{"paper_id":"e301d4bd-08e6-4520-93aa-fd5fb61f7074","body_text":"Gynecol Surg (2004) 1:265–266\nDOI 10.1007/s10397-004-0053-9\nCASE REPORT\nAlexander E. P. Heazell · James B. Davis ·\nNighat R. Bhatti · Ulises Zanetto\nA case of tubal endometriosis mimicking the appearances\nof tubal pregnancy at laparoscopy\nPublished online: 31 August 2004\n/C23 Springer-Verlag Berlin / Heidelberg 2004\nAbstract Tubal pregnancy is a common gynaecological\nemergency. Due to the accuracy of transvaginal ultra-\nsonography and serum human chorionic gonadotrophin\n(hCG) analysis is being managed more frequently by\nlaparoscopy in asymptomatic patients. A case of pre-\nsumed tubal pregnancy is presented in which the evidence\ngenerated by ultrasonography, hCG levels and laparos-\ncopy all suggested tubal pregnancy. However, histologi-\ncal examination showed a tubal endometrioma. This case\nhighlights the importance of histological analysis of all\nsurgical specimens and provides a rare differential diag-\nnosis of tubal mass.\nKeywords Tubal endometrioma · Tubal pregnancy ·\nTransvaginal ultrasonography · Serum human chorionic\ngonadotrophin (hCG)\nIntroduction\nTubal pregnancy is a common gynaecological emergency,\nwhich is due to the accuracy of transvaginal ultrasono-\ngraphy and serum human chorionic gonadotrophin (hCG)\nanalysis is being managed more frequently by laparos-\ncopy in asymptomatic patients. A case of presumed tubal\npregnancy is presented in which the evidence generated\nby ultrasonography, hCG levels and laparoscopy all sug-\ngested tubal pregnancy is presented.\nCase report\nA 37-year-old parous woman presented to the gynaecology service\nwith 6-week amenorrhea, a positive urine pregnancy test, a single\nepisode of light vaginal bleeding and lower abdominal pain. In\naddition to a normal vaginal delivery at term, the patient also had a\nhistory of two first trimester miscarriages. She had no significant\ngynaecological history and no known risk factors for tubal preg-\nnancy. On examination, there was mild tenderness in the right iliac\nfossa; the cervical os was closed, and there was no adenexal ten-\nderness or cervical excitation.\nUltrasound scan showed a thickened endometrium (17 mm)\nwith no evidence of an intrauterine gestation sac. A 2.2 cm mass\nwas seen adjacent to the right ovary, with some associated free\nfluid. A serum hCG was 3,485 iu/l. In accordance with the RCOG\nguideline (RCOG, 2001), the patient was counselled as to the\npossibility of a tubal pregnancy, and consented to a laparoscopy,\nsalpingectomy and laparotomy if necessary.\nAt laparoscopy, a 2 cm bluish coloured mass was noted in the\nisthmic portion of the right fallopian tube; this was surrounded by\nadhesions (Fig. 1). There was a small amount of blood in the Pouch\nof Douglas, and the left tube had normal appearances. A diagnosis\nof right tubal pregnancy was made. A decision was made to pro-\nceed to laparotomy in view of the close proximity of the mass to the\nuterus—a right partial salpingectomy was performed. The patient\nmade an uncomplicated recovery.\nA. E. P. Heazell ( )) · J. B. Davis · N. R. Bhatti\nDepartment of Obstetrics and Gynaecology,\nCity Hospital,\nDudley Road, Birmingham, B18 7QH, UK\ne-mail: alex_heazell@talk21.com\nTel.: +44-121-5074042\nFax: +44-121-5075467\nU. Zanetto\nDepartment of Histopathology,\nCity Hospital,\nBirmingham, UK\nFig. 1 Laparoscopic appearances of lesion in right tube\n\nHistology revealed a 21/C14815/C14815-mm mass in the specimen.\nSections showed that the fallopian tube lumen was reduced, and\nthere were aggregates of glands, which had an appearance typical\nof endometrium. There was also decidualisation of the stroma\nwithin the muscle wall—this was in keeping with endometriosis.\nThere was no evidence of trophoblastic tissue (Fig. 2). Ten days\npost-laparotomy, transvaginal ultrasound scan revealed a small\namount of fluid in the endometrial cavity and thickened endome-\ntrium (17 mm) with no evidence of a gestation sac. At this point,\nthe serum hCG had fallen to 175 iu/l, and a diagnosis of failing\nintrauterine pregnancy was made.\nDiscussion\nEctopic pregnancy is a common gynaecological emer-\ngency, which with the advent of transvaginal ultrasound\nand rapid, accurate serum hCG assays is more often\nmanaged in asymptomatic, haemodynamically stable pa-\ntients. Endometriosis is also a common gynaecological\ndisorder, with a prevalence between 43–45% [4, 5]; it is\nusually asymptomatic, but may cause pelvic pain and\ninfertility [5]. The cause of endometriosis is unknown,\nand it is also associated with tubal damage [4]. In animal\nstudies, species that do not develop endometriosis do not\ndevelop ectopic pregnancy [3].\nOf all tubal pregnancies, 28% affect the isthmic region\nof the tube [2]. In 25% of cases, the macroscopic ap-\npearances of endometriosis are hardened cicatrial lesions\nof purplish-blue colour in the isthmo-ampullary region of\nthe tube [1]. Given the reported association between en-\ndometriosis, tubal dysfunction and tubal pregnancy, and\nthe similarities in macroscopic appearances of both le-\nsions, it is important to be aware of the differential di-\nagnosis of a tubal lesion prior to its excision and the\nnecessity for histological examination of the surgical\nspecimen.\nReferences\n1. Cioltei A, Tasca L, Titiriga L, Maakaron G, Calciu V (1979)\nNodular salpingitis and tubal endometriosis II. Diagnosis and\ndifferential diagnosis. Acta Eur Fertil 10:147–160\n2. Douglas CP (1963) Tubal ectopic pregnancy. Br Med J 2:838–\n841\n3. Hunter RHF (2002) Tubal ectopic pregnancy: a patho-physio-\nlogical explanation involving endometriosis. Hum Reprod 17:\n1688–1691\n4. Liu DTY, Hitchcock A (1986) Endometriosis: its association\nwith retrograde menstruation, dysmenorrhoea and tubal pa-\nthology. Br J Obstet Gynaecol 93:859–862\n5. Winkel CA (2003) Evaluation and management of women with\nendometriosis. Obstetr Gynaecol 102:397–407\nFig. 2 Low power view (/C14825) of lesion in right tube. Endometrial\nglands are marked by arrows\n266","source_license":"CC0","license_restricted":false}