A 41-year-old woman, gravida 1, para 0, at 7 weeks gestational age by egg implantation date confirmed by early sonogram presented to the emergency department with sudden-onset abdominal pain. The patient reported that she initially tried over-the-counter antacids, simethicone, and milk of magnesia without relief. The patient denied shortness of breath, chest pain, nausea, vomiting, vaginal bleeding, or constipation. She reported a medical history of fibroid uterus, irritable bowel syndrome, infertility for 2 years, and 1 previous failed trial of in vitro fertilization. In this current pregnancy, the patient was attempting her second in vitro fertilization and taking progesterone suppositories twice per day and estradiol once daily. The patient’s surgical history included an ovarian cystectomy 10 years prior. On physical examination, the patient was tachycardic (pulse rate, 102 beats/min), normotensive (blood pressure, 126/81 mm Hg), afebrile, and without skin pallor. An abdominal examination demonstrated a tense, distended abdomen in all quadrants, with greater tenderness of the right lower quadrant than the left and rebound in both quadrants. Serum β-human chorionic gonadotropin level was 3951 mIU/mL.
An OSE of the thoracic and lumbar spines, sacrum, and lower extremities revealed hypertonic paraspinal muscles on the right at the T10-T11 spinal levels. Chapman reflex points were identified at the tip of the transverse process of the fifth lumbar vertebra extending parallel with the iliac crest and on the right between the 10th and 11th dorsal transverse space.
The patient was unable to tolerate a TVUS. An MR image revealed moderate fluid in the cul-de-sac with heterogeneity suggesting hemorrhagic components and an enlarged uterus with multiple fibroids. The largest fibroid was in the left side of the uterine body with a partial submucosal component, an exophytic subserosal fibroid was in the fundus, and smaller fibroids were seen within the uterine wall. An intrauterine pregnancy was identified. The left ovary was without abnormality, and the right ovary was difficult to visualize. A complete structure was identified in the right ovary. No normal appendix was seen. This patient subsequently underwent diagnostic laparoscopy.
After entering the abdomen, inspection included the appendix, liver, gallbladder, uterus, fallopian tubes, and ovaries. Hemoperitoneum was noted in the abdominal cavity, and evacuation of 700 mL of blood was performed. The patient’s right ovary had a hemorrhagic structure emanating from within. The subserosal fibroid seen on the MR image was additionally identified. Histologic analysis confirmed the presence of chorionic villi within the ovarian tissue. The rest of the visible abnormal tissue was removed from the ovary via ovarian wedge resection and cauterized to achieve adequate hemostasis. The fallopian tube and utero-ovarian ligament were not involved with the ectopic pregnancy. The rest of the abdominal structures appeared normal. The patient tolerated the procedure well and had an uneventful recovery.