|Year : 2022 | Volume
| Issue : 3 | Page : 152-156
Spectrum of unusual ectopic pregnancies on imaging: Case series
Madhuri Pundlikrao Udgire1, Varun Vasant Nimje2, Shubham Baburao Bodhankar2, Tushar Suresh Yadav2, Rushabh Chordiya2
1 Department of Obstetrics and Gynecology, K. B. Bhabha Municipal General Hospital, Mumbai, Maharashtra, India
2 Department of Radiodiagnosis and Imaging, N.K.P. Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
|Date of Submission||05-Apr-2022|
|Date of Decision||04-Jun-2022|
|Date of Acceptance||20-Jun-2022|
|Date of Web Publication||05-Aug-2022|
Varun Vasant Nimje
Department of Radiodiagnosis and Imaging, N.K.P. Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Ectopic pregnancy is a life-threatening condition commonly encountered in the emergency department and possesses high morbidity and mortality association in women of childbearing age. However, there are some unusual ectopic pregnancies that are rare. Objective: The purpose of this case series is to illustrate and familiarize clinicians with imaging findings along with risk factors and management strategies of less commonly encountered unusual ectopic gestations. Materials and Methods: Patients referred to the department of radiodiagnosis and imaging with unusual ectopic pregnancy were included. A 1–7 MHz convex transducer was used for transabdominal examinations, and a 3–12 MHz endovaginal ultrasound probe was used for transvaginal examinations. Conclusion: Incidence of gestations with ectopic implantations is rising, and knowledge of the imaging appearance of uncommon ectopic gestations is important for clinicians in correct diagnosis and timely treatment initiation.
Keywords: Cervical ectopic, ectopic pregnancy, heterotopic pregnancy, ovarian ectopic
|How to cite this article:|
Udgire MP, Nimje VV, Bodhankar SB, Yadav TS, Chordiya R. Spectrum of unusual ectopic pregnancies on imaging: Case series. Apollo Med 2022;19:152-6
| Introduction|| |
Although mortality rates from ectopic pregnancy have declined over the past three decades due to earlier detection of ectopic pregnancy, it still remains a significant cause of death among women of childbearing age. Ectopic pregnancy implantations need to be considered when a patient of childbearing age group has a positive pregnancy test, discomfort, and vaginal bleeding. Because these unusual ectopic pregnancies are uncommon, clinicians may be unfamiliar with their imaging presentations. This article describes imaging findings, risk factors, and therapeutic techniques for unusual ectopic pregnancies such as heterotopic pregnancy, advanced ectopic pregnancy, ovarian ectopic pregnancy, and cervical ectopic pregnancy.
| Materials and Methods|| |
Patients referred to the department of radiodiagnosis and imaging having unusual ectopic gestation were included. A 1–7 MHz convex transducer was used for transabdominal examinations, and a 3–12 MHz endovaginal ultrasound probe was used for transvaginal examinations. The examination started with transabdominal B-mode examination of the pelvis to localize the pregnancy. After localization of the pregnancy, whenever possible, transvaginal ultrasound was performed to confirm the diagnosis. Magnetic resonance imaging (MRI) was performed on GE 1.5 Tesla HDXT, Version 23.0 machine.
Case 1: Ruptured advanced tubal ectopic pregnancy
A 29-year-old female (gravida 2, para 1, live 1) with 13-weeks amenorrhea presented to the casualty complaining of acute-onset lower abdominal pain. She had one previous normal vaginal delivery. Her urine pregnancy test was detected positive 3 days ago following which she did not visit any hospital. She had no history of vaginal bleeding or contraceptive use such as intrauterine devices. General examination revealed signs of shock with severe pallor, heart rate of 112/min, and blood pressure of 90/70 mmHg. She had tenderness over both the iliac fossae. On vaginal examination, tenderness was present in all the fornices. Her urine pregnancy test was positive. Her hemoglobin was 5 g/dL and b-hCG level was 87,566 IU/L. Other routine hematologic and biochemical investigations were normal.
