Mature cystic teratomas (dermoid cysts) are common benign ovarian neoplasms. About 10% of dermoid cysts are detected duringpregnancy. Multiple gynecologic pathologies occurring together are uncommon, and both an ectopic pregnancy and dermoid cystare seen concurrently being unknown and poorly documented. Here, we report a case of ectopic pregnancy and dermoid cystoccurring simultaneously in a 30-year-old woman

D’Costa, Grace

Giri, Sulagna

Ramraje, Sushma

Sengupta, Abhishek

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 230
Case Report
Coexisting pathology of ectopic pregnancy and dermoid cyst: An uncommon 
occurrence
Sushma Ramraje1, Sulagna Giri2, Grace D’Costa3, Abhishek Sengupta4
From 1Associate Professor, 2Assistant Professor, 3Professor and Head, 4Resident Pathologist, Department of Pathology, Grant Government Medical 
College, Mumbai, Maharashtra, India
Correspondence to: Dr. Sushma Ramraje, 2/15, Dhanwantari, Sir J J Hospital Campus, Byculla, Mumbai - 400 008, India. 
E-mail: sushmaramraje@gmail.com
Received – 04 March 2018 Initial Review – 03 April 2018 Published Online – 21 June 2018
Mature cystic teratomas (dermoid cysts) contribute to about 33% of all benign ovarian neoplasms occurring between 10 and 30 years of age [1,2]. Majority of 
the dermoid cysts are asymptomatic at diagnosis with 10–15% 
being bilateral. About 10% of dermoid cysts are detected during 
pregnancy [3].
About 1–2% of all reported pregnancies in the developed 
world are ectopic pregnancies. Incidence in developing countries 
is higher but with little documentation [3,4]. Multiple gynecologic 
pathologies occurring together are uncommon, and both an 
ectopic pregnancy and dermoid cyst are seen concurrently being 
unknown and poorly documented [1]. Here, we report a case of 
ectopic pregnancy and dermoid cyst occurring simultaneously in 
a 30-year-old woman.
CASE REPORT
A 30-year-old multipara was brought to the surgical outpatient 
department by her relatives about 3 weeks after her last menstrual 
period with a chief complaint of pain in the right lower abdomen 
for 10 days. The pain was intermittent, dull aching, and non-
radiating. She did not give any history of fever, trauma, vomiting, 
diarrhea, hematuria, melena, or any past major surgical or medical 
illness. She was two gravida with two living children delivered by 
cesarean section.
At presentation, she was alert but in severe abdominal pain. 
She was normotensive with a normal heart rate. On physical 
examination, the abdomen was soft with tenderness in the right 
iliac fossa and a pelvic mass of size 12–14 weeks. However, 
there was no guarding. General and systemic examination was 
within normal limits. Obstetrics and gynecology reference was 
done. On per speculum examination, cervix was not visualized 
and was pushed up. On per vaginal examination, the cervix was 
felt pushed up. Free fluid was present bilaterally and a mass 
measuring 12–14 weeks with restricted mobility was felt in the 
posterior pouch.
She was hemodynamically stable and her hemoglobin and 
hematocrit were 10.6 g/dL and 29%, respectively. Blood tests 
showed mild anemia (red blood cell count 3.8 × 1012/L; hemoglobin 
10.6 g/dL; and hematocrit 29%) with near normal white blood 
cell count but an increased neutrophilic count (10,940/cumm; 
segmented neutrophil granulocytes 92%; lymphocytes 03%; 
monocytes 03%, and eosinophils 02%). All other biochemical 
investigations were normal. She was non-reactive for human 
immunodeficiency virus, Hepatitis B Ag, and hepatitis C virus. 
Human chorionic gonadotropin β (HCG), cancer antigen 125, 
and alpha-fetoprotein levels were 2901 mIU/mL, 54.8 U/L, and 
2.48 ng/mL, respectively.
The patient had regular menstrual cycles occurring every 
24–27 days and lasting for approximately 3 days. She had no 
history of the pelvic inflammatory disease or any other pelvic 
pathology and was healthy and was not on any medication.
Ultrasonography showed a large well-defined hyperechoic 
lesion with few cystic areas without any calcification or mural 
nodules measuring 9.7 cm × 6.5 cm × 9 cm extending to the pouch 
of Douglas suggestive of a large dermoid cyst. Both ovaries were 
not seen separately, and hence, the right or left side could not be 
ascertained. A CECT revealed a well-defined lesion measuring 
11 cm × 9 cm × 7.5 cm with fat and fluid levels in the left adnexal 
region and extending in the pouch of Douglas (Fig. 1). No 
enhancing mural nodule, solid component, or calcification were 
seen. Both ovaries and tubes were not seen separately.
ABSTRACT
Mature cystic teratomas (dermoid cysts) are common benign ovarian neoplasms. About 10% of dermoid cysts are detected during 
pregnancy. Multiple gynecologic pathologies occurring together are uncommon, and both an ectopic pregnancy and dermoid cyst 
are seen concurrently being unknown and poorly documented. Here, we report a case of ectopic pregnancy and dermoid cyst 
occurring simultaneously in a 30-year-old woman.
Key words: Gynecologic, Multiple, Pathologies
Ramraje et al. Coexisting pathologies: A diagnostic dilemma on frozen section
Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 231
An exploratory laparotomy with frozen section was 
advised. On opening the abdomen, the operating surgeon 
identified the cyst in the pouch of Douglas and a separate 
globular mass just behind the ovarian cyst. Both the ovarian 
cyst and the globular mass were sent for frozen section. 
We received an ovarian cyst measuring 10 cm x10 cm x3 
cms. It was smooth and congested externally. On cutting 
open, pultaceous cheesy material containing hair oozed out 
