Case presentation
A 38-year-old gravida 5 para 4 woman presented with an increasing lower abdominal pain for 5 days, brownish vaginal discharge, nausea, and episodes of vomiting. This was a spontaneous conception. Apart from some tenderness in both adnexa, the abdominal and vaginal examination was unremarkable. Laboratory investigations revealed a serum β-hCG of 169,863 mIU/mL. Transvaginal ultrasound was performed using an endocavitary 5–9 MHz transducer. Grayscale ultrasound confirmed by color dopplers revealed a viable intrauterine pregnancy of 9 weeks and 5 days and a heterogeneous complex left adnexal mass suggestive of being a HP. The ovaries were unremarkable, and a small pelvic fluid collection was also seen. Doppler ultrasound of the described mass revealed a ‘ring of fire’ sign (Figure 1).
MRI imaging was done using a 1.5 T device (Siemens, Germany). A phased-array surface coil was centered over the abdomen to the symphysis pubis. Images were acquired from the level of the hepatic hilum to the symphysis pubis. The sequences included the turbo spin-echo (TSE) technique, gradient-echo (FLASH), and T1 and T2 weighting to obtain axial and coronal images. No contrast was given.
MRI study revealed a left adnexal rounded mass lesion (56 x 35 x 46 mm) intimately anterior to the normal left ovary, displaying a mixed hyper- and hypo-intense signal at T1 and T2 WI. It had a thick wall showing a high T2 signal (Figures 2-4).
The patient was taken to the operating theatre after careful counseling and informed consent. Under general anesthesia, a laparoscopy was performed which revealed a distended left fallopian tube. The other (right) tube and both ovaries were unremarkable. A left salpingectomy was performed, and this was sent for histopathological assessment. The postoperative course was uneventful, and the patient was discharged home after confirming the viability of the intrauterine pregnancy.
Histopathological examination of the specimen showed a dilated congested segment of the left fallopian tube while microscopic examination revealed fragments of a blood clot, decidual tissue, and chorionic villi with trophoblasts noted within the dilated fallopian tube consistent with a tubal ectopic pregnancy.