On transvaginal ultrasound, there was evidence of an empty endometrial cavity and a live fetus in the left adnexa surrounded by mild free fluid. The crown-rump length (CRL) of the fetus was corresponding to the gestational age of 12 weeks 1 day [Figure 1]. Diagnosis of live ruptured ectopic gestation was kept, and the patient was taken for emergency exploratory laparotomy. During the exploratory laparotomy, a live 12-week fetus was seen within the left adnexa with ruptured left fallopian tube [Figure 2]. One liter of hemoperitoneum was evacuated. Left salpingectomy was performed and sent for histopathology. Both the ovaries were normal. The patient received transfusion of packed red cells and fresh frozen plasma intraoperatively and postoperatively.
|Figure 1: Transvaginal ultrasound image showing fetus in the left adnexa with crown-rump length corresponding to 12 weeks 1 day (Case 1)|
Click here to view
|Figure 2: (a) Intraoperative photograph showing fetus in the left adnexa surrounded by blood. (b) Specimen of fetus corresponding approximately to 12 weeks (Case 1)|
Click here to view
Case 2: Heterotopic pregnancy in spontaneous conception with septate uterus
A 27-year-old primigravida with 7 weeks of amenorrhea presented to the casualty with acute-onset pain lower abdomen which was associated with vaginal bleeding and vomiting. She had no history of ovulation induction for infertility or previous ectopic pregnancy. Her urine pregnancy test was positive. On examination, she was tachycardic (heart rate: 108/min) with low blood pressure of 90/64 mmHg. Her abdomen was moderately tender on palpation. She was anemic with hemoglobin level of 7 g/dL.
On transabdominal ultrasound examination, there was evidence of a live intrauterine pregnancy in the right endometrial cavity of a septate uterus. The left endometrial cavity was empty. Another gestational sac with live pregnancy was noted in the left adnexa medial to the left ovary [Figure 3] and [Figure 4]. It was surrounded by echogenic collection on all sides suggestive of clotted blood. The patient had moderate hemoperitoneum [Figure 5]. She underwent emergency exploratory laparotomy. There was ruptured left tubal ectopic pregnancy with associated hemoperitoneum and multiple blood clots in the pelvic cavity [Figure 6]. Left salpingectomy was performed with evacuation of hemoperitoneum. The patient received intraoperative blood transfusion. The patient had repeat ultrasound of the pelvis after about 1 week which demonstrated the absence of gestational sac within the right endometrial cavity and confirmed missed abortion of intrauterine pregnancy.
|Figure 3: Grayscale transabdominal ultrasound image showing simultaneous evidence of intrauterine (arrow) and left adnexal gestational sac (arrowhead). Endometrium in the fundus shows indentation (asterisk) with normal external uterine contour suggesting septate uterus (Case 2)|
Click here to view
|Figure 4: (a) Intrauterine fetus and (b) fetus in the left adnexa showing the presence of cardiac activity (Case 2)|
Click here to view
|Figure 5: Transabdominal ultrasound image showing free fluid with echoes (asterisk) reaching up to the inferior surface of the liver suggesting hemoperitoneum (Case 2)|
Click here to view
|Figure 6: Intraoperative photograph showing ruptured ectopic pregnancy in the left fallopian tube (arrow) with normal bilateral ovaries (Case 2)|
Click here to view
Case 3: Ruptured live ovarian ectopic pregnancy
A 32-year-old female, gravida 2, para 1, live 1, presented to the outpatient department with a history of pain in the left lower abdomen and amenorrhea of 7 weeks with a positive urine pregnancy test which she took at her home the day before. Pain was dull aching and started since morning. She had a prior history of pelvic inflammatory disease. Her previous cesarean section was approximately 2 years ago. Her general examination was within normal limits. She had mild tenderness in the left iliac fossa. Blood pressure was 120/70 mmHg, and heart rate was 86/min. Her hemoglobin was 12 g/dL, and other hematological parameters were within normal limits.
She was advised pelvic ultrasound for confirmation of pregnancy. On transvaginal ultrasound, trilaminar endometrial cavity was found without evidence of gestational sac. There was evidence of gestational sac with live fetus which was attached to the left ovary [Figure 7] and [Figure 8]. The fetal pole was corresponding to the gestational age of 6 weeks 3 days. Mild free fluid with moving echoes was present in the pelvis raising the possibility of ruptured ovarian ectopic pregnancy. The patient underwent exploratory laparotomy which revealed a heterogeneous mass contiguous to the left ovary with intact left fallopian tube. There was approximately 300 mL of blood within the pelvic cavity confirming the diagnosis of ruptured ovarian ectopic pregnancy. Hemoperitoneum was evacuated and wedge resection of the ectopic gestation from the left ovarian tissue was performed preserving as much ovarian tissue as possible. Postoperative stay of the patient was uneventful. Ovarian ectopic pregnancy was confirmed on histopathology.
