Case presentation
A 22-year-old woman, gravid 2, abortion 1 (spontaneous, GA <10 weeks) with a negative past medical history of sexually transmitted disease or infertility was presented to the Emergency Department complaining of two weeks of menstrual retardation, spastic abdominal pain, and spotting. She was wrongly administered one tablet of Letrozole 2.5 mg orally for ten days and also injected one dose of subcutaneous Human Chorionic Gonadotropin (HCG) previously. Her vital signs were stable. The abdomen was tender on examination with absent bowel sounds. Pelvic bimanual examination revealed a left adnexal fullness. Laboratory data revealed a serum Beta HCG level of 2700 mIU/mL and mild anemia (Hemoglobin level=9mg/dl).
The ultrasound evaluation showed a complex mass (50*70 mm) suggestive of ectopic pregnancy and hematoma in the left adnexa with moderate free abdominopelvic fluid. The right side was intact. There was no evidence of an intrauterine pregnancy at that time.
The patient underwent laparoscopic surgery; 1 liter of hemoperitoneum was drained. There was an unruptured left-sided ampullary ectopic pregnancy ∼3× 3 cm; the products of conception were removed via salpingostomy, suction, and irrigation. The right fallopian tube was normal. We inspected the abdomen and pelvis carefully but we did not find any other abnormal findings.
On the first postoperative day, the serum Beta HCG level was 1300 mIU/mL (50% drops). On the next week’s follow-up, the serum Beta HCG level elevated to 1600 mIU/mL. The ultrasonography reported a round hypoechoic right adnexal mass (15*12 mm) which was highly suggestive of ectopic pregnancy. The left adnexa was unremarkable. The uterine cavity was empty. The patient with the diagnosis of bilateral ectopic pregnancy was a candidate for medical therapy. Methotrexate 1 mg/Kg intramuscular was injected. The serum Beta HCG level was reported 2300 mIU/mL on both the fourth and seventh days after medical treatment.
The patient was re-evaluated via ultrasonography, which reported the increased size of the right adnexal mass due to the complex of ectopic pregnancy and hematoma. Because the serum Beta HCG level was not reduced by at least 15% in comparison to the 4th and 7th day of the treatment, she received a second dose of Methotrexate. After the second Methotrexate dosage, the serum Beta HCG level was reduced to zero. During the one-month follow-up period, the patient had no complications.