ACRT Journal

Introduction

A pregnancy involving the implantation of the blastocyst in sites other than the endometrium of the uterine cavity is called an ectopic pregnancy. Some of the uncommon implantation sites for such an ectopic pregnancy include the interstitial segment of the fallopian tube, uterine myometrium (cornual), ovary, and peritoneal cavity [1]. Among the various ectopic sites, the most common is a tubal ectopic pregnancy (96%), followed by the abdominal cavity (1%) and ovaries (3%) [2].

Another form of complicated early pregnancy is a hydatidiform mole which is due to disordered proliferation of trophoblastic epithelium and villous edema. It is a type of Gestational Trophoblastic Disease (GTD) and can be classified as complete or incomplete. A distinguishing fact between them is that complete mole pregnancies are diploid, androgenic in origin with no evidence of foetal tissue. Whereas a partial is usually triploid, with evidence of foetal tissue [3]. The chances of a molar pregnancy transitioning into a post-gestational trophoblastic neoplasia are 15~20% from a complete mole and less than 1~5% from partial [4,5]. The definitive diagnosis of a molar pregnancy remains histopathological examination [6].

In normal pregnancies, beta human chorionic gonadotropin (β-hCG) may begin to rise from eight days following ovulation and almost doubles (49% increase) in over 48 hours. In ectopic pregnancies or if early pregnancy loss is suspected, then a slower-than-expected rate of increase or a decrease in β-hCG levels is seen in the majority of cases [7]. The levels of β-HCG in molar pregnancies have often seen to be significantly higher [8]. Both these complications can require emergency surgical intervention, and we present a case with a suspected ectopic molar pregnancy. As the guidelines for such a presentation are unavailable and the only guidance is through a handful of case reports, we found it incumbent to share our clinical findings.

Case Report

A 23-year-old Pakistani female, primigravida, at 6 weeks 6 days presented with complaints of lower abdominal pain and irregular vaginal bleeding. She had no prior history of pelvic infections (pelvic inflammatory disease, PID), pelvic surgery, or previous irregular periods. On examination, she remained hemodynamically stable, the abdomen was soft, non-tender and there showed no evidence of any palpable mass or free fluid. Further intimate gynecological examinations (per vaginal and per speculum) remained inconclusive. The patient’s initial β-HCG levels were 65,112 mIU/ml at 5 weeks 4 days and rose to 94,814 mIU/ml, 9 days later. Following a transvaginal ultrasound (TVS), a partial septate/arcuate uterus of normal size, with no intrauterine gestational sac was seen. Additionally, a large heterogenous mass was seen residing in the left adnexal location, measuring approximately 5.4 x 4.6cm in size. There were no obvious well-defined cystic structures seen suggestive of a gestational sac within the lesion and the left ovary was not well visualized separately. The mass showed a diffusely heterogeneous echotexture and the presence of multiple linear structures with multiple other anechoic areas interspersed within it. A Colour Doppler revealed significant peripheral, as well as central areas of colour flow. One of the largest anechoic cystic areas was measured to be of 17 x 11.4cm.

In view of the clinical history, the patient's possibility of a left adnexal ectopic pregnancy with an associated hematoma was considered. However, the possibility of an associated molar pregnancy could not be ruled out in view of the marked elevation in β-HCG levels. The patient had no pre-operative renal, hepatic, or hematological abnormalities and underwent laparoscopic surgery under general anesthesia. Intra-operatively, a 5 cm, hyper vascular, left adnexal mass was extracted along with blood clots from the Pouch of Douglas (Figure 1). The left ovary was not visualized and therefore thought to be adherent with the left adnexal mass. Other intra-operative findings revealed friable unhealthy granulation tissue on the lateral pelvic wall and were consequently excised. Post-operative period remained uneventful and her β-HCG levels dropped to 33,590 mIU/ml 8 hours following the surgery and further decreased to 2,659 mIU/ml 6 days later.

A histopathological examination (HPE) of the excised mass showed ovarian tissue with areas of hemorrhage and necrosis along with infiltration by variably sized chorionic villi and trophoblasts. The granulation tissue comprised of reactive fibrous tissue, hemorrhage, haemosiderin-laden macrophages, and ultimately negative for malignancy.