Ruptured Abdominal Ectopic Pregnancy in a 45-Year-Old Woman Using Long-Term Contraception: A Case Report in Salmaniya Medical Complex ()
1. Introduction
Ectopic pregnancy refers to the implantation of a fertilized ovum outside the uterine cavity. Abdominal ectopic pregnancy is the rarest form, accounting for less than 1% of all ectopic pregnancies. It carries a high risk of morbidity due to delayed diagnosis and potential for massive hemorrhage. This case report presents a surgically managed ruptured abdominal ectopic pregnancy and highlights key diagnostic and management challenges [1]-[5].
2. Literature Review
Abdominal ectopic pregnancies have been reported in various anatomical locations including the omentum, bowel, and peritoneal surfaces. Risk factors include prior pelvic surgery, tubal damage, and assisted reproductive techniques. However, cases also occur in women without identifiable risk factors. Diagnostic challenges stem from atypical presentations and limitations of transvaginal ultrasound. Surgical intervention remains the mainstay of treatment, with laparotomy preferred in unstable patients [6] [7].
3. Case Presentation
3.1. Patient Profile
3.2. Clinical Presentation
The patient presented to the emergency department in Salmaniya medical complex with sudden severe abdominal pain, dizziness, and signs of hypovolemic shock. Vitals on arrival: BP 80/50 mmHg, HR 130 bpm, SpO2 92% on room air. Abdominal examination revealed distension, tenderness, guarding, and rebound tenderness. Pelvic exam showed no vaginal bleeding and a closed cervix.
3.3. Laboratory Findings
WBC: 21.3 × 10⁹/L
Hemoglobin: 5.3 g/dL → 13.2 g/dL post-transfusion
Platelets: 261 → 135 × 10⁹/L
PT: 14 sec, INR: 1.1
TSH: 0.5 mIU/L, T4: 14.2 pmol/L
RBS: 14.2 mmol/L
Creatinine: 87 µmol/L
β-hCG: 6259 IU/L → 2191 IU/L (Day 1) → 822 IU/L (Day 3)
3.4. Imaging
Ultrasound: No intrauterine pregnancy, significant hemoperitoneum.
CT Pulmonary Angiography (Day 1): Subsegmental PE in apicoposterior segment of left upper lobe, bilateral consolidation, minimal pleural effusion.
4. Management
4.1. Surgical Findings
Emergency laparotomy revealed approximately 3 liters of hemoperitoneum with clots mainly in the left upper quadrant. The fallopian tubes and ovaries were normal. A thickened mesenteric segment with active bleeding was identified and clamped. The bleeding source was confirmed to be an abdominal ectopic pregnancy implanted on the omentum.
4.2. Transfusion Support
Figure 1. Intraoperative image showing ruptured abdominal ectopic pregnancy with hemoperitoneum and active bleeding from the omental implantation site.
Figure 2. Intraoperative image showing the gestational sac implanted on the omentum, surrounded by hemoperitoneum.
4.3. Outcome and Follow-Up
Postoperatively, the patient developed a pulmonary embolism, confirmed by CT pulmonary angiography. Anticoagulation therapy was initiated.
Histopathological examination of the excised omental tissue revealed adipose tissue with blood clots, decidua, and chorionic villi (some hydropic). No villitis or gestational trophoblastic disease was identified. The findings confirmed products of gestation in the omentum, consistent with abdominal ectopic pregnancy.
Serial β-hCG levels showed a consistent downward trend, confirming complete removal of trophoblastic tissue and successful resolution.
5. Discussion
This case illustrates the diagnostic complexity of abdominal ectopic pregnancy, particularly in the context of contraceptive use. Progestin-only contraceptives, such as Implanon, may increase the risk of ectopic implantation due to altered tubal motility and endometrial receptivity.
The postoperative pulmonary embolism likely reflects a multifactorial etiology, including the prothrombotic state of pregnancy, major abdominal surgery, and massive transfusion. These overlapping risk factors emphasize the importance of thromboembolic prophylaxis.
6. Conclusion
Abdominal ectopic pregnancy remains a rare but critical diagnosis. Clinicians must maintain a high index of suspicion, especially in patients presenting with an acute abdomen and hemodynamic instability. Pregnancy testing should be routine in all reproductive-aged women presenting with abdominal pain, regardless of contraceptive history.