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UNUSUAL PRESENTATION OF PRIMARY OVARIAN PREGNANCY

Dharmesh Balsarkar*, MA Joshi**, Jayesh Dhareshwar***, R R Satoskar****, Ninaad Awsare*****, Rajesh Mahey*****, Vijay Kumar*****
*Lecturer; **Registrar; ***Associate Professor; ****Hon. Professor and Head of Unit; Department of Obstetrics and Gynaecology, LTMG Hospital, Sion, Mumbai - 400 022.

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Primary ovarian pregnancy is a rare entity, the reported incidence being 1 in 25,000 to 40,000 pregnancies. The diagnosis is difficult and the still continues to challenge the practising clinician. We had a case of ovarian pregnancy, the patient was operated and a right sided oopherectomy was done. The diagnosis was later confirmed on histopathology.

INTRODUCTION

Primary ovarian pregnancy is a rare entity, the diagnosis of which continues to challenge the practising clinician. Since the first case reported by St. Maurice in 1682, many cases have been reported in the literature. In 1951, Heartig estimated that ovarian pregnancy occurs in 1 in 25,000 to 40,000 pregnancies. [4]

A case of ovarian pregnancy is presented below.

CASE REPORT

Mrs. XYZ, 18 year old primigravida was admitted on 3/3/2000 at LTMG Hospital, Sion. She had a history of two and half months of amenorrhoea for which MTP was done in a private hospital, 15 days back. Following MTP, she continued to have bleeding per vaginum off and on, for which she had come to LTMG Hospital. She had no history of any major medical or surgical illness in the past.

On examination, her general condition was satisfactory. Pulse was 88 per minute, regular. Blood pressure was 110/70 mm of Hg. Systemic examination was normal. Haemoglobin was 10.5 gm%. Per abdominal examination revealed no guarding, tenderness or rigidity. Vaginal examination revealed that the uterus was anteverted and bulky. There was a mass in the posterior fornix, which could not be felt separate from the uterus. Both the lateral fornices were clear.

Fig 1 : Shows Rt ovary enlarged; it also showed amniotic sac containing 6 cm intact embryo with haemorrhage surrounding

Fig 2

 

Ultrasound examination was performed and a diagnosis of bicornuate uterus with pregnancy in the right horn was suspected. The patient was posted for MTP. Dilatation and curettage did not reveal any products of conception. Hence a decision for exploratory laparotomy was made.

On opening the abdomen by vertical midline infraumbilical incision, the uterus was found to be normal in size with no evidence of any anomalies. Left ovary and tube were normal. On the right side, medial end of the tube, ovarian and round ligaments were traceable. Right ovary was enlarged and showed an amniotic sac containing 6 cm (CRL) intact embryo with areas of haemorrhage around it (Figs. 1 and 2). The right tube was normal. There was no other pathology in the pelvis.

Right sided oopherectomy was performed. Abdomen was closed in layers after peritoneal toileting. The postoperative period was uneventful and the patient was discharged on the 8th post-operative day in good condition.

On histopathology, multiple sections were studied from different areas. Section from the haemorrhagic zone revealed blood clots and chorionic villi. Another area of the mass revealed chorionic villi embedded in the ovarian tissue (Fig. 3).

Fig 3	Fig 4
Fig 5
Histopathology of ovarian pregnancy showing blood clots and chorionic villi,embedded in ovarian tissue

 

DISCUSSION

Primary ovarian pregnancy is one of the rarest type of extra uterine pregnancies. It is reported as 1 in 25,000 to 1 in 40,000 pregnancies. With few exceptions the initial diagnosis is made on the operating table and the final diagnosis only on histopathology on the basis of the four Spiegelberg criteria establishing that the pregnancy is limited to the ovary and does not involve the tube. [7]

The cause of primary ovarian pregnancy remains obscure. Borrow concluded that chance is the reasonable explanation of ovarian pregnancies. [1] Other hypotheses have suggested interference in the release of ovum from the ruptured follicle, malfunction of the tubes and inflammatory thickening of the tunica albuginea. In contrast to patients with tubal pregnancies, se with ovarian pregnancies seldom have history of PID. However, Grimes et al reported reproductive system pathology or infertility in more than 50% of his 24 cases. [3]

The signs and symptoms of ovarian pregnancy are similar to those of disturbed tubal pregnancy. However, in our case the patient neither had any abdominal pain nor any fornicial tenderness. Rupture in the first trimester is the usual rule in an ovarian ectopic but the pregnancy may advance to full term. [2]

With the improvement in the ultrasonographic skills and instrumentation especially the vaginal probe, ovarian pregnancy has been diagnosed preoperatively. [6]

No case of repeat ovarian pregnancy has been reported in contrast to approximately 15% recurrent tubal pregnancy rate. In contrast to the tube, rupture of the ovary is a frequent phenomenon occurring periodically at ovulation. In view of this and the study of Portundo, who reported seven intrauterine pregnancies in 8 patients with ovarian pregnancies after surgery, it is clear that fertility after an ovarian pregnancy remains unmodified. [5]

ACKNOWLEDGEMENT

We thank our Head of Department and Dean for allowing us to use and publish the hospital data.

REFERENCES

1.Borrow RC, McElin TW, West RH, Buckingham JC. Am J Obstet and Gynecol 1965; 91 : 1095-6.

2.Darbar RD, Reddy CCM, Deshpande NR, Nagalotimath SJ. J Obst and Gyn India 1976; 28 : 310.

3.Grimes HG, Nosal RA, Gallagher JC. Ovarian pregnancy - a series of 24 cases. Obstet Gynecol 1983; 61 : 174.

4.Hertig AT. Discussion of Gerin-Lojoie L, Ovarian pregnancy. Am J Obstet and Gynecol 1951 : 62 : 920.

5.Portundo JA, Ochoa C, Gomez BJ, Uribaron A. Fertility and contraception of 8 patients with ovarian pregnancy. Int J Fertitility 1984; 29 : 254.

6.Russel JB, Cutler LR. Transvaginal ultrasonographic detection of primary ovarian pregnancy with laparoscopic removal. Fertil Steril 1989; 51 : 1055.

7.Spigelberg O. Arch Gynecol 1878; 13 : 73.

 

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