Archives of Perinatal Medicine 20(3), 168-170, 2014
CASE REPORT
Primary ovarian ectopic pregnancy: an unusual case study
with conservative management by wedge resection
AHMED SAMY EL-AGWANY, A.M. FOUAD1
Abstract
The word ectopic comes from the Greek word “ektopos” which means “out of place”. Ovarian pregnancy is rare
occurring in 1-3% of all ectopic pregnancies. Ectopic is a potentially life threatening adverse pregnancy outcome
that requires prompt evaluation and treatment. It results in significant maternal morbidity, fetal loss, repeat
ectopic, impairment of subsequent fertility. Though ovarian pregnancy has a distinct pathology, it can be a source
of clinical and intraoperative diagnostic difficulty. We report a case of primary ovarian pregnancy with conservative management by wedge resection.
Key words: ectopic, ovarian, pregnancy
Background
Ovarian pregnancy is a rare event with incidence
between 1 in 2100 to 1 in 7000 pregnancies, or 1-3% of
all ectopic pregnancies [1]. The incidence has increased
with causes attributed to better diagnostic modalities,
increased use of intra-uterine devices, ovulatory drugs,
history of pelvic inflammatory disease (PID) and assisted
reproductive techniques [2-4].
Ovarian pregnancy is frequently misdiagnosed clinically as a tubal ectopic pregnancy. Intraoperative, it is
difficult to differentiate ovarian pregnancy, ruptured corpus luteal cyst or hemorrhagic ovarian cyst. There is an
obvious need to differentiate between tubal ectopic and
ovarian ectopic pregnancies as it will aid in management.
Thus, here it lies the necessity of reporting our case
[5, 6].
Case report
A 28 year-old multigravida woman presented with
lower abdominal pain, mild vaginal bleeding with 10
weeks of amenorrhea. She did not have any past history
of pelvic inflammatory disease or insertion of an intrauterine device. Tachycardia (110 bpm), blood pressure
100/70 mm Hg, with abdominal guarding and tenderness
were noted on examination. Per vaginal inspection revealed mild bleeding and bi-manual examination was
painful with the presence of a 5 cm right adnexal mass.
Haemoglobin was 8.5 gm/dl and pregnancy test was
positive. Transvaginal sonography showed a gestational
sac with a pulsating foetus in the region of the right
ovary with a crown rump length corresponding to the
nine gestational week, and with intra-abdominal haemor1
rhage suspicious of ovarian ectopic pregnancy. Culdocentesis was positive for haemoperitoneum. Ruptured
ectopic pregnancy was diagnosed and emergency laparotomy was performed.
The operative findings revealed ruptured right ovarian pregnancy. Wedge resection and enucleating the
mass from the ovary and hemostatic suturing of the ovarian defect were performed on the right side and the
specimen was sent for histopathological examination
(Fig. 1, 2).
The ovary was enlarged with a foetus attached. The
micro sections showed multiple chorionic villi lined by
trophoblastic cells along with deciduas in the ovarian
tissue. Thus, a diagnosis of primary ovarian pregnancy
was made.
The patient had an uneventful postoperative period
and was discharged without complications. Follow up
with $-hCG weekly till zero occurred in 2 weeks.
Fig. 1. Ruptured ovarian ectopic pregnancy
Department of Obstetrics and Gynecology, Alexandria University, Egypt
Primary ovarian ectopic pregnancy
Fig. 2. The gestational sac with the fetus inside
Discussion
Ovarian pregnancies constitute 1-3% of ectopic pregnancies [1]. Younger age, endometriosis, pelvic inflammatory disease, intra-uterine devices, ovulatory medications, and assisted reproductive techniques 3 are risk
factors.
The incidence is likely to be underestimated as many pregnancies die and involute spontaneously. More
than 90 percent of ovarian pregnancy present acutely [7].
Abdominal pain, with or without vaginal bleeding, is a
common clinical symptom along with symptoms similar
to those of tubal pregnancies, including circulatory collapse [7].
In the case-report, the patient denied any history of
risk factors. It can be hypothesized that this ovarian
pregnancy resulted from intrafollicular fertilization that
took place following failure of ovum extrusion after follicular rupture. The combination of symptoms of acute
abdomen with history of amenorrhoea, raised $-hCG
levels, and an ultrasonographical empty uterus should
also trigger an investigation for not only tubal pregnancy, but also ovarian ectopic pregnancy [5, 6].
