Ruptured Ectopic Tubal Gestation: An Unsolvable Conundrum on Imaging!

Abstract

An ectopic pregnancy (EP) is a condition in which a fertilised ovum implants in a location other than normal endometrial cavity. It is diagnosed by estimation serum beta-HCG level and transvaginal ultrasonography. Despite being a common condition, the complex radiologic appearance of ruptured EP has rarely been described in the literature. We share a unique case of ruptured EP on MR imaging.A 25-year female, P0 G1, presented to Gynaecology/ Obstetrics Department with 2-month amenorrhea and lower abdominal pain. The investogram specifically showed serum -HCG levels within normal limits (42.89 mIU/ml). Ultra-sonography showed a large pelvic indeterminate mass with normal uterus. Doppler study showed no significant flow, which was inconclusive for EP. CT scan showed a complex, heterogeneous, iso-to hyper-dense, solid / cystic, minimally enhancing, mass in the cul-de-sac involving bilateral adnexa. Foci of calcifications were noted within it. The MRI examination of the pelvis revealed a large 11x9x11 cm in APxTRxCC, thick walled T1, T2 hyper-intense complex haemorrhagic mass with fluid-fluid levels and post-contrast rim enhancement. Normal ovaries were seen (Figure 1). No free fluid in the pelvis was seen. At this point, we raised the differentials of haematosalpinx, tubo-ovarian complex, and tubal endometriosis. The patient was vitally stable, so proceeded to salpingectomy; and the sample was sent for histopathology, which showed wall of fallopian tube distended by blood and fibrin with few hyalinised chorionic villi; compatible with ruptured ectopic tubal gestation. We did retro-spective analysis of MRI, which showed fallopian tube defect at left adnexa (Figure 2). It was hypothesised that hematoma in the pelvis was walled off by thick wall and did not lead to hemoperitoneum/free fluid. The patient underwent normal postoperative recovery and survived.