Author Information
J Chawla LJ*, Gokhale A**.
(* Third Year DNB Trainee, * Consultant. Deenanath Mangeshkar Hospital
and Research Center ,
Pune , India
Abstract
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.
Introduction
Ovarian ectopic is an
uncommon form of ectopic gestation, accounting for 0.15- 3% of all ectopics.[1]
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.[2] We present a case of primary
ovarian ectopic pregnancy managed successfully by operative laparoscopy.
Case
Report
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.
Discussion
Ovarian pregnancy is a
rare form of ectopic pregnancy with an incidence of one in 7000 deliveries.[2]
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.[1] 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.[2] 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.
References
- Gon S, Majumdar B, Ghosal T, Sengupta M. Two cases of Primary Ovarian Pregnancy. Online J Health Allied Scs, 2011;10(1):26. Available from: http://cogprints.org/7840/1/2011-1-26.pdf
- Dahiya K, Duhan N, and Kunica Chechi K. Primary Ovarian Ectopic Pregnancy. Journal of Gynecologic Surgery. 2012;28(3):212-214. Available from: http://online.liebertpub.com/doi/pdf/10.1089/gyn.2011.0049
Citation
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