Laparoscopic Management of Primary Ovarian Pregnancy

Introduction

A pregnancy confined to the ovary represents 0.5%–1% of all ectopic pregnancies and is the most common type of nontubal ectopic pregnancy. ¹ Preoperative diagnosis of ovarian pregnancy is seldom made. Currently laparoscopy, is the “gold standard” for diagnosis and management of ovarian ectopic pregnancy. This report describes a case of a primary ovarian pregnancy that was managed successfully by laparoscopy.

Case

A 30-year-old, multiparous female reported to an emergency department with complaints of pain in her lower abdomen associated with vomiting for 2 days and bleeding from her vagina for 4 days following 6 weeks of amenorrhea. Her previous menstrual cycles were regular, and she had all vaginal deliveries, with the last childbirth 1 year prior to presentation. She was not sterilized and had not been using any form of contraception.

On examination she noted to be hemodynamically stable, without any abdominal tenderness, guarding, or rigidity. A pelvic examination revealed mild bleeding through the os with a bulky uterus, a right fornicial mass, and tenderness, although there was no cervical motion tenderness. Routine blood reports were normal except for a weakly positive urine pregnancy test and a serum ß–human chorionic gonandotropin (ß-hCG) level of 8366 mIU/mL. Transvaginal sonography revealed a multiloculated cyst (5.2×4.5cm) in the right ovary, acontralateral normal ovary, and an empty uterus with thickened endometrium and without any free fluid in the cul de sac.

Laparoscopy was planned in view of the clinical diagnosis of ovarian pregnancy. A right ovarian cystectomy was performed, combined with wedge resection to restore ovarian integrity, along with bilateral tubal sterilization.

Results

Recovery of the patient was uneventful and she was discharged on the second postoperative day. Serum ß-hCG testing was followed up; her level became normal after 2 weeks. Histopathologic testing showed sheets of decidual cells in the ovarian stroma, with numerous blood vessels, follicles, and degenerated trophoblastic-cells confirming the clinical diagnosis (Fig. 1).

OPEN IN VIEWER

FIG. 1.

Chorionic villi within the ovarian stroma. N, normal ovarian stroma; CV, chorionic villi. “5A” is the slide number.

Discussion

Primary ovarian pregnancy is a rare entity. The reported incidence is 0.5%–1% of all ectopic gestations. ¹ This type of ectopic pregnancy must fulfill Spiegelberg criteria for diagnosis, which are: the Fallopian tube, including the fimbria, ovarica is intact and clearly separate from the ovary; the gestational sac definitely occupies the normal position of the ovary; the sac is connected to the uterus by the utero-ovarian ligament; and the ovarian tissue is unquestionably shown in the wall of the sac. ² Unfortunately, all of these criteria are surgical and histologic, thus, making the diagnosis difficult before surgery.

Most often, a primary ovarian pregnancy is confused with a corpus luteal cyst or endometrioma. ³ Raised ß-hCG in the absence of an intrauterine pregnancy with normal Fallopian tubes and a cystic ovary can be a clue to the presence of an ovarian pregnancy, which is based on the classic sonographic description of a cyst with a wide echogenic outer ring on, or within the, ovary. A yolk sac or embryo is rarely seen. ⁴ In the present case, evaluation of all of the diagnostic studies, particularly the serum ß-hCG level and transvaginal sonography raised the suspicion of an ovarian pregnancy preoperatively.

Classic symptoms of tubal gestation are abdominal pain, amenorrhea, and bleeding; however, persistent pelvic pain alone is the most frequent clinical manifestation of ovarian gestation. Although an adnexal mass is palpable in as many as 60% of ovarian pregnancies, the mass is frequently confused with a corpus luteal hematoma.

Ovarian pregnancy had been conventional treated by ipsilateral oopherectomy. However the recent focus is on conservative surgery, such as ovarian cystectomy or wedge resection, either performed by laparotomy or laparoscopy. ⁵ Tinelli et al. described two cases of ovarian ectopic that were detected and treated during laparoscopy for suspected ectopic pregnancy. ⁶ The conservative surgical procedure is excellent for potentially preserving future fertility. Only rarely, is the hemorrhage so profuse that oophorectomy is required to control the bleeding. Patel et al. treated a case of ovarian ectopic pregnancy successfully. That pregnancy was diagnosed in a 41-year-old female laparoscopically by oophorectomy to control the patient's excessive bleeding. ⁷ Pharmcologic agents have a limited role, as diagnosis of an ovarian ectopic pregnancy may be difficult to establish preoperatively. In addition, laparoscopy is a less-invasive approach, with reduced postoperative morbidity and a shorter hospital stay, compared to laparotomy.

Conclusions

Laparoscopy is the current “gold standard” for diagnosis and treatment of ovarian ectopic pregnancy. Although ovarian pregnancy is a rare event, awareness of this condition along with a ß-hCG asssy and transvaginal sonography could assist in preoperative diagnosis.