Chronic Ectopic pregnancy is an enigma which accounts for 6% of all ectopic pregnancies. The diagnosis is confounded by stable hemodynamics, chronic symptoms and high incidence of false negative pregnancy test; and often diagnosed on surgical exploration. Characteristic findings include chronic inflammatory mass and degenerated trophoblastic tissue.
A 44 year old multiparous widow presented with 2 days of fever, abdominal pain, diarrhea and vomiting. She was unable to recall her LMP and denied PV bleeding. She was treated initially as acute gastroenteritis, discharged home but returned hours later with severe sepsis. The right iliac fossa was tender and guarded. UPT was negative. Although having a normal full blood count, acute renal failure and severe metabolic acidosis had set in. A provisional diagnosis of intraabdominal sepsis was made and was referred to surgical team. She was resuscitated and started on IV antibiotics,but deteriorated rapidly in the ward, was intubated and admitted to ICU. A CT abdomen noted bilateral pleural effusion, free fluid in the peritoneal cavity and features of ileitis. The decision was therefore made to continue medical therapy. Unfortunately she succumbed 2 days later. A post mortem revealed a right ovarian inflammatory mass. Histopathology showed gestational trophoblastic tissue, establishing a diagnosis of an undetected chronic ectopic ovarian pregnancy.
Unlike ‘acute’ ectopic pregnancy which clinicians are more acquainted to, chronic ectopic pregnancy is a diagnostic challenge due to high incidence of negative pregnancy tests as a consequence of the very small amount of live villi, subtle symptoms and poor specificity on sonography. It may mimic other surgical or medical conditons. A CT or TVS with Doppler may be helpful but often than not is found during surgery. The treatment involves either conservative surgery or methotrexate therapy.
Diagnosis of chronic ectopic pregnancy requires high index of suspicion. Although rare its importance should never be understated.