SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Chronic Ectopic Pregnancy — Recognition & Management

Chronic ectopic pregnancy occurs when a tubal pregnancy dies in situ and leaks blood slowly over days to weeks, rather than rupturing acutely. The resulting blood becomes walled off by bowel, omentum, and pelvic peritoneum to form an organized pelvic hematocele. Because there is no acute hemoperitoneum, the presentation is subacute and easily mistaken for a tubo-ovarian mass, pelvic abscess, or ovarian tumour — the diagnostic challenge is thinking of it at all.

🔎 AT A GLANCE — WHO TO SUSPECT

Risk Factors (as for any ectopic)

Prior ectopic pregnancy or tubal surgery

Pelvic inflammatory disease / tubal damage, prior STI

IUCD in situ, assisted reproduction (IVF), tubal ligation history

Smoking; structural tubal anomalies

Classic Presenting Picture

Menstrual history: irregular spotting or a missed period weeks earlier — often vague, not a clean "6–8 weeks amenorrhea"

Pain: dull, chronic, or recurrent lower abdominal/pelvic ache rather than sudden severe pain

Exam: tender, fixed adnexal/pelvic mass — often mistaken for a tubo-ovarian abscess or ovarian tumour

🩹 CLINICAL PRESENTATION

Subacute onset — symptoms evolve over days to weeks, patient often presents late

Low-grade fever may be present, mimicking pelvic infection

Anaemia and pallor from slow, ongoing internal blood loss — fatigue is a common complaint

A sense of pelvic fullness or pressure, sometimes with bowel or bladder symptoms if the mass is large

No signs of acute abdomen or hemodynamic compromise in the typical case — this is precisely what delays diagnosis

Key point: a urine or serum pregnancy test can be weakly positive, or even negative if the trophoblast died long enough ago — a negative test does not rule this out.

🚨 WHEN "CHRONIC" TURNS URGENT

New tachycardia, hypotension, or postural dizziness

Sudden worsening of pain — may indicate a fresh bleed into the hematocele

Rapidly increasing abdominal distension or peritonism

Significant or rapidly falling haemoglobin

Any of the above → treat as acute abdomen and escalate for urgent surgical review

🧪 DIAGNOSTIC WORKUP

Serum β-hCG Pattern

Typical: low, plateaued, or declining — reflects dead trophoblast, unlike a rising titre

Caution: may even be negative in long-standing cases — repeat testing does not exclude the diagnosis

Imaging

Transvaginal ultrasound: complex, heterogeneous adnexal mass with internal echoes (organizing clot); little or no free fluid; no live gestational sac

MRI: useful second-line study when ultrasound findings are equivocal or malignancy cannot be excluded

Diagnostic laparoscopy: often required for a definitive diagnosis — reveals an organized hematoma encasing the tube, dense adhesions to bowel/omentum, and degenerating trophoblastic tissue

Always send tissue for histopathology — confirms trophoblast and excludes the mimics below.

🧭 KEY DIFFERENTIALS TO EXCLUDE

1

Tubo-ovarian abscess / pelvic inflammatory mass

2

Haemorrhagic or ruptured corpus luteal cyst

3

Ovarian neoplasm (benign or malignant)

4

Pedunculated or degenerating fibroid

5

Appendiceal mass / abscess, diverticular abscess

🛠️ MANAGEMENT

Surgery is the mainstay — the organized hematoma and fibrosis mean medical management is rarely appropriate here

Laparoscopy where feasible; laparotomy for dense adhesions, a large hematocele, or if the patient is unstable

Salpingectomy is usually required — the tube is typically too damaged for tube-conserving surgery

Evacuate the hematocele, perform careful adhesiolysis, and correct anaemia (transfusion if indicated)

Add antibiotics if secondary infection of the hematocele is suspected

Why not methotrexate? Medical therapy targets actively dividing trophoblast with a rising β-hCG. In chronic ectopic, the trophoblast is already dead and organized within a fibrosed clot — methotrexate has little tissue to act on and response cannot be monitored reliably.

Tubal (Ampullary/Isthmic)

Most common site overall and for chronic presentation

Ampullary tears leak more slowly — classic chronic picture

Interstitial / Cornual

Can grow larger before symptoms appear — higher bleeding risk if it does rupture

May need cornual resection or hysterectomy in severe cases

Ovarian

Rare; frequently mistaken for a haemorrhagic ovarian cyst

Diagnosis often made only at surgery/histopathology

Cervical / Caesarean Scar

Chronic presentation less typical — usually presents with painless bleeding

Needs senior-led, imaging-guided management given bleeding risk

Don't Skip This

Follow-Up & Counselling

10–20%

APPROX. RISK OF
FUTURE ECTOPIC

A history of one ectopic pregnancy meaningfully raises the risk of another — counselling and early scanning in future pregnancies matter.

Follow serial β-hCG post-operatively until undetectable, to exclude persistent trophoblast

Give Anti-D immunoglobulin if the patient is Rh-negative

Counsel on future ectopic risk and the value of an early first-trimester scan in the next pregnancy

Discuss fertility implications of salpingectomy, and offer contraception counselling until the patient is ready to conceive again

Correct anaemia fully; offer psychological support — pregnancy loss with a delayed, confusing diagnosis is often distressing

Reminder: think of chronic ectopic in any woman of reproductive age with a tender pelvic mass and vague symptoms — a negative pregnancy test does not exclude it.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary for structured teaching and triage; confirm diagnosis with imaging, laparoscopy, and histopathology, and follow local protocols.