A 37-year-old, nulliparous patient was admitted to our Emergency Department complaining about continuous, dull, lower abdominal pain. She had a history of a positive urine pregnancy test a week ago, with her last menstrual period indicating a pregnancy of 5 weeks and 5 days. Her past medical and surgical history was uneventful. She had not been subjected to any fertility treatment modalities and reported no risk factors connected to ectopic pregnancy.
Clinical examination revealed a mild tenderness in deep palpation of the right lower quadrant without signs of peritoneal irritation. Pain was elicited during physical examination, located at the right adnexa, and no vaginal bleeding was recorded. The patient was hemodynamically stable. Her initial blood test results were within a normal range, except from an elevated serum beta-chorionic gonadotropin at 5436 mIU/mL. Transvaginal ultrasound was performed, and the findings suggested multiple, subserosal fibroids (with the greatest diameter: 41 mm), a single intrauterine gestational sac (mean diameter 7.3 mm), including a fetal pole with a crown-rump length of 1.7 mm and positive cardiac activity. In the right fallopian tube, a hypoechoic mass measuring 64*32*29 mm with minimal blood flow on the Doppler investigation was depicted, while the Douglass pouch was free of fluid. The ovaries appeared normal. Differential diagnosis included hydrosalpinx, hematosalpinx, ovarian torsion, and heterotopic pregnancy (Figure 1).
Due to persisting mild pain, the patient was hospitalized and monitored in our obstetrics department. The patient remained clinically stable and was subjected to additional transvaginal sonographic evaluation daily. On the 3rd day of hospitalization, the ultrasonographic evaluation revealed a viable intrauterine pregnancy and mild accumulation of free fluid in the lower abdomen, suggesting a possible rupture of a coexisting tubal pregnancy. At that time, the patient complained about pelvic pain more acute than usual alongside with nausea while the vital signs and hemoglobin level were within the normal range (Figure 2).
After extended counselling and written consent, an emergent exploratory laparoscopy was performed. Under general anesthesia, with the patient in a lithotomy position, trocars were placed in standard sites, with intention to avoid any injury of the uterus, with the least possible manipulations, in order for the intrauterine pregnancy to be preserved. A mild amount of blood and clots and an ectopic pregnancy with active bleeding in the ampulla of the right fallopian tube were visualized, and right salpingectomy and evacuation of hemoperitoneum were conducted. A single intravenous dose of antibiotics was administered intraoperatively, and immediate confirmation of fetal heartbeat of the intrauterine gestation was done postoperatively (Figure 3).
Oral progesterone was administered in a daily dose of 600 mg in order to prevent a miscarriage of the intrauterine pregnancy, due to possible lack of corpus luteum. After an uneventful recovery, the patient was discharged 2 days postoperatively with a viable ongoing pregnancy of 7 weeks. Recommendations concerning routine antenatal assessment were given. The final histopathological analysis of the specimen confirmed the diagnosis of an ectopic pregnancy. After an uncomplicated full-term pregnancy (40 w and 1 day), a healthy, female newborn weighting 3295 g was born via a spontaneous vaginal delivery (Figure 4).