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BMJ Case Rep. 2010; 2010: bcr0120102615.
Published online 2010 September 29. doi:  10.1136/bcr.01.2010.2615
PMCID: PMC3027340
Rare disease

An ectopic pregnancy under the liver

Abstract

Ectopic pregnancy is a common but potential life-threatening condition. The most common ectopic location is in the fallopian tube. Here we report a case of an ectopic pregnancy in a non-communicating fallopian tube placed under the liver.

Background

Ectopic pregnancies occur in about 1% of all pregnancies in Denmark.1 Most commonly in the fallopian tube, but interstitial, cervical, ovarian and abdominal localisations have been described. There are numerous paratubal and tubal abnormalities that can occur at any point in the female life. However, there are very few cases of undescended fallopian tube and ovaries.2

To our knowledge, the combination of an ectopic pregnancy in an undescended fallopian tube has been described only twice.3 4

Case presentation

A 33-year-old-woman presented to the gynaecological emergency department with pain under right curvature. There was no prior gynaecological morbidity except for an earlier induced abortion. The patient had menostasia for 6 weeks and 5 days and positive urinary human chorionic gonadotrophin (HCG); there was no vaginal discharge.

A transvaginal ultrasound (TVS) was performed and showed no intrauterine pregnancy. On the right side there was a process of 34 × 17 mm suspected as a corpus luteum and on the left side a normal ovary, and 53 × 20 mm free-fluid was seen in the recto-uterine-pouch. Blood samples showed normal haemoglobin and β-HCG of 918. The patient was clinically unaffected and the abdomen soft on palpitation.

The next day the β-HCG has fallen to 760, the patient was relatively unaffected and was discharged from hospital on suspicion of a tubarian spontaneous miscarriage. She was to be monitored by β-HCG.

After 3 days the β-HCG level had increased to 1270 and the patient was given methotrexate (MTX) on suspicion of early ectopic pregnancy.

However, a week after MTX the patient was readmitted to hospital due to pain under right curvature. β-HCG had fallen to 259, but the patient was severely affected by pain and the abdomen was no longer unaffected on palpitation with rebound tenderness.

A TVS was performed and showed no sign of ectopic pregnancy or intra-abdominal liquid. At laparoscopy, using standard laparoscopic equipment and instrumentation, a unicornuate uterus with a normal left fallopian tube and a normal left ovary was identified. The right ovary was found high on the right pelvic wall looking unusually long. There was no right fallopian tube outgoing from the uterus, but a structure resembling a fallopian tube was seen over the right flexure of colon transversus (figures 13). Glued to this was a process, interpreted as an ectopic pregnancy of a non-communicating fallopian tube. In the abdomen, 100–200 ml blood was found. The patient had an unremarkable postoperative course.

Figure 1
Right ovary at the pelvic entrance.
Figure 3
Ectopic pregnancy by right curvature.
Figure 2
Ovary and salpinx with ectopic pregnancy near right curvature.

Investigations

Due to a history of repeated pyelonephritis plus the congenital abnormality of the fallopian tube an intravenous urography was performed with normal findings.

Treatment

The ectopic fallopian tube was removed laparascopically and the ectopic pregnancy was confirmed by histological examination.

Outcome and follow-up

The patient was followed-up with serial serum HCG until normal values. She was informed to postpone the next pregnancy because of the MTX.

Discussion

An ectopic pregnancy presented by pain under right curvature is rare. The fallopian tube is formed by the cephalic part of the Mullerian duct and the uterus and the upper one-third of the vagina is formed by the caudal part. We have described a congenital malformation with an ectopic part of salpinx situated under the liver and a uniconuate uterus.

The case is supported by the histological finding that the ectopic pregnancy was situated in a non-communicating fallopian tube.

To our knowledge, the combination of an ectopic pregnancy in a non-communicating fallopian tube has been described only twice before,3 4 and in only one of these cases the diagnosis is supported by histological verification. Earlier cases have both been on the left side and have been accompanied by a splenic agenesia on the same side, which we did not find.

Learning points

  • Pain under the right curvature can in rare cases be an ectopic pregnancy located in a non-communicating fallopian tube, especially if the anamnesis describes cyclic pains situated in the same place.

Footnotes

Competing interests None.

Patient consent Obtained.

References

1. Bakken IJ. Chlamydia trachomatis and ectopic pregnancy: Percent epidemiological findings. Curr Opin Infect Dis 2008;21:77–82 [PubMed]
2. Pearlman S, Hertweck P, Fallat ME. Paratubal and tubal abnormalities. Semin Pediatr Surg 2005;14:124–34 [PubMed]
3. Seoud MA, Khayyat H, Mufarrij IK. Ectopic pregnancy in an undescended fallopian tube: an unusual presentation. Obstetr Gynecol 1987;69:455–7 [PubMed]
4. Knudsen HJH, Clausen IH. An extra-uterine pregnancy in an ectopic fallopian tube. Zentralblatt fur Gynäkologie 1994; 116:9 [PubMed]

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