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Ovarian Ectopic Pregnancy: a 10 Years’ Experience and Review of Literature

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Ovarian Ectopic Pregnancy: a 10 Years’ Experience and Review of Literature Iran J Reprod Med Vol. 12. No. 12. pp: 825-830, December 2014 Original article Ovarian ectopic pregnancy: A 10 years’ experience and review of literature Lajya Devi Goyal1 M.D., Rimpy Tondon2 M.D., Poonam Goel2 M.D., Alka Sehgal2 M.D. 1. Department of Obstetrics and Abstract Gynecology, Guru Gobind Singh Medical College and Hospital, Background: Primary ovarian pregnancy is one of the rarest forms of ectopic Faridkot, Panjab, India. pregnancy having incidence of 1/7000-1/40,000 in live births and 0.5-3% of all 2. Department of Obstetrics and ectopic gestations. Intrauterine contraceptive device (IUCD), salpingitis, infertility, Gynecology, Govt. Medical and assisted reproductive techniques are the important risk factors. Approximately, College, Chandigarh, India. 75% terminate in first trimester and are often misdiagnosed as corpus luteum haemorrhage. Preoperative diagnosis by ultrasonography (USG) in early pregnancy can help in conservative medical/ surgical management. Objective: The aim of the present study was to find the incidence, risk factors, role of USG in pre-operative diagnosis, feasibility of conservative management with medical method or minimal invasive surgery in developing countries like India. Materials and Methods: We did a retrospective cross-sectional study of ovarian pregnancies managed at Government Medical College and Hospital Chandigarh between July 2000 to July 2010. We analyzed the incidence, risk factors, clinical presentation, management of ovarian pregnancy, and reviewed the literature. Results: Incidence of ovarian pregnancy was 4.9% of all ectopic pregnancies (14/523). Thirteen (93%) patients presented in first trimester with acute pain abdomen and of these ten patients had bleeding per vaginum. One (7%) patient referred from peripheral hospital at term gestation with ultrasonographic diagnosis of breech presention with plecenta previa. Pre-operative diagnosis was made only in two cases (11%). All cases were managed by laparotomy. Excision of the sac with Corresponding Author: conservation of the ovary was done in eleven cases (78%) and oophorectomy was Lajya Devi Goyal, Department of done in two cases (14%). Obstetrics and Gynecology, Guru Conclusion: Incidence of ovarian pregnancy is on the rise. Although Gobind Singh Medical College and Hospital, Faridkot, Panjab, India. ultrasonography can detect ovarian gestations in unruptured cases but cannot easily Email: [email protected] differentiate ovarian from other tubal gestation in ruptured state. Medical Tel: (+91) 941 7658846 management is usually not feasible it most of the patients present in ruptured state. Conservative surgical approach is the management of choice. Received: 21 October 2013 Revised: 5 July 2014 Accepted: 17 August 2014 Key words: Ectopic pregnancy, Ovarian pregnancy, Infertility. Introduction ovarian pregnancy. In advance pregnancies last criterion i.e. detection of ovarian tissue in varian pregnancy is uncommon the wall of sac may not be satisfied as form of ectopic pregnancy with an parenchyma is compressed laminated and O incidence of 1/7000-1/40,000 live distended by developing foetus (3). births and 0.5-3% of all ectopic gestations (1). The actual incidence could be up to 1 in Advance ovarian pregnancies are exceptional. 1400 deliveries if the criteria other than those Approximately 75% terminate in first trimester of Spielberg are taken into consideration. and are often misdiagnosed as corpus luteum These criteria combine biochemical and USG haemorrhage (2). The Spielberg criteria findings and include a) serum βhCG level (1878)- a) fallopian tube as the affected site ≥1000 IU/L b) no gestational sac in uterine at must be intact b) the foetal sac must occupy transvaginal ultrasound c) ovarian the position of the ovary c) the ovary must be involvement should be confirmed on connected to the uterus by ovarian ligament exploration, with bleeding, visualization of and d) ovarian tissue must be located in the chorionic villi or presence of atypical cyst as sac wall, are essential for confirmation of early the ovary d) normal tubes e) absence of Devi Goyal et al serum βhCG after treatment of ovary (4). gestations fourteen were ovarian, four Intrauterine contraceptive device (IUCD) use cervical, three abdominal and 502 were tubal was the only risk factor quoted in the past gestation. All patients fulfilled Speigelberg’s literature and salpingitis and infertility are not criteria. One case of ovarian pregnancy implicated but recent literature quote presented at term (10). The mean age of the increased incidence with infertility and patients was 27 years. Mean gestational age assisted reproductive techniques (5-7). was 42 days. Eight patients presented with Role of USG in diagnosis of ovarian amenorrhea. One patient presented at term gestation has been described but most of the gestation and in five patients there was no patients present with ruptured ectopic and are history of amenorrhea. Most common in circulatory collapse so preoperative presenting complaint was acute pain diagnosis of ovarian ectopic on sonography is abdomen in 13 (93%) patients followed by not easy (8, 9). We conducted a retrospective vaginal bleeding in 10 (71%) patients. Six analysis and reviewed the case records of patients showed evidence of circulatory fourteen ovarian pregnancies including one collapse at presentation. Vaginal findings case of term ovarian pregnancy among 523 showed ectopic pregnancy in eleven patients. ectopic gestations and 33285 deliveries. There was history of IUCD use in five cases The aim of the present study was to find the incidence, risk factors, possibility of pre- (duration 1-6 years). operative USG diagnosis, feasibility of History of infertility was present in two conservative management with medical cases, of these one patient had undergone method or minimal invasive surgery. ovulation induction and intra uterine insemination in the preceding cycle. History of Materials and methods spontaneous or induced abortion was present in five cases and six patients were nullipara A retrospective cross-sectional study of (three were primigravida and three had ovarian pregnancies was conducted in previous one or two first trimester abortions). department of Obstetrics and Gynecology in Pregnancy test was positive in thirteen our Institute over a period of ten years i.e. July patients (pregnancy test was not done in case 2000-July 2010. The case records of ovarian of term ovarian pregnancy). βhCG test was pregnancies were searched in central record done in seven patients only (range: 1600- department of the hospital after taking 3200 IU/L) as other patients could not afford permission from medical record section to due to financial constraints. review the records of all those patients USG findings revealed echogenic sac with diagnosed with ovarian pregnancy for fetal cardiac activity in the ovary only in two academic and research purpose. cases. Adnexal mass was present on USG in Verbal consent was taken telephonically five cases varying from 4x4cm to 7x6cm. Rest from all the patients. Baseline information, of the cases showed free fluid in peritoneal presenting features, investigations and cavity with clots in pouch of doughlas. Term operative details were recorded. There is no ovarian pregnancy was misdiagnosed as control group in this study, because it breech presentation with placenta previa on investigates and reports the present files. USG. All patients underwent laparotomy. Intra operative findings revealed sac in the process Results of extrusion and surface bleeding from right ovary in nine cases. There were 523 ectopic pregnancies Term ovarian pregnancy was also in the among 33285 deliveries (1.7%). In ectopic right sided ovary. Left ovarian pregnancy 826 Iranian Journal of Reproductive Medicine Vol. 12. No. 12. pp: 825-830, December 2014 Ovarian pregnancy presented as an adnexal mass in two cases cases. Oophrectomy was done in two and ruptured cystic mass in two cases. Intra cases as sac was deep seated and operative diagnosis of corpus luteal bleeding could not be controlled. In term hemorrhage was suspected in three cases ovarian pregnancy entire ovary was however ovarian pregnancy were confirmed incorporated in sac so excision of the sac by histopathology examination in all these was done. On follow up pregnancy test cases. Excision of the sac with was negative in all cases of early ovarian conservation of the ovary was done in 11 pregnancies (Table I). Table I. Age, parity, risk factor, diagnosis and treatment of ovarian pregnancy Period of Serial Age Ultrasonography Intraoperative Parity Gestation Risk Factors Treatment number (years) Findings/ β-hCG findings (weeks) Ecogenic Sac with sac extruding Excision of sac B/L 1 24 G P L A 6+2 CuT-2yr 5 2 2 2 FCA in R adnexa from R ovary salpingectomy Primary infertility Nil sac extruding 2 22 Nulliparous ovulation induction, FF in peritoneal cavity Excision of sac from L ovary IUI sac in R ovary with Excision of sac B/L 3 26 G P L A 6 CuT-1yr FCA G sac in R ovary 4 2 2 1 salpingectomy βhCG -2200iu/l 5×5 cm L adnexal L ovary embedded 4 28 P L Nil CuT-3yrs L Oophrectomy 3 3 mass, echogenic area in clots MTP in early Placenta previa, pregnancy Live 2.2 kg fetus 5 24 G P L 40 Breech, Excision of sac 2 1 1 Continuation of in R ovarian sac oligohydraminos pregnancy FF in peritoneal cavity R ovarian 2cm 6 35 G P L 6+1 Nil Excision of cyst 2 1 1 βhCG 1880iu/l mass R adnexal mass Protruding sac 7 24 Primi 6+1 Nil Excision of sac FF from R ovary R ovarian sac with 8
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