{"paper_id":"bc79cfba-90b5-4d22-a2ae-37ed54dabf95","body_text":"2 Departments of Gynaecology and Obstetrics, Karaelmas University, Faculty of Medicine, ZONGULDAK, TURKEY\nDOI: 10.5146/tjpath.2010.01002\nViewed: 6155\n-\nDownloaded :\n2770\nThe most common site of implantation in heterotopic and ectopic pregnancies is the Fallopian tube. Although less common, implantation may also occur in the tubal fimbriae, abdominal cavity, uterine interstitium, and uterine cornua. However, ovarian heterotopic pregnancies are quite rare[1-9].\nOvarian heterotopic pregnancy may be clinically and radiologically confused with tubal ectopic pregnancy, hemorrhagic corpus luteum cysts, or endometriotic cysts. Ectopic pregnancy should be considered in patients who present with pelvic pain and have risk factors, regardless of whether they have menstrual irregularities. Serum beta hCG levels and a careful radiologic study are important for diagnosis[3,5,9]. Macroscopically, ovarian heterotopic pregnancy appears as a space-occupying hemorrhagic mass in the ovary with a blue−purple color. During surgery, approximately two-thirds of these cases are confused with hemorrhagic corpus luteum[3-6].\nIn the present case, no symptoms or clinical signs suggestive of ovarian heterotopic pregnancy was detected during routine prenatal check-ups. During the caesarean section performed during the 36th week of the pregnancy due to placenta previa, the discovery of a hemorrhagic mass in the left ovary and a pre-diagnosis of endometrioma prompted the surgeons to perform a wedge resectomy. The histomorphological features of placental tissue from the ectopic fetus were consistent with a pregnancy in its first trimester. Placental tissues appeared to be surrounded by inflammatory cells and fibrous tissue in the hematoma. The remnants of the chorionic villi were fibrotic and degenerated, and very few trophoblastic cells were observed. These findings indicate that the ovarian heterotopic pregnancy had ended in the first trimester, which is consistent with the literature, along with involution of the placental tissue. Ovarian heterotopic pregnancies typically exhibit an asymptomatic course due to ending of the pregnancy at an early stage and involution of the placental tissue.\nThe clinical diagnosis of heterotopic pregnancy should be supported by a histopathological diagnosis. Histopathological examination reveals chorionic villouslike structures, trophoblastic cells, and/or membranes within the hematoma. Some ectopic pregnancies may form a chronic inflammatory mass, with trophoblastic tissue involution. This condition is known as a ‘chronic ectopic pregnancy,' and many samples are required to detect the few degenerated villi. Demonstrating trophoblastic cells by immunohistochemical techniques contributes significantly to diagnosis[1-9].\nIn the present case, the histomorphological appearance was confused with an organised hematoma, due to placental tissue that had undergone involution. However, the immunohistochemical determination of keratin, hPL, hCG, and a few trophoblastic cells verified the diagnosis of ovarian heterotopic pregnancy.\nTreatment of these cases is complicated by the coexisting intrauterine pregnancy. Removal of the gestational sac by laparoscopy or laparotomy is the treatment of choice. However, selective embryo reduction by direct injection of potassium chloride or hyperosmolar glucose into the ectopic gestational sac is another treatment option[9-13].\nIn conclusion, ovarian ectopic (or heterotopic) pregnancy should be considered in the differential diagnosis of hemorrhagic ovarian masses, particularly in pregnancies resulting from assisted reproductive technologies. In such cases, establishing a preoperative diagnosis is very difficult. A detailed histopathological examination and the use of immunohistochemical techniques provide important information during differential diagnosis.\n1) Rojansky N, Schenker JG: Heterotopic pregnancy and assisted\nreproduction--an update. J Assist Reprod Genet 1996, 3:594–601 [ Özet ]\n2) Milicevic S, Vilendecic Z, Dokic M, Radunovic N, Stamenovic S,\nStankovic A, Ljubic A: Heterotopic pregnancy: still a diagnostic\npuzzle. J Obstet Gynaecol 2008, 28: 458–459 [ Özet ]\n3) Grimes HG, Nosal RA, Gallagher JC: Ovarian pregnancy: a series\nof 24 cases. Obstet Gynecol 1983, 61: 174 [ Özet ]\n4) Shahabuddin AK, Chowdhury S: Primary term ovarian pregnancy\nsuperimposed by intrauterine pregnancy: a case report. J Obstet\nGynaecol Res 1998, 24:109–114 [ Özet ]\n5) Melilli GA, Avantario C, Farnelli C, Papeo R, Savona A:\nCombined intrauterine and ovarian pregnancy after in vitro\nfertilization and embryo transfer: a case report. Clin Exp Obstet\nGynecol 2001, 28:100–101 [ Özet ]\n6) Selo-Ojeme DO, GoodFellow CF: Simultaneous intrauterine and\novarian pregnancy following treatment with clomiphene citrate.\nArch Gynecol Obstet 2002, 266: 232–234 [ Özet ]\n7) Anastasakis E, Jetti A, Macara L, Daskalakis G: A case of\nheterotopic pregnancy in the absence of risk factors. A brief\nliterature review. Fetal Diagn Ther 2007, 22: 285–288 [ Özet ]\n8) Breyer MJ, Costantino TG: Heterotopic gestation: another\npossibility for the emergency bedside ultrasonographer to\nconsider. J Emerg Med 2004, 26: 81–84 9) Tay JI, Moore J, Walker JJ: Ectopic pregnancy. BMJ 2000,\n320:916–919 [ Özet ]\n10) Al-Sunaidi M, Tulandi T: Surgical treatment of ectopic\npregnancy. Semin Reprod Med 2007, 25: 117–122 [ Özet ]\n11) Pschera H, Gatterer A: Laparoscopic management of heterotopic\npregnancy: a review. J Obstet Gynecol Res 2000, 3: 157–161 [ Özet ]\n12) Doubilet PM, Benson CB, Frates MC, Ginsburg E:\nSonographically guided minimally invasive treatment of unusual\nectopic pregnancies. J Ultrasound Med 2004, 23: 359–370 [ Özet ]\n13) Strohmer H, Obruca A, Lehner R, Egarter C, Husslein P,\nFeichtinger W: Successful treatment of a heterotopic pregnancy\nby sonographically guided instillation of hyperosmolar glucose.\nFertil Steril 1998, 69:149–151 [ Özet ]\nKeywords :\nEctopic pregnancy, Ovary, Endometrioma","source_license":"CC0","license_restricted":false}