Advanced Tubal Ectopic Pregnancy Presenting with a Formed Fetus: Case Analysis and Review of Literature

Abstract

Background:

Ectopic pregnancy (EP) complicates approximately 1% to 2% of pregnancies. Most EPs implant in the fallopian tube and present in the first trimester; continuation beyond 10 weeks is extremely uncommon.

Case presentation:

An 18-year-old primigravida at 12 weeks’ gestation presented with acute-onset lower abdominal pain, syncope, and 1 week of dark-red spotting. She was hypotensive (BP 90/60 mmHg) and tachycardic (112 bpm) with pale conjunctivae. Abdominal examination revealed lower-quadrant tenderness; pelvic exam showed a closed cervix and a tender posterior fornix. Transabdominal ultrasound demonstrated an empty uterus, a gestational sac with a fetal pole adjacent to the right adnexa, and moderate free intraperitoneal fluid.

Management and outcome:

Emergency laparotomy was performed. Approximately 800 mL of hemoperitoneum was evacuated. The right fallopian tube was found ruptured in the ampullary segment with extrusion of a formed fetus. Right salpingectomy was performed, and hemostasis achieved. The patient received 2 units of packed red blood cells intraoperatively and recovered without complication. A follow-up ultrasound at 6 weeks showed a normal remaining adnexa.

Conclusion:

This rare case of a 12-week tubal ectopic pregnancy with an advanced fetus highlights critical diagnostic challenges. Delayed presentation and lack of early prenatal imaging allowed the tubal pregnancy to progress to late gestation. High clinical suspicion and prompt ultrasound evaluation are essential for early detection of atypical ectopic pregnancies, to prevent catastrophic hemorrhage and preserve fertility.

Introduction

Ectopic pregnancy (EP) is the implantation of a fertilized ovum outside the uterine cavity. ¹ It occurs in about 1% to 2% of pregnancies^2,3 and remains a leading cause of first-trimester maternal death. ² Known risk factors include prior pelvic infection, tubal surgery, or assisted reproduction, but many cases occur without obvious predisposition.^4,5 Over 95% of EPs implant in the fallopian tube (typically the ampullary segment)^3,5; non-tubal locations (interstitial, cervical, ovarian, abdominal) are much less common. Because the fallopian tube has limited distensibility, most tubal EPs rupture by about 7 to 8 weeks’ gestation. ⁶ Clinically, patients often present with amenorrhea, pelvic or abdominal pain, and vaginal bleeding. ⁷

Diagnosis relies on serial β-hCG measurements and transvaginal ultrasound (TVUS).^1,8 Ultrasound signs of EP may include an empty uterine cavity, an adnexal mass or gestational sac separate from the ovary (eg, “tubal ring” or “blob” sign), and free pelvic fluid.^8,9 Direct visualization of an extrauterine fetal heartbeat is rare. ⁷ When EP is detected early (before rupture), systemic methotrexate can be used for treatment. ¹⁰ Otherwise, surgical management (laparoscopy or laparotomy) is required, with salpingectomy favored in cases of rupture or uncontrolled bleeding. ⁴ Preservation of future fertility is an important consideration in management. Early antenatal care and prompt imaging are critical to identify EP before rupture and severe hemorrhage occur.^1,11

This report describes an exceptionally rare presentation of a 12-week tubal ectopic pregnancy with a formed fetus. We highlight the diagnostic and management challenges of such advanced ectopic gestations, review the limited literature on second-trimester tubal ectopic pregnancy, and emphasize the critical importance of early prenatal imaging and timely intervention to prevent catastrophic maternal outcomes.

Case Presentation

An 18-year-old primigravid woman at an estimated 12 weeks’ gestation, calculated from a reliable last menstrual period, presented to the emergency gynecology outpatient department with acute lower-abdominal pain of 1 day duration. The pain was crampy, progressive, and associated with an episode of syncope. She had a 1-week history of dark-red vaginal spotting and intermittent abdominal cramps, but had not sought care until the symptoms worsened. The pregnancy had been unplanned and diagnosed by a urine pregnancy test 6 weeks earlier; she reported prior use of post-coital emergency contraception. She had no history of pelvic surgery or trauma.

On examination, she was acutely ill-looking, with blood pressure 90/60 mmHg, pulse rate 112 beats per minute, respiratory rate 20 breaths per minute, and temperature 36°C. Conjunctivae were pale. Chest and cardiovascular examinations were unremarkable. The abdomen was tender in the lower quadrants without obvious guarding or rigidity. Pelvic examination revealed a closed cervix and a bulging, tender posterior fornix. There was no cervical motion tenderness. The working diagnosis was ruptured ectopic pregnancy.

