|Year : 2021 | Volume
| Issue : 1 | Page : 31-33
Ovarian ectopic pregnancy: A success story
Beenish Maqsood1, Amina Butt1, Khawaja Rohan Aziz2
1 Department of Obstetrics and Gynecology, Dr Sulaiman AlHabib Hospital, Takhassussi, Riyadh, Saudi Arabia
2 4th Year Medical Student, University of Leeds, UK
|Date of Submission||16-Dec-2020|
|Date of Acceptance||02-May-2021|
|Date of Web Publication||14-Jun-2022|
Dr. Beenish Maqsood
Dr. Sulaiman Alhabib Hospital, Takhassussi Branch
Source of Support: None, Conflict of Interest: None
Ovarian pregnancy is a rare form of ectopic pregnancy. Clinical and imaging diagnosis is challenging and so can be the management, as was in our case, where the pregnancy being located in the ovary was not clear in the beginning. Various case series have concluded that an ovarian pregnancy, in a few cases, can present as an adnexal mass. We present a case of left ovarian pregnancy in a 31-year-old woman. Transvaginal ultrasound showed an empty uterus and a left adnexal mass. A suboptimal rise in beta-human chorionic gonadotropin (β-hCG) levels suggested an ectopic pregnancy. The patient declined a surgical intervention, even after explaining the risks and a likely need of surgery, in view of high β-hCG level. A single dose of methotrexate was given in the presence of hemodynamic stability and absence of pain. Subsequently, a laparoscopy was performed when the patient presented with pain abdomen and a rising β-hCG level, 7 days after methotrexate was administered. Ovarian wedge resection was done. Histopathological assessment confirmed the diagnosis. Increasingly, operative laparoscopy is the method employed for the surgical management of ovarian ectopic pregnancy. In view of concerns about future fertility, the current practice is to resect ovarian pregnancy and preserve healthy ovarian tissue.
Keywords: Adnexal mass, laparoscopy, ovarian ectopic pregnancy, ovarian wedge resection
|How to cite this article:|
Maqsood B, Butt A, Aziz KR. Ovarian ectopic pregnancy: A success story. Saudi J Laparosc 2021;6:31-3
| Introduction|| |
Primary ovarian ectopic pregnancy (OEP), the implantation of the gestational sac in the ovary, is one of the rarest forms of ectopic pregnancy. Its incidence, after natural conception, ranges from 1 in 2000 to 1 in 60,000 deliveries and accounts for 3% of all ectopic pregnancies.,
The diagnosis of ovarian pregnancy remains a challenge, and many cases are still missed on ultrasonography. The criteria for diagnosing ovarian pregnancy are mainly surgical and cannot be established by ultrasonography. In spite of this limitation, increasingly more cases are diagnosed on ultrasonography, with advanced techniques.
Endoscopic surgery is now regarded as the criterion standard for the surgical management of ectopic pregnancy (Royal College of Obstetricians and Gynecologists). However, in only a few case series, operative laparoscopy was exclusively used for the treatment of women with OEP., In many case reports, open surgery is still used for the treatment of women with ovarian pregnancy despite the benefits of the minimal access approach.
In view of concerns about future fertility, the current practice is to resect the ovarian pregnancy and preserve healthy ovarian tissue. Oophorectomy is rarely indicated. Follow-up beta-human chorionic gonadotropin (β-hCG) levels must be obtained, in view of possibility of persisting trophoblastic tissue.
| Case Report|| |
Thirty-one-year-old woman, para 0 with previous miscarriage, 8 weeks pregnant, attended routine antenatal care. Ultrasound scan showed empty uterus with left adnexal mass, 2.1 cm × 2.1 cm. β-hCG level showed a suboptimal rise from 7532 to 8293 IU/L after 48 h, which was suggestive of an ectopic pregnancy. However, the patient was clinically stable. Furthermore, ultrasound scan did not show the presence of any free fluid in the pelvis. We discussed management options with her and offered laparoscopy in view of high β-hCG levels. Even though we discussed, in detail, the chances of failure of the medical treatment and the risk of rupture of ectopic pregnancy with the patient, she chose medical management. Hence, a single intramuscular injection of methotrexate was given to her, with β-hCG levels planned on days 1, 4, and 7.
