Chronic tubal pregnancy without positive pregnant tests, a rare but possible scenario.

OBJECTIVE: Chronic ectopic pregnancy is a variant of ectopic pregnancy featured with a low or normal serum beta-human chorionic gonadotropin (ß-hCG) test. Obscure clinical presentations and non-specific images make chronic ectopic pregnancy a diagnostic dilemma until now. CASE REPORT: A 40-year-old female was misdiagnosed as tubo-ovarian abscess initially due to chronic lower abdominal pain, negative pregnancy test, and a complicated pelvic mass on abdominal CT scan and serial follow-up ultrasonography. Diagnostic laparoscopy was performed because of persistent pelvic mass with abdominal pain and irregular vaginal bleeding. Left tubal salpingectomy was performed and pathology reported a hematocele with inactive trophoblast tissue. Chronic ectopic pregnancy was proved. The symptoms resolved completely after our surgery. CONCLUSION: An abnormal adnexal mass with a history of recent pregnancy could still be possible for chronic ectopic pregnancy even with a negative pregnancy test. Diagnostic laparoscopy and pathology confirmation could be helpful when the clinical manifestation is confusing.

Chronic ectopic pregnancy: case report and systematic review of the literature.

BACKGROUND: Chronic ectopic pregnancy (CEP) is a variant of ectopic pregnancy (EP) characterized by low or absent serum human chorionic gonadotropin (hCG) levels, resistance to methotrexate (MTX), and an adnexal mass with fibrosis, necrosis, and blood clots due to repeated and gradual fallopian tube wall disintegration. CEP may complicate the course of patients with EP and is difficult to diagnose. CASE PRESENTATION: The case of a 36-year-old woman with EP, low serum hCG levels, a small echogenic adnexal mass, and resistance to MTX is presented. Salpingectomy was performed and histology demonstrated CEP with fibrosis, necrosis, and a hematocele within degenerated chorionic villi. SYSTEMATIC LITERATURE REVIEW: In a database search, 19 case reports, 3 case-control studies, and 3 case series describing 399 patients with CEP were identified. Serum hCG was negative in 40/124 cases (32%) with reported levels of serum hCG. The most common presenting symptom was abdominal pain (284/399 [71%]), followed by irregular vaginal bleeding (219/399 [55%]), and fever (20/399 [5%]). 73/399 (18%) women were asymptomatic. An adnexal mass was seen in 144/298 (48%) cases with perioperative ultrasound examination and with a mean largest diameter of 6.8 cm. Data on treatment modalities and outcomes were available for 297 women. Of these, 89% underwent surgery as first-line therapy. Laparoscopy was performed in most cases. MTX was the first-line therapy in a minority of cases. Complete resolution was achieved by first-line therapy in 287/297 (97%) cases. Adverse events were reported in 218 patients with CEP. Among those, adverse events ≥ grade 3 were seen in 186/218 (85%) cases. There was no case of treatment-related mortality. CONCLUSION: CEP is a variant of EP with low or absent trophoblast activity. A prolonged clinical course is typical and surgery is the mainstay of treatment.

Chronic tubal pregnancy manifesting as a heterogeneous adnexal mass with prominent neovascularization in a woman with a negative serum ß-human chorionic gonadotropin level.

A 41-year-old woman (gravida 2, para 1) underwent elective termination of pregnancy at approximately 7 weeks of gestation. At 1 month after the elective abortion, she was referred due to abnormal results in a cervical cytological examination. Transvaginal ultrasonography showed a heterogeneous mass of 16 mm in diameter in the left adnexal region. At 3 months after her referral, the asymptomatic left adnexal mass had increased to 55 mm in diameter. Prominent vascular flow was detected in the solid portion by color Doppler ultrasonography. Magnetic resonance imaging showed suspected hemorrhage in the left adnexal cystic mass. Three-dimensional computerized tomographic angiography showed the prominent development of tortuous blood vessels in the left adnexal region, which originated from the left ovarian artery. The patient had a negative ß-human chorionic gonadotropin (hCG) level. Left salpingectomy was performed by a single-port laparoscopic approach. A pathological examination revealed degenerated villous tissue with ß-hCG-positive syncytiotrophoblasts.

The diagnostic conundrum of chronic ectopic pregnancy: A case report.

Chronic ectopic pregnancy (CEP) is a rare condition caused by implantation of trophoblastic tissue in the fallopian tube, which causes protracted tissue destruction at the site of attachment. The process of minor rupture and bleeding results in chronic inflammation, giving rise to a haematocele which often resembles a pelvic mass. Unlike ectopic pregnancy, the level of serum human chorionic gonadotropin (hCG) in patients with CEP is usually low or undetectable as chorionic villi are generally sparse. Therefore, CEP often poses a specific diagnostic challenge for clinicians, as both biochemical markers and imaging modalities are unreliable in its diagnosis. Nevertheless, in cases where serum bhCG is significantly elevated in the presence of a large pelvic mass, the possibility of a malignant ovarian germ cell tumour (MOGCT) must be considered and investigated appropriately. Here, we present a rare case of a young woman who was referred to a gynaecological cancer centre with an acute abdomen for the treatment of MOGCT but was subsequently diagnosed with CEP following laparotomy. In our case report, we highlight the diagnostic conundrum of CEP and MOGCT and discuss the surgical challenges both these conditions pose, especially as many of these women are young and desire fertility preservation.