|Figure 7: Transvaginal grayscale ultrasound image showing gestational sac with fetal pole (arrow) attached to the left ovary (asterisk) with adjacent fluid with echoes suggestive of hemoperitoneum (arrowhead) (Case 3)|
Click here to view
|Figure 8: On spectral Doppler examination, the fetus in the gestational sac shows cardiac activity (Case 3)|
Click here to view
Case 4: Live cervical ectopic pregnancy
A 25-year-old, gravida 2, para 1, live 1, with amenorrhea of 1 month 20 days and positive urine pregnancy test presented to the casualty complaining of pain in lower abdomen and vaginal spotting since 6 hours. She had a history of prior cesarean section 3 years back. She had no history of contraceptive use or previous abortions. She was tachycardic (pulse: 102/min) with otherwise normal vital signs. On vaginal examination, the external os was closed with active vaginal bleeding. Her hemoglobin was 11 g/dL. A transvaginal ultrasound indicated a gestational sac in the cervical canal with empty endometrial cavity [Figure 9]. The gestational sac contained a live fetus with CRL corresponding to the gestational age of 6 weeks 5 days. The patient underwent MRI of the pelvis to exclude uterine scar pregnancy. MRI examination showed ballooned out cervix with the presence of gestational sac within which established the diagnosis of cervical pregnancy [Figure 10]. As the patient was hemodynamically stable, the patient was managed with intra-amniotic injection of methotrexate under ultrasound guidance followed by suction curettage. The patient had uneventful stay after the procedure.
|Figure 9: Transvaginal grayscale ultrasound image showing gestational sac with fetus (arrow) and yolk sac within the cervical canal (Case 4)|
Click here to view
|Figure 10: (a) Sagittal T2-weighted magnetic resonance imaging images of the pelvis showing empty endometrial cavity (arrow) and (b) gestational sac within the cervical canal (arrowhead). Incidental finding of anterior wall intramural uterine fibroid (Case 4)|
Click here to view
This case series compiles the imaging features and management of most of the unusual ectopic pregnancies at one place.
Few other types of ectopic gestations were not encountered during this study.
| Discussion|| |
Ectopic pregnancy is implantation of zygote at sites apart from the uterine endometrium, occurs in about 1.5%–2% of gestations, and is potentially fatal. Fallopian tube damage caused by pelvic inflammatory disease, prior tubal surgery, or history of previous ectopic gestation is significantly related to an increased risk of ectopic pregnancy. In addition, even in women without damaged fallopian tubes, the use of assisted reproductive techniques, particularly in vitro fertilization, increases the likelihood of an ectopic pregnancy.
An ectopic pregnancy is often diagnosed before the second trimester, with the most frequent gestational age at diagnosis being between 6 and 10 weeks. The patient's symptoms are determined by whether or not a tubal rupture has taken place. Women suffering from an hemoperitoneum experience significant abdominal discomfort with pain and varying degrees of hemodynamic instability.
Due to the absence of a submucosa within the wall of the fallopian tube, implantation of the ovum occurs within the muscle wall, and rapidly growing trophoblasts destroy the muscle layer, resulting in fallopian tube rupture. The gestational age of presentation for ectopic pregnancies within fallopian tubes is 6.9 ± 1.9 and 7.2 ± 2.2 weeks for unruptured and ruptured ectopic pregnancies, respectively. Our case demonstrated a live pregnancy in the fallopian tube that progressed up to the gestational age of 12 weeks 1 day making it peculiar in being advanced ruptured live tubal ectopic pregnancy.
Heterotopic pregnancy is characterized by simultaneous existence of intrauterine and extrauterine gestations, most commonly within either of the fallopian tubes but less often in the cervix or ovary. The increased prevalence is related to the widespread utility of assisted reproductive techniques. In our case, however, there was no such history. Heterotopic pregnancy can occur without predisposing risk factors, and the presence of intrauterine gestation does not preclude the potential for ectopic pregnancy.
Depending on the patient's condition, conventional therapy for a heterotopic pregnancy is surgery which can be either laparoscopic or open laparotomy. The main goal of the procedure should be to preserve the intrauterine gestation with minimal uterine manipulation. A local injection of methotrexate or potassium chloride is used to treat an ectopic pregnancy with an intact tube.
Ovarian pregnancy is a rare type of ectopic pregnancy, having an incidence of 1 in 7000–40000 live births and accounting for 0.5%–3.0% of all ectopic pregnancies. Advanced ovarian pregnancy is extremely rare. Due to the increasing prevalence of sexually transmitted diseases and pelvic inflammatory diseases, assisted reproductive procedures, and improved availability of diagnostic services, the overall prevalence of ectopic pregnancy has increased.
The goal of surgical management is to take out the ectopic pregnancy while leaving the ovary intact. There seems little reason for removal of the entire ovary in the absence of coexisting disease in the same ovary or severe bleeding. Therefore, partial oophorectomy by laparoscopy or wedge resection by exploratory laparotomy is recommended.