(Fig. 2-top). Rokitansky’s protuberance or any solid papillary 
areas were not identified. Fallopian tube was not attached to 
the ovarian cyst.  The separate globular mass measured 5 cm 
x4 cm x3 cms. It was congested and hemorrhagic on external 
and cut surface (Fig. 2-bottom). Frozen section of the ovarian 
cyst showed stratified squamous epithelium and numerous 
pilo-sebaceous units in the subepithelium (Fig. 3). Also seen 
were adipose tissue and keratinous material. The globular 
mass revealed chorionic villi and trophoblastic tissue (Fig. 4) 
against a haemorrhagic background. A diagnosis of dermoid 
cyst with ectopic pregnancy was given. Histopathology of both 
the specimens confirmed a benign mature cystic teratoma and 
an ectopic pregnancy.
DISCUSSION
Dermoid cysts are common ovarian neoplasms and are bilateral in 
10–15% of cases. They are mostly asymptomatic and discovered 
incidentally during laparotomy [2]. Few patients may present 
with abdominal pain and mass, nausea, vomiting, constipation, 
and anorexia. Torsion, rupture, infection, and hemorrhage are 
some common complications. About 10% of dermoid cysts are 
detected at pregnancy [1].
The prevalence of ectopic pregnancy in developed countries 
is 1–2%, with the percentage being higher in developing 
countries [4]. This increase is the result of risk factors such as pelvic 
inflammatory disease, smoking in women of reproductive age, 
and use of assisted reproductive technology. The patients usually 
present with severe and persistent pain and vaginal bleeding at 
6–10 weeks’ gestation [5]. Syncope, shock, shoulder tip pain, and 
abdominal tenderness can occur in some women. Cervical motion 
tenderness and a palpable adnexal mass have been reported [6].
Our patient did not have any of the mentioned risk factors 
and was hemodynamically stable. She was diagnosed with a 
dermoid cyst clinically and neither an intrauterine nor an ectopic 
Figure 1: A contrast-enhanced computed tomography revealed a 
well-defined lesion seen in the left adnexal region and extending in 
the pouch of Douglas
Figure 2: Ovarian cyst containing pultaceous cheesy material (top); 
separate globular mass congested and hemorrhagic on external and 
cut surface (bottom)
Figure 3: Frozen section of the ovarian cyst showing stratified 
squamous epithelium with the presence of numerous pilosebaceous 
units in the subepithelium (H and E; ×40)
Figure 4: Frozen section of the globular mass showing chorionic villi 
and trophoblastic tissue (H and E; ×40)
Ramraje et al. Coexisting pathologies: A diagnostic dilemma on frozen section
Vol 4 | Issue 3 | May - Jun 2018 Indian J Case Reports 232
pregnancy was suspected although her beta-HCG levels were 
2901 mIU/Ml. Mature ovarian cystic teratomas have rarely been 
reported to secrete HCG and may mislead to emergency surgery 
for treating a suspected extrauterine pregnancy [7].
A case of ectopic pregnancy with dermoid cyst was described 
almost a century ago by Matin, in 1917 [8]. There are only a few 
case reports on the coexistence of ectopic pregnancy and dermoid 
cyst [9,10]. Authors have described only five previous reports on 
the occurrence of a mature cystic teratoma of the fallopian tube 
discovered at laparoscopy for an ectopic pregnancy [11]. A benign 
teratoma of the fallopian tube occurring in association with a tubal 
pregnancy and a case of ruptured right ectopic pregnancy and 
dermoid cyst of the left adnexa has also been reported [12,13]. 
Recently, a case of a female patient who suffered from early 
abdominal pregnancy complicated by parasitic bilateral dermoid 
cysts has been described [14].
Although dermoid cysts and endometriosis are commonly 
found separately in women of reproductive age, few cases 
of endometriosis coexisting with dermoid cyst have been 
reported [15]. Thorough literature search revealed only sporadic 
cases of the dermoid cyst and ectopic pregnancy, the coexistence of 
endometriosis and dermoid cyst, and dermoid cyst superinfection. 
However, an extensive search on PubMed/Medline for an ectopic 
pregnancy of pouch of Douglas and coexisting dermoid cyst did 
not reveal any case reports.
To the best of our knowledge, this is the first case report of 
the dermoid cyst and ectopic pregnancy occurring together in 
the pouch of Douglas. Both the ovaries and fallopian tubes were 
not identified separately on CECT as well as during surgery, and 
hence, we reiterate that the dermoid cyst and ectopic pregnancy 
occurred together in the pouch of Douglas.
CONCLUSION
Coexisting pathologies in a single organ present a challenge to 
both, the clinician and the histopathologist. This case highlights 
the importance of pathologies that justify immediate surgical 
intervention and the need for the physician to be meticulous in 
putting together a differential for acute pelvic pain. Furthermore, 
studies should focus on multiple pathologies with special 
reference to ovarian mass having an increased risk for aberrant 
implantation during pregnancy or not.
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Funding: None; Conflict of Interest: None Stated.
How to cite this article:  Ramraje S, Giri S, Costa GD, Sengupta A. 
Coexisting pathology of ectopic pregnancy and dermoid cyst: An uncommon 
occurrence. Indian J Case Reports. 2018;4(3):230-232.


Coexisting pathology of ectopic pregnancy and dermoid cyst: An uncommon occurrence

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Coexisting pathology of ectopic pregnancy and dermoid cyst: An uncommon occurrence

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