; the "ghost" outlines of a few necrotic chorionic villi were identified” (figure1). The other lesion noted at the distal end of the fallopian tube close to the fimbria was a viable decidua, and unvascularised small chorionic villi (figure 2).
Figure
1: Chronic ectopic pregnancy
Figure 2: Viable ectopic pregnancy (Arrow shows viable decidua, and unvascularised small chorionic villi)
Discussion:
The incidence of ectopic pregnancy has been increasing over the past few decades in the UK. Currently the reported incidence is estimated at 11.5/1000 pregnancies. This condition remains at times a clinical challenge due to its varied clinical presentations and masquerading features.
Concurrent chronic and acute ectopic pregnancies are rare with an unknown incidence. Based on our literature search there has been no previous case report. We performed Medline and Google search using the following key words: concurrent, ectopic pregnancy, chronic.
Our case was not a diagnosed ectopic pregnancy at the second presentation. It was therefore managed as a case of a pregnancy of unknown location. Observational studies have shown that 44–69% of pregnancies of unknown location resolve spontaneously with expectant management (1–5). Within this group of patients, there would be ectopic gestations that also spontaneously resolve following absorption or tubal abortion (2,6). There are some recommendations that in case of patients with suspected pregnancy of unknown location, if the serum ßhCG is 1000–1500 iu/l and they have minimal or no symptoms, they can be managed expectantly. Studies have shown that such patients have generally a good long-term fertility outcome (7). Active intervention is required if patient become symptomatic or serum ßhCG levels begin to rise or plateau (3, 5). Intervention has been shown to be required in 23–29% of patients managed expectantly (1, 3). It is therefore important to highlight the value of serial serum ßhCG measurements.
Ectopic pregnancies with very low ßhCG levels are unlikely to rupture and, as stated above, may resolve spontaneously (8). However, in cases when gestational age is uncertain, a chronic ectopic pregnancy should be considered. Chronic ectopic pregnancy is thought to constitute 85% of ectopic pregnancies with very low ßhCG (9). Recurrent small episodes of bleeding in chronic ectopic pregnancies can result in gradual disintegration of the tubal wall and a pelvic inflammatory mass may eventually be formed. Since the trophoplastic tissue may have become unviable, the ßhCG level may become very low or absent. However, despite this, a chronic ectopic pregnancy can infarct and cause hemorrhage (10).
Chronic ectopic pregnancy is a problematic diagnosis. The clinical presentation can be mild, with absent or subtle symptoms. The high incidence of negative pregnancy tests or very low ßhCG and the poor specificity of sonographic patterns can be misleading. The correct diagnosis can only be established at surgery or following histopathological examination of the resected specimen.
The presentation of chronic ectopic pregnancy as an inflammatory mass can cause problems in differential diagnosis. The involution of the trophoblast may allow the menstrual cycles to re-establish and the convoluted, blood- filled tube often involving the ipsilateral ovary may simulate tumour or an endometriotic mass. Expectant management might not therefore be appropriate, as differential diagnosis of the mass would also include pelvic malignancy. The extent of surgical management would depend on the size of the mass, involvement of adjacent organs and the reproductive history of the patient. This might vary from conservative surgical excision of the mass (11) to salpingo-oophorectomy or even more extensive surgery. The mass formed may be also an incidental finding following laparotomy for other causes, years later (12-13). Extensive microscopic sampling of a so-called chronic ectopic pregnancy may be required to demonstrate a few ghost villi (as in our case) as the main diagnostic sign.
Our patient did not use any contraception after her initial discharge following the expectant management. Spirtos et al reported follow up data on forty-four patients with ectopic pregnancies who had serial serum progesterone determination, up to 40 days following their surgery. Out of these patients, 50% demonstrated ovulatory luteal activity (serum progesterone at least 3 ng/mL) before day 24 and 84% before day 40. The study concluded that if the hormonal contraception is not introduced within six weeks after surgery, the onset of folliculogenesis is missed in approximately three-quarters of cases and hence the possibility of further pregnancy. They therefore recommended that contraception should be introduced immediately after surgery, if further pregnancy is unwanted or contraindicated (14).
After medical management of ectopic pregnancy, using methotrexate, patients are advised to use contraception for at least 3 months due to concerns over teratogenic toxicity (15). This practice, in effect would prevent the possibility of recurrent ectopic pregnancy. However, with regards to contraception after conservatively managed ectopic pregnancy or pregnancy of unknown location, there are no specific recommendations in the literature due to lack of data. Furthermore, there are no studies to determine the period of time after which it is safe for these patients to conceive again, without an increased risk of recurrence. Considering the fact that ovulation can be resumed quickly after managed ectopic pregnancy, we think it is important to counsel patients regarding the possible risk of recurrence and the immediate need for contraception.
This case report highlights the importance of close monitoring of patients who are managed expectantly and the low threshold for re-investigating these patients if any clinical suspicion arises. This would increase the possibility of detecting cases with chronic ectopic pregnancy. In case of our patient, we believe failure to use any contraception and presence of a chronic tubal pregnancy, led to a recurrence within ipsilateral tube.
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