Laparotomy was performed in our cases as the
patients arrived in hemodynamically unstable condition.
The established modes of surgical treatment of ovarian
pregnancy are either removal of the entire ovary containing the ectopic gestation or performing a wedge resection of the ovary. Because of viable ovarian tissue of
the affected side and young age of the patient, wedge
resection with enucleation of the sac was done.
Over a century ago, Spiegelberg [8] described criteria for an ovarian pregnancy. They were: the fallopian
tubes, including fimbria, must be intact and separate
from the ovary; the gestational sac must occupy the normal position of the ovary; the ovary must be attached to
169
the uterus through the utero-ovarian ligament; and,
there must be ovarian tissue attached to the pregnancy
in the specimen [8]. Histologically, our case revealed placental and trophoblastic tissue in the ovarian tissue,
indicative of the ovarian origin of the ectopic pregnancy.
Hence, a diagnosis of primary ovarian pregnancy was
made.
The differential diagnosis for ovarian pregnancy,
remains a clinical challenge that is to distinguish an ovarian ectopic pregnancy from a corpus luteum or hemorrhagic cyst [9] or even ruptured chocolate cyst. A corpus
luteum in an early or failing intrauterine or tubal pregnancy can mimic a cystic adnexal mass without clear
intrauterine gestation.
Conclusion
Ovarian ectopic pregnancy is rare and expected to
rise as more patients opt for fertility therapy. Despite
modern diagnostic modalities, these patients continue to
present in circulatory collapse. The necessity to maintain a high index of suspicion is required to ensure an
efficient mode of treatment, appropriate prognosis, and
patient counselling. Usually surgical treatment in form
of oophorectomy or wedge resection of the ovary is required.
Ethical approval
Written informed consent was obtained from the patient
for publication of this case report and accompanying images.
Acknowledgments
I acknowledge the cooperation of EL-Shatby Maternity
University Hospital residents who participated in appointing the patient and following up. We also appreciate
the commitment and compliance of the patient who reported the required data and attended for the regular
follow up.
References
[1] Comstock C., Huston K., Lee W. (2005) The ultrasonographic appearance of ovarian ectopic pregnancies. Obstet. Gynecol. 105: 42-45.
[2] Gaudoin M.R., Coulter K.L., Robins A.M., Verghese A.,
Harretty K.P. (1996) Is the incidence of ovarian ectopic
pregnancy increasing? Eur. J. Obstet. Gynecol. Reprod.
Biol. 70: 141-3.
[3] Das S., Kalyani R., Lakshmi V., Kumar M.L.H. (2008) Ovarian Pregnancy. Indian J. of Pathology and Microbiology
51(1): 37-8.
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A.S. El-agwany, A.M. Fouad
[4] Grimes H.G., Nosal R.A., Gallagher J.C. (1983) Ovarian
pregnancy: a series of 24 cases. Obstet. Gynecol. 61:174.
[5] Roy J., Sinha Babu A. (2013) Ovarian pregnancy: Two case reports. AMJ 2013, 6, 8, 406-10. http//dx.doi.org/10.
4066/AMJ, 1760.
[6] Prakash Kumar Nath, Subhasis Panigrahy, Sudhansu Sekhar Nath, Prasant Kumar Rout, Chintamani Mohanta
(2013) Primary ovarian ectopic pregnancy: a rare case
report. Journal of Evolution of Medical and Dental Sciences; Vol. 2, Issue 48, Page: 9339-41.
[7] Raziel A., Schachter M., Mordechai E., Friedler S., Panski M., Ron-El R. (2004) Ovarian pregnancy — a 12-year
experience of 19 cases in one institution. Eur. J. Obstet.
Gynecol. Reprod. Biol. 114(1): 92-6.
[8] Spiegelberg O. (1873) Zur Casuistik der Ovarialschwan-
gerschaft. Arch. Gynekol. 13: 73-79.
[9] Juan Y.C., Wang P.H., Chen C.H., Ma P.C., Liu W.M.
(2008) Successful treatment of ovarian pregnancy with laparoscopy-assisted local injection of etoposide. Fertil. Steril. 90: 1200.
J
Ahmed Samy El-agwany
El-shatby Maternity Hospital
Alexandria University
Alexandria, Egypt
e-mail: [email protected]