J Chawla LJ*, Gokhale A**.
(* Third Year DNB Trainee, * Consultant.
Deenanath Mangeshkar Hospital
and Research Center,
.) Pune, India
We present a case report of a primary ovarian ectopic presenting in early gestation, with rupture and shock. This rare ectopic pregnancy is difficult to diagnose and transvaginal ultrasound failed to diagnose it. Laparoscopy is the gold standard in diagnosing and managing this condition.
Ovarian ectopic is an uncommon form of ectopic gestation, accounting for 0.15- 3% of all ectopics. It is often difficult to diagnose; frequently the first clinical sign is shock. Though transvaginal ultrasound is invaluable in the diagnosis of an ovarian pregnancy, it can be mistaken for a hemorrhagic corpus luteum or ovarian cyst. Ovarian pregnancy occurs in a fertile patient in contrast to tubal ectopic pregnancy (which is more frequently associated with infertility) and has been shown to have significant association with intrauterine contraceptive device (IUCD) use. We present a case of primary ovarian ectopic pregnancy managed successfully by operative laparoscopy.
A 22 year old woman presented in the casualty with acute abdominal pain for 3 hours and blurring of vision. The patient, a second gravida with a previous abortion, gave no history of vaginal bleeding or contraceptive use and had 6 weeks of amenorrhea. On clinical examination, she was drowsy, pale, and with peripheral pulse and blood pressure not recordable. On cardiac auscultation, heart rate was 120 /minute. Abdominal guarding was present with generalized lower abdomen tenderness. Vaginal examination revealed tenderness in both fornices and fullness in the pouch of
Douglas. A clinical diagnosis of
possible ruptured ectopic pregnancy was made. Urine pregnancy test was
positive. Transvaginal ultrasonography revealed moderate free fluid in the
pelvis, normal sized uterus and thin endometrium. Fallopian tubes and ovaries
were not visualized. On laparoscopy, 2 liters of hemoperitoneum was
drained. The right fallopian tube
appeared distended at the ampullary region, while the fimbriae appeared normal
with no evidence of tubal abortion. The right ovary showed the presence of a
hemorrhagic cystic structure with an active bleeding point. Right
salpingo-oophorectomy was done and the specimen was sent for histopathological
examination. On gross examination, the ovary measured 4x4x2 cm. The cut surface
showed grayish white appearance with a few, irregular hemorrhagic areas. The
right tube measured 3.5 cms and showed dilated lumen with no hemorrhagic areas.
Microscopic examination of the ovary revealed corpus luteum with a few foci of
congestion and hemorrhage and a fair number of syncitiotrophoblasts suggestive
of villi.(figure 1). No trophoblasts or villi were seen in the tube.
Figure 1. Syncytiotrophoblasts.
Ovarian pregnancy is a rare form of ectopic pregnancy with an incidence of one in 7000 deliveries. It usually terminates by rupture in the first trimester in 91.0% cases, 5.3% in second trimester and 3.7% in the third trimester. In this case, the patient presented in the first trimester; in shock.
Ovarian pregnancy is a diagnostic dilemma: usually it is difficult to obtain a diagnosis before surgery. Ovarian rupture destroys the integrity of the organ and occasionally, that of the fallopian tube, preventing recognition of such a gestation. Over the past ten years, diagnostic advances have resulted in earlier diagnosis: the availability of a highly specific radioimmunoassay for HCG, the development of transvaginal ultrasound and the widespread use of laparoscopy account for this fact. In our case, ultrasonographic features of an adnexal mass were unclear, due to the massive hemoperitoneum, however clinical suspicion was very strong.
As suggested by Spiegelberg (1878), primary ovarian pregnancy must be differentiated from distal tubal pregnancy, a condition that can secondarily involve the ovary at its surface. He outlined four criteria for the diagnosis of primary ovarian gestation: 1. The fallopian tube with its fimbriae must be intact; 2. The gestational sac should occupy the normal position of the ovary; 3. The gestational sac should be connected to the uterus by the uteroovarian ligament; and 4. The ovarian tissue must be present in the specimen attached to the gestational sac. Subsequently , other authors stated that ovarian tissue must be present around the gestational sac in several positions, at some distance from one another; in addition, the tube must not only be intact, but must also be free from any evidence of gestation, thus eliminating the possibility of secondary ovarian implantation. Even at the time of surgery, differential diagnosis between ovarian pregnancy and bleeding corpus luteum may be difficult. Macroscopic examination alone is insufficient and only indirect signs may be indicative. In the present case, dilatation of the tube and active bleeding from the ovary made the diagnosis of the site of ectopic, difficult. Hence a salpingo- oophorectomy was done to get a definitive diagnosis after histopathological examination which confirmed the diagnosis of a primary ovarian pregnancy. With the growing advances in laparoscopy, the trend in management of an ovarian pregnancy has shifted towards conservative surgery such as cystectomy or wedge resection. But in a case like ours, where the patient presented with clinical shock, it is not possible to follow an organized diagnostic approach and removal of the products of conception and cessation of active bleeding in order to save the life of the patient is the primary motive. Although rare, ovarian pregnancy can lead to severe morbidity and mortality in a young age group. Hence it should be considered as an important differential diagnosis for a young woman in the reproductive age group presenting with an acute abdomen and in shock. Operative laparoscopy is safe and effective approach in recent times and must be the first choice of treatment in such cases.
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Chawla LJ, Gokhale A. Diagnostic dilemma in a rare case of primary ovarian ectopic pregnancy. JPGO 2015. Volume 2 No. 2. Available from: http://www.jpgo.org/2015/02/diagnostic-dilemma-in-rare-case-of.html