Presentation
Early pregnancy. 1 week of pelvic pain, no PV bleeding.
Patient Data
There is a small intrauterine fluid collection with rounded margins and subtle echogenic rim. The appearance is highly suggestive of an early intrauterine pregnancy, although no yolk sac or fetal pole is present at this stage.
In the left adnexa, there are two rounded heterogeneous structures with rim vascularity, which both appear to be within the ovary. There is a small to moderate volume of free fluid in the pelvis.
Ultrasound 1 week later shows progression to a viable intrauterine pregnancy.
Persistent two "ring of fire" structures in the left ovary, but the pelvic hemorrhage has resolved. The larger of the two now has more apparent internal reticular appearance compatible with a hemorrhagic CL.
Patient was no longer symptomatic at this stage.
Case Discussion
Difficult case on initial presentation. Two "ring of fire structures" in the left adnexa as well as free fluid are worrisome for an ectopic pregnancy. However both are clearly within the ovary, and the intrauterine appearance is very highly suggestive of a gestational sac. The possibility of a heterotopic pregnancy with an ovarian ectopic (both rare entities) was thought to be much less likely than an intrauterine pregnancy with a second, hemorrhagic corpus luteum.
As the patient was clinically stable, she was observed without treatment.
Repeat ultrasound one week later shows progression of intrauterine pregnancy and resolution of the pelvic free fluid confirming the favored diagnosis of two CLs one of which causing pelvic hemorrhage and pain.
This case highlights the importance of prioritising the survival of a potential intrauterine pregnancy over early instigation of therapy in a clinically stable, potential ectopic.
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