Baseline laboratory investigations showed hematocrit of 26% with blood group O positive and non-reactive rapid HIV and hepatitis screening. Two units of blood were cross-matched in preparation for surgery. A preoperative transabdominal ultrasound was performed and demonstrated a gestational sac with a formed fetal pole located adjacent to the right adnexa with associated free intraperitoneal fluid, findings that were interpreted as consistent with an ectopic pregnancy (Figure 1). After resuscitation with intravenous crystalloids and informed consent, the patient was transferred for emergency laparotomy under general anesthesia.

Figure 1.

(a) and (b) Preoperative transabdominal ultrasound image showing a gestational sac with a formed fetal pole located adjacent to the right adnexa and moderate free intraperitoneal fluid (arrow), consistent with ectopic pregnancy.

Intraoperatively, a Pfannenstiel incision was performed. Approximately 800 mL of hemoperitoneum was evacuated. The right fallopian tube was markedly distended and ruptured at the ampullary region, measuring approximately 6 × 8 cm, with extrusion of a formed fetus into the peritoneal cavity (Figure 2). The left fallopian tube and both ovaries were grossly normal. A right salpingectomy was performed with hemostasis secured; the specimen, including products of conception, was removed (Figure 3). Estimated blood loss was 200 mL in addition to the hemoperitoneum. The total operative time was 65 minutes. She received 2 units of packed red blood cells intraoperatively and was transferred to recovery in stable condition with blood pressure 110/70 mmHg and pulse rate 73 beats per minute.

Figure 2.

Intraoperative photograph showing ruptured right ampullary ectopic pregnancy with a formed fetus extruded into the peritoneal cavity and hemoperitoneum.

Figure 3.

Surgical specimen of the right fallopian tube following salpingectomy with attached products of conception.

The postoperative course was uneventful. She was managed with intravenous fluids, analgesia, and ceftriaxone prophylaxis for 48 hours. She ambulated on day one and resumed oral intake within 12 hours. Postoperative hematocrit improved to 32%. The urinary catheter was removed on the first day, and she passed urine freely. She was discharged on the fifth postoperative day in good condition after counseling on contraception, fertility implications of salpingectomy, and the importance of early antenatal care in future pregnancies. At 6-week follow-up, she was asymptomatic, the surgical wound was well-healed, and ultrasound confirmed normal pelvic anatomy of the remaining adnexa.

Discussion

Second-trimester tubal ectopic pregnancy is extraordinarily rare. Tubal ectopic pregnancies typically rupture by about 7 to 8 weeks, ⁶ so a 12-week intact tubal pregnancy is highly unusual. In fact, only a few such cases are reported in the literature. One case involved an intact tubal pregnancy at 14 weeks of gestation, ⁹ another at 13 weeks 6 days, ¹² and Restaino et al ⁷ described a tubal ectopic at 10 + 4 weeks following emergency contraception. These examples underscore that a formed fetus in a tubal EP at this gestational age is essentially unprecedented.

Our patient’s presentation was suggestive of a ruptured ectopic pregnancy. Ultrasound findings were diagnostic: an empty uterine cavity with a right adnexal gestational sac containing a live fetus, accompanied by free intraperitoneal fluid. These findings match prior reports of advanced ectopic gestation.^9,12 For example, Kunwar et al ¹² noted an empty uterus with a live 13 + 6 week fetus in the adnexa. In practice, the combination of an intrauterine pregnancy being absent on imaging and identification of an extrauterine gestation with fetal cardiac activity is pathognomonic for ectopic pregnancy.^8,13 Notably, at advanced gestations, the classic “tubal ring” sonographic sign may disappear, so careful scanning for fetal parts or free fluid is essential. ¹⁴ Our case highlights the need to perform a prompt ultrasound in any early pregnancy with pain or bleeding, even after emergency contraception or late in the first trimester, to avoid delayed diagnosis. ⁷

In low-resource settings, diagnosis is often delayed by limited access to timely transvaginal ultrasound and quantitative β-hCG testing, a shortage of trained personnel, and barriers to care (transport, cost, awareness). These factors increase the risk of rupture and adverse outcomes. ⁵ Practical mitigations include basic training in point-of-care ultrasound for frontline clinicians, streamlined referral pathways for suspected ectopics, and community education to encourage earlier presentation. ¹⁵ The pathophysiology of such an advanced tubal ectopic is not fully understood. ¹ It presumably requires an unusually compliant tubal segment or slow trophoblastic invasion to prevent early rupture.^9,11,16 Normally, tubal pregnancies not detected by 6 to 9 weeks will rupture, making this case highly atypical. ⁴ We did not find any prior tubal ectopic with a gestation older than 14 weeks, highlighting the exceptionality of our case.^7,9,11,12,16