On the 4th day, β-hCG level was 7433 IU/L. On the 7th day, the patient presented to Emergency Department with lower abdominal pain, and the β-hCG level had risen to 8940 IU/L, which was more than that observed 4 days after methotrexate. Therefore, a diagnostic laparoscopy was performed as an emergency procedure. Intraoperatively, we noticed a large left-sided ovary with a 2 cm mass and around 100 ml of blood in the pouch of Douglas [Figure 1]. Both the tubes were intact. The preliminary diagnosis was an ovarian ectopic pregnancy. A hemorrhagic corpus luteal cyst with aborted tubal ectopic pregnancy was another possible diagnosis.
|Figure 1: Picture taken during laparoscopy showing ectopic pregnancy on the left ovary|
Click here to view
The mass was excised, using wedge resection technique, with conservation of the ovary, to restore the ovarian integrity for an eventual successive pregnancy. We sent the resected tissue for histopathology examination, and the report confirmed the presence of chorionic villi embedded in the ovarian tissue and hence the diagnosis of OEP.
Typically, OEP has the appearance of a hemorrhagic ovarian mass at surgery [Figure 1]. However, ovarian pregnancies can also pose a diagnostic dilemma at surgery as they can be misdiagnosed as hemorrhagic corpus luteum or ovarian cysts, as was illustrated in our case.,
In an attempt at resolving this diagnostic ambiguity, a study advised that an ovarian hemorrhagic mass associated with normal tubes, a serum concentration of β-hCG >1000 IU/mL, and absent intrauterine sac suggests an ovarian pregnancy. This serves as a useful guide, with the main limitation being cases with β-hCG <1000 IU/L.
The β-hCG level was followed on outpatient basis that showed a progressive decline. This patient conceived after 6 months after surgery, the outcome being a healthy live pregnancy at term.
| Discussion|| |
Ovarian pregnancy still remains a diagnostic challenge. There are a few cases reporting an accurate preoperative diagnosis, utilizing sonography. The correct diagnosis is most frequently made at the surgery and requires histopathological confirmation. Diagnosis of ovarian pregnancy should be suspected from an elevated β-hCG, lack of intrauterine gestation, a complex ovarian mass on ultrasonography. Conventionally, diagnosis has been made using the Spiegelberg criteria which includes: (i) gestational sac located in the region of the ovary, (ii) pregnancy is attached to the uterus by the ovarian ligament, (iii) tube on the involved side is intact, and (iv) ovarian tissue in the wall of the gestational sac is proved histologically. However, these criteria cannot be established preoperatively.
In general, the important diagnostic tool for ovarian pregnancy is ultrasonography. However, ultrasound diagnosis of ovarian pregnancies is difficult preoperatively, when an embryo is not found by ultrasound scan. A case series regarding the ultrasound appearances of ovarian ectopic pregnancy showed that although it was uncommon to see yolk sac or embryo, ovarian pregnancies usually appeared on or within the ovary as a cyst with a wide echogenic ring outside. This can be distinguished from a corpus luteum, which may also have a ring-like appearance, as the majority of the corpus luteum rings appear less echogenic than the ovary itself, whereas for ovarian pregnancies, it is greater. Therefore, finding such a ring on imaging of suspected ectopic pregnancies increases the possibility of an ovarian pregnancy. Nevertheless, compared to preoperative diagnosis, ovarian pregnancies are twice as likely to be diagnosed during surgery, such as for a ruptured corpus luteum or tubal ectopic pregnancy or following pathologic review of an apparent hemorrhagic ovarian cyst.
Increasingly, operative laparoscopy is the method of choice in the management of OEP. Although ipsilateral oophorectomy is definitive in its management, this is becoming less common in favor of fertility-preserving surgical management. These include partial ovariectomy (wedge resection), ovarian cystectomy, or blunt dissection of the trophoblastic tissue. Trophoblastic tissue may persist after conservative surgical management and requires follow-up β-hCG tracking postoperatively. However, in a case series of 12 patients, no case required further treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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