OJHAS Vol. 10, Issue 1:
of Primary Ectopic Ovarian Pregnancy
Sonia Gon, Assistant Professor, Department of Pathology,
Bipasa Majumdar, Assistant Professor, Department of Pathology,
Resident in Pathology,
Mallika Sengupta, Assistant Professor, Department of Obst. & Gynaecology,
RG Kar Medical College & Hospital, Kolkata-700004, India.
Address for Correspondence
West Bengal - 713206, India.
Gon S, Majumdar B, Ghosal T,
Sengupta M. Two Cases
of Primary Ectopic Ovarian Pregnancy. Online J Health Allied Scs.
Submitted: Jan 31,
2011; Accepted: March 31, 2011; Published:
April 15, 2011
Primary ovarian pregnancy
is one of the rarest varieties of ectopic pregnancies. Patients frequently
present with abdominal pain and menstrual irregularities. Intrauterine
devices have evolved as probable risk factors. Preoperative diagnosis
is challenging but transvaginal sonography has often been helpful. A
diagnostic delay may lead to rupture, secondary implantation or operative difficulties. Therefore, awareness of this
rare condition is important in reducing the associated risks. Here, we report two cases of primary
ovarian pregnancies presenting with acute abdominal pain. Transabdominal
ultrasonography failed to hint at ovarian pregnancy in one, while transvaginal
sonography aided in the correct diagnosis of the other. Both cases were
confirmed by histopathological examinations and were successfully managed
Primary; Ovarian; Pregnancy; Transvaginal Ultrasound
Ectopic Pregnancy is
an important health problem and accounts for 10% of all maternal mortality.(1)
Primary ovarian pregnancy is even rarer accounting for 0.15–3% of all ectopic gestations.(2) The diagnosis of an ovarian
ectopic pregnancy is seldom made before surgery.(3) Ultrasound, especially
transvaginal scanning (TVS) has proved to be an invaluable tool in the
diagnosis of this condition.(4) We had two cases
of primary ovarian pregnancies out of 280 ectopic pregnancies during
2005-2008, incidence being 0.71%.
A 24 years old female,
with 45 days' amenorrhoea, complained of severe pain of sudden onset,
in the right iliac fossa and suprapubic region for 2 days. The patient,
a third gravida, had a previous history of two full term normal
vaginal pregnancies. The last child had been born two and a half years
earlier and thereafter, she was using intrauterine device.
On per vaginum examination,
the cervix and vagina were healthy and the uterus was enlarged to 7
weeks' size. All her fornices as well as the cervical movements were
tender. Her routine hematological and biochemical tests were within
normal limits except for mild leucocytosis with neutrophilia. Keeping
pelvic inflammatory disease (PID)/tubo-ovarian mass as provisional
diagnoses, an abdominal ultrasonography (USG) was suggested which revealed
free fluid in pouch of Douglas but no intrauterine sac. On laparotomy
the right tube appeared normal but the right ovary was enlarged and
haemorrhaegic. The left tube and ovary showed no abnormality.
Right sided salpingo-oophorectomy with left sided tubal ligation was
done and specimen was sent for histopathological examination.
On Gross examination,
the ovary weighed 35 gms and measured 4.5x3.5x2.5 cms; the cut surface
showed blood clots and corpus luteum; no embryo was identified grossly.
The fallopian tube, measuring 5.2cm, appeared normal. On microscopic
examination, the sections showed corpus luteum within ovarian stroma
along with extensive areas of haemorrhage and scattered chorionic villi
A 24 years old female
patient was admitted in the surgical emergency ward on 13.03.2008 with
a history of severe left sided lower abdominal pain. There was no history
of difficulty in micturition, defaecation or vaginal bleeding. The last
menstrual period of the patient was on 19.01.08. She had no history
of PID or any contraceptive use.
On clinical examination
she was pale; with a pulse rate of 108/minute and blood pressure
of 110/70 mm Hg. The abdomen was slightly distended and both her iliac
fossae were tender. The vaginal examination revealed tenderness in all
the fornices. The clinical diagnosis of a possible ruptured ectopic
pregnancy or an acute PID was made. Her urine showed positive results
for pregnancy test. The TVS revealed a left adnexal, hyperechogenic
mass measuring 30 x 25 mm. The endometrium was 9 mm thick and there
was moderate free fluid in the pouch of Douglas (Figure 2).