Management of this patient followed standard guidelines.^4,17 Because she was hypotensive with an estimated 800 mL hemoperitoneum, emergency laparotomy was indicated. ¹⁷ We chose emergency laparotomy because the patient was hemodynamically unstable with an estimated 800 mL hemoperitoneum, and open surgery allows faster hemorrhage control and specimen removal. Laparoscopy is a valid alternative for hemodynamically stable patients with limited bleeding and when skilled staff and equipment are available, but it may be unsafe or impractical in unstable patients or low-resource settings. ⁴ Intraoperatively, the right ampullary tube was found ruptured, with the fetus extruded into the peritoneal cavity. Right salpingectomy was performed to achieve hemostasis. By contrast, salpingostomy, resecting only the pregnancy and preserving the tube, is reserved for small, unruptured ectopics when fertility preservation is paramount.^17,18 The patient received 2 units of packed red blood cells for anemia. This approach aligns with recommendations that ruptured, hemorrhagic tubal ectopics be managed by resection of the affected tube.^4,18

Reported postoperative outcomes in the literature show that advanced or ruptured ectopic pregnancies are associated with increased blood loss, longer recovery, and higher rates of postoperative complications. ¹ Ruptured ectopic pregnancy is a leading cause of death in the first trimester, and hemorrhage from rupture remains an important direct cause of maternal mortality, especially in settings with delayed diagnosis or limited access to emergency surgery and blood transfusion.^1,19,20 Published studies consistently show that minimally invasive management of ectopic pregnancy is associated with markedly shorter hospital stays (often same-day or 1-2 days), whereas open laparotomy typically requires longer admission (commonly 2-5 days), especially for ruptured cases.^20-22 Factors that increase the likelihood of prolonged admission include hemodynamic instability, significant blood loss and the need for transfusion or prolonged operative care, features commonly present in ruptured ectopic series.^20,21

Impact on fertility and risk of recurrence were addressed with the patient. The contralateral (left) tube was grossly normal, ²³ which is favorable for future conception. Indeed, in 1 large series, 100% of women treated surgically for tubal ectopic had a normal opposite tube. ²³ Published data suggest that roughly 50% to 60% of women conceive after an ectopic pregnancy, but approximately 10% to 15% may experience a repeat ectopic.^23,24 These outcomes were explained during counseling. The patient was advised that, although losing 1 tube may modestly reduce overall fertility, her preserved tube still offers a good chance of an intrauterine pregnancy. We emphasized the importance of early obstetric care and ultrasound in any future pregnancy, given her history.

Finally, this case highlights public health lessons. The patient’s history of emergency contraception illustrates that EP can occur even after such measures. Studies show that pregnancy after emergency levonorgestrel does not have a higher ectopic rate than baseline. ²⁵ However, guidelines advise performing a pregnancy test if menses are delayed after emergency contraception and obtaining an ultrasound if positive.^2,7,25 Additionally, delays in seeking care contributed to this presentation: the patient had 1 week of spotting before presenting. Improving education on early pregnancy warning signs and expanding access to first-trimester ultrasound, especially in low-resource settings, could facilitate earlier detection of ectopic pregnancies. ³

In summary, timely recognition and management led to an excellent outcome in this patient. No maternal morbidity occurred beyond the ectopic rupture. The key learning points are to maintain a high index of suspicion for ectopic pregnancy at any gestational age and to ensure early ultrasound evaluation in women with pain or bleeding, regardless of how advanced the pregnancy may seem. Recognition that an ectopic pregnancy can rarely present with a formed fetus is crucial for preventing catastrophic complications.

Limitations

This report describes a single clinical case and therefore has inherent limitations. Its findings cannot be generalized to all patients with similar conditions, and the design does not permit causal inference or statistical comparisons. Follow-up was limited to the short-term period after discharge, and longer-term reproductive and functional outcomes are not available. Additionally, resource limitations prevented some advanced diagnostics and longer inpatient monitoring that may be available in higher-resource settings. These limitations are typical of case reports; nonetheless, the clinical details presented can inform clinicians in similar settings and highlight areas where larger, prospective studies are needed.

Conclusion

This case of a 12-week tubal ectopic pregnancy with a live fetus underscores several important lessons. First, even late first-trimester pregnancies may be ectopic, so clinicians must maintain vigilance for EP at any gestational age. Second, prompt imaging is essential: an empty uterus on ultrasound in the setting of pain or bleeding should immediately raise concern for an ectopic gestation. Third, emergency contraception failure does not exclude the possibility of ectopic implantation; a positive pregnancy test after EC mandates an early ultrasound. Fourth, rapid surgical management of ruptured ectopic pregnancy, including salpingectomy when indicated, is life-saving, and preserving contralateral tubal function optimizes fertility prospects. Finally, public health efforts to improve early antenatal care and education about warning signs of EP can help detect these cases sooner. Overall, this report highlights the diagnostic challenges of an exceptionally rare presentation and reinforces best practices to prevent morbidity and mortality in ectopic pregnancy.