Actively leaking ectopic pregnancy

Case contributed by Dennis Odhiambo Agolah
Diagnosis certain


Nulliparous presenting with lower abdominal pains three days per vaginal bleeding. PDT positive. To rule out ectopic pregnancy.

Patient Data

Age: 20 years
Gender: Female

A trans-abdominal targeted intra-abdominal-pelvic sonographic evaluation yields a thick-walled, echogenic, and internally irregularly outlined fluid-filled structure within the right adnexal region/ipsilateral infero-medial right para-ovarian aspect. A conspicuous echogenic acardiac focus (intrinsically sighted within the structure above) corresponds to 7 weeks gestation by crown-rump length. Moderate low-level echo-filled free fluid is noted within the Douglas pouch and extending into the right upper abdominal quadrant consistent with hemorrhage/hemoperitoneum. Both ovaries appeared bilaterally normal, with the right ovary exhibiting a normal-looking corpus luteum. The anteverted and non-gravid uterus showed smooth outer contours with no focal myometrial/endometrial lesions.

Case Discussion

In the setting of a positive pregnancy test, amenorrhea, and a clinical question to exclude ectopic pregnancy, urgent and targeted abdominal-pelvic ultrasound imaging comes in handy as part of the clinical management. The sonographic features unequivocally pointed towards a leaking right-sided extra-uterine ectopic pregnancy in this scenario. The subsequent quantitative laboratory serum beta HCG titer level of 4731 mIU/mL further strengthened the diagnosis. However, the ectopic gestational sac demonstrated insignificant peripheral hyperfusion (atypical ring of fire; on color Doppler mapping). The acardiac intra-gestational sac focus suggested an embryonic demise at seven weeks gestation.

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