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OVARIAN DERMOID OR CHRONIC ECTOPIC- A Diagnostic Dilemma

Poornima R Ranka*, Alka S Gupta**,Shashank V Parulekar***
*Third Year Resident; **Associate Prof.; ***Prof.; Dept. of Obstetrics and Gynaecology, Seth GS Medical College, KEM Hospital, Parel, Mumbai - 12.
A case of chronic tubal ectopic pregnancy is being reported which was diagnosed on exploratory laparotomy in suspicion of an ovarian tumour in a patient who was already operated for tubal ligation 5 years back and had no menstrual history suggestive of ectopic pregnancy and was haemodynamically stable.

This case report has been published as it is quite unusual and rare that, patient may present 5 years after a minilap tubal ligation with adnexal mass, stable vital parameters regular menses, with the ultrasound also not diagnosing the ectopic.

INTRODUCTION

Ectopic pregnancy has 1% incidence in the world population1 and 1/8th of cases present as chronic ectopic pregnancy with haematocoele. [2]

Chronic ectopic pregnancy in the form of pelvic haematocoele may be present due to slow leakage of blood from a tubal pregnancy after death of the ovum and followed by a collection in the pouch of Douglas or one of the adnexa and further may elicit a reaction leading to thickening and walling of the collection simulating an ovarian tumour. [2]

One of the aetiology of ectopic pregnancy being failed tubal ligation [3-5] there is 16-50% incidence of ectopic pregnancy in cases of failed tubal ligation. [6,7]

CASE REPORT

Mrs. KK, 35 year female, married since 15 years G3 P3 L3, minilap tubal ligation done in village 5 years back, came with chief complaints of abdominopelvic pain since 3 months. There were no menstrual, bowel, bladder complaints, nor history of ammenorrhoea. She was haemodynamically stable and all her routine investigations were normal. Clinically, Per abdomen - Soft, suprapubic vertical scar of minilap T1 seen. Per speculum - Cervix vagina were normal, healthy. Per vaginum - Uterus normal, felt separately left adnexa normal right adnexal mass, 6 x 6 cm size, partly cystic and solid, nontender no cervical movements tenderness.

 
Fig 1: Shows sonography with right adnexal mass.

Ultrasonography done showed a well defined solid and cystic right adnexal mass 6.8 x 5.7 x 7.5 cm, as shown in Figure 1 and Figure 2. Uterus and rest of adnexa were normal; no free fluid present. Probable diagnosis by ultrasonography was ovarian dermoid or cystadeno carcinoma of the ovary.

 

 
Fig 2: Showing normal left adnexa

 

Exploratory laparotomy was performed and a large mass adhered to the omentum, small intestines and sigmoid colon was found behind the right adnexa and pouch of Douglas. Right fallopian tube revealed a rupture at the isthmus. The mass had variegated consistency. On handling it ruptured, with old clots weighing 800 gram, which were removed and right sided Salpingo - oophorectomy was done. Ovary could not be preserved due to dense adhesions with the tube. On inspection neither of the tubes showed any sign of tubal ligation. Left adnexa was normal. Products of conception could not be separately identi-fied in these clots. They were sent for histopathological examination.

Postoperatively patient was given 2 units of blood, she recovered uneventfully.

Histopathological examination of the clots and debris showed villi and products of conception.

DISCUSSION

Ectopic pregnancy following a failed tubal ligation has an incidence of 16-50% as of otherwise a risk of ectopic pregnancy which is 1%. [1]

Despite the history of tubal ligation and abdominal scar for the same, there was no evidence of tubal ligation on laparotomy.

As mentioned earlier, 1/8th of ectopics i.e. 0.125% develop into a chronic ectopic pregnancy and a pelvic haematocoele as seen in our case. Blood stained vaginal discharge mimicking menstruation could be due to uterine pregnancy changes. [2] Due to slow seepage of blood, patient remains haemodynamically stable. Chronic reaction can lead to formation of margins or walling of the ruptured tube, products of pregnancy and blood clots simulating an adnexal or ovarian mass.

In view of her clinical presentation, examination and ultrasonography findings, the patient was suspected to have an ovarian mass.

This case is being reported to remind the readers that pregnancy, especially a pregnancy in an abnormal site can be present in any woman, anytime in her life time, despite permanent sterilization, her marital status, menstrual history, clinical and ultrasound findings, especially more in the reproductive age group.

ACKNOWLEDGEMENT

We would like to thank our Dean of Seth GS Medical College, KEM Hospital for permitting us to publish this interesting case.

REFERENCES

  1. Willams Obstetrics 20th Edn. (Appleton and Lange and Co.). 1997.
  2. Munrorker’s operative obstetrics, 10th edn., B Tindall. 1995.
  3. Conson, Batzer. J Reproductive Medicine 1986; 31 : 78.
  4. Coste and Colleagues. Am J Epidemiology 1991; 133/839/199.
  5. Marchbanks and Co-workers. JAMA 1988; 259 : 1823.
  6. Mc Causland. American J Obst Gyn 1980; 136 : 97.
  7. Tatunm, Schmidt. Fertil, Steril. 1977; 28 : 407.
  8. Kalchman, Meltzer. AMJ, Obst Gynecol 1966; 96 : 1139.
  9. Young and Associates. Obstet Gynecol 1991; 78 : 749.

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