Figure 1: Microphotograph
showing well preserved chorionic villi (arrow) amidst haemorrhagic area.
Ovarian stroma with corpus luteam is seen in the adjacent area. (H &
Figure 2: Transvaginal
ultrasonography showing left adnexal, ill-defined hyperechogenic mass
with free fluid.
On laparoscopy, a left
ovarian hemorrhagic mass measuring 3.8x3.2 cm was seen with a completely
normal fallopian tube separate from the ovary.
A left sided wedge excision of the haemorrhagic mass of the ovary was
done and the specimen was sent for histopathological examination. On
Gross examination, the ovary weighed 30gms and measured 2.0x1.5 cms.
The external surface as well as the cut surface was haemorrhagic.
On microscopic examination, plenty of chorionic villi lying dispersed
in a background of haemorrhagic ovarian stroma were identified.
Primary ovarian pregnancy
is a rare entity; first case being reported by St. Maurice(5) in 1682. The reported incidence is 0.15–3%
of all ectopic gestations.(2) It can be
classified as primary and secondary. Primary when ovum is fertilized
while still within the follicle, secondary when fertilization takes
place in the tube and the conceptus is later regurgitated to be implanted
in the ovarian stroma. They can be intrafollicular or extrafollicular.
Intrafollicular is invariably primary and extrafollicular may be primary
or secondary where ovarian tissue is usually absent in the gestational
The Spiegelberg (6)
criterias define ovarian pregnancy which includes: (a) intact ipsilateral
tube, clearly separate from the ovary; (b) gestational sac occupying
the position of the ovary; (c) sac connected to the uterus by the ovarian
ligament; and (d) histologically proven ovarian tissue located in the
Risk factors such as
PID and prior pelvic surgery may not play a significant role in its
etiology in contrast to patients with tubal pregnancies. Ovarian pregnancy
is more frequent with the use of IUD (7) corroborating with Case 1.
The clinical appearance of ovarian pregnancy differs and when
asymptomatic may be missed until late gestation.(8) The diagnosis is
seldom made before surgery (3). Ultrasound, especially TVS has proved
to be an invaluable tool in the diagnosis, as in Case 2, where hyperechoic
appearance of the trophoblast surrounded by thickened hypoechoic ovarian tissue is the
only indication of an ovarian ectopic gestation.(4) Even then, it
can be mistaken for a hemorrhagic corpus luteum or ovarian cyst. Ovarian
pregnancies usually terminate in rupture during the first trimester
in 91.0% cases, 5.3% in second trimester and 3.7% in third trimester.(1)
Both of our cases presented in 1st trimester. Only one
case has been reported in literature where ovarian pregnancy has progressed
to full term delivery.(9)
The diagnosis is difficult
and is a continuous challenge to the gynecologist and surgical practitioners.
Ovarian rupture destroys the integrity of the organ and occasionally,
that of the fallopian tube, preventing the recognition of such a gestation.
Ovarian pregnancy can be treated conservatively with single dose Methotrexate. However,
the preferred mode of treatment is oophorectomy by either laparotomy
or laparoscopy.(10) In the past, ovarian pregnancy had been treated
by ipsilateral oophorectomy, but the trend has since shifted toward
conservative surgery such as cystectomy or wedge resection performed
at either laparotomy or laparoscopy. Currently, laparoscopic surgery
is the treatment of choice.(7) Fertility after ovarian pregnancy has
been reported to be unmodified.(10)
In the present case reports,
both the cases presented with lower abdominal pain of acute onset and
a provisional diagnosis of ectopic pregnancy, acute PID or a tubo-ovarian
mass was made. In one of the cases, TVS showed a left ovarian echogenic mass and free fluid in pouch of Douglas;
and thus, aided in the diagnosis of an ovarian pregnancy. Both were
treated by operative methods - Case 1 underwent laparotomy and Case
2, laparoscopy. Histopathological examination confirmed the diagnosis
of an ovarian pregnancy in each case. Regarding fertility after ovarian
pregnancy, the present cases fail to shed any light; as Case 1 underwent
permanent sterilization and Case 2 was, unfortunately lost to follow
pregnancy is a rare event, awareness of this condition is important
in reducing the associated morbidity and mortality. Hence, it can be
concluded that ovarian ectopic pregnancy should be entertained as one
of the important differential diagnoses in a female of reproductive
age group presenting with acute abdomen.
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