While ectopic pregnancies are common, the frequency of cervical pregnancies is under 1% of all ectopic pregnancies and ranges from 1 in 1000 to 1 in 18,000 gestations. Cervical pregnancies have been associated with high morbidity and, previously, a negative impact on the fertility of affected individuals. The risk factors for cervical ectopic pregnancy include iatrogenic causes such as dilation and curettage, prior cesarean delivery, previous surgery involving either cervix or uterus, and in vitro fertilization. There was no predisposing factor found in our case.
The patient's picture at the time of diagnosis has a significant impact on the course of management, since it changes significantly depending on whether the patient is hemodynamically stable or not. In the case of stable patients, there are better chances of choosing more conservative therapies, but unstable patients have fewer options, and radical intervention may be the only way to save the patient's life. Methotrexate, with or without intra-amniotic potassium chloride, represents a major advancement in terminating cervical ectopic, particularly when a fetal cardiac activity is present. The patient must be hemodynamically stable and should comply posttreatment monitoring. Operative laparoscopy is also one of the management options in cases of ruptured ectopic pregnancy. Karasu and Akselim found in a prospective study of 53 women that single-incision laparoscopic surgery with adequate surgical skill and team is an effective and safe procedure in emergency ruptured tubal pregnancy situations.
| Conclusion|| |
Although ectopic pregnancies are fairly common these days, the effects of ectopic implantation are life threatening. Knowledge of the imaging appearance of unusual ectopic pregnancies is important for the clinician to be enable to arrive at correct diagnosis and timely initiation of treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Dr. Madhuri Udgire: Conceived the original idea and designed the study, drafted the manuscript, critical revisions to the manuscript and final approval to the manuscript Dr. Varun Nimje: Helped drafting the manuscript, critical revisions to the manuscript, data acquisition, final approval to the manuscript. Dr. Shubham Bodhankar: Critical feedback to the manuscript, data acquisition, final approval to the manuscript. Dr. Tushar Yadav: Critical revisions to the article, data acquisition, final approval to the manuscript. Dr. Rushabh Chordiya: Critical revisions to the manuscript, data acquisition, final approval to the manuscript.
| References|| |
Dibble EH, Lourenco AP. Imaging unusual pregnancy implantations: Rare ectopic pregnancies and more. AJR Am J Roentgenol 2016;207:1380-92.
Barnhart K. Ectopic pregnancy. N Engl J Med 2009;361:379-87.
Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ 2005;173:905-12.
Khalil MM, Badran EY, Ramadan MF, Shazly SA, Ali MK, Badee AY. An advanced second trimester tubal pregnancy: Case report. Middle East Fertil Soc J 2012;17:136-8.
Saxon D, Falcone T, Mascha EJ, Marino T, Yao M, Tulandi T. A study of ruptured tubal ectopic pregnancy. Obstet Gynecol 1997;90:46-9.
Alptekin H, Dal Y. Heterotopic pregnancy following IVF-ET: Successful treatment with salpingostomy under spinal anesthesia and continuation of intrauterine twin pregnancy. Arch Gynecol Obstet 2014;289:911-4.
Tandon R, Goel P, Saha PK, Devi L. Spontaneous heterotopic pregnancy with tubal rupture: A case report and review of the literature. J Med Case Rep 2009;3:8153.
Goyal LD, Tondon R, Goel P, Sehgal A. Ovarian ectopic pregnancy: A 10 years' experience and review of literature. Iran J Reprod Med 2014;12:825-30.
Joseph RJ, Irvine LM. Ovarian ectopic pregnancy: Aetiology, diagnosis, and challenges in surgical management. J Obstet Gynaecol 2012;32:472-4.
Gun M, Mavrogiorgis M. Cervical ectopic pregnancy: A case report and literature review. Ultrasound Obstet Gynecol 2002;19:297-301.
Albahlol IA. Cervical pregnancy management: An updated stepwise approach and algorithm. J Obstet Gynaecol Res 2021;47:469-75.
Samal SK, Rathod S. Cervical ectopic pregnancy. J Nat Sci Biol Med 2015;6:257-60.
Maiti GD, Jose T, Gupta S, Chatterjee V. A rare case of spontaneous heterotopic pregnancy with successful pregnancy outcome following laparoscopic management of coexisting ruptured tubal pregnancy in Non-ART set up. Int J Reprod Contracept Obstet Gynecol 2018;7:2515-7.
Karasu Y, Akselim B. Feasibility of single-incision laparoscopy for ruptured ectopic pregnancies with hemoperitoneum. Minim Invasive Ther Allied Technol 2019;28:46-50.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]