Document Detail

Case report of a primary ovarian pregnancy in a primigravida.
Jump to Full Text
MedLine Citation:
PMID:  19881157     Owner:  NLM     Status:  In-Data-Review    
Abstract/OtherAbstract:
Primary ovarian pregnancy occurs quite rarely and that too usually in young highly fertile multiparous women using intra uterine device. We present a case where a young primigravida presented with abdominal pain and was diagnosed as ectopic pregnancy and was confirmed intra-operatively and histopathologically as primary ovarian pregnancy, managed with partial ovariectomy.
Authors:
Subrat Panda; Laleng M Darlong; Santa Singh; Tulon Borah
Related Documents :
23137847 - Fetal sex pairing and adverse perinatal outcomes in twin gestations.
24229497 - The outcome of twin pregnancies discordant for trisomy 21.
6690997 - The establishment and maintenance of pregnancy using in vitro fertilization and embryo ...
8725767 - Unanticipated pregnancy with intrauterine growth retardation after radiation-induced ov...
20023297 - Understanding the mechanisms of human tubal ectopic pregnancies: new evidence from knoc...
7518877 - The hormonal profile in ectopic pregnancies.
Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Journal of human reproductive sciences     Volume:  2     ISSN:  1998-4766     ISO Abbreviation:  J Hum Reprod Sci     Publication Date:  2009 Jul 
Date Detail:
Created Date:  2009-11-02     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101473512     Medline TA:  J Hum Reprod Sci     Country:  India    
Other Details:
Languages:  eng     Pagination:  90-2     Citation Subset:  -    
Affiliation:
Department of Obstetrics and Gynecology, North East Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): J Hum Reprod Sci
Journal ID (publisher-id): JHRS
ISSN: 0974-1208
ISSN: 1998-4766
Publisher: Medknow Publications, India
Article Information
? Journal of Human Reproductive Sciences
open-access:
Received Day: 24 Month: 3 Year: 2009
Revision Received Day: 30 Month: 4 Year: 2009
Accepted Day: 09 Month: 5 Year: 2009
Print publication date: Season: Jul?Dec Year: 2009
Volume: 2 Issue: 2
First Page: 90 Last Page: 92
ID: 2800936
Publisher Id: JHRS-02-90
PubMed Id: 19881157
DOI: 10.4103/0974-1208.57231

Case report of a primary ovarian pregnancy in a primigravida
Subrat PandaAF0001
Laleng M Darlong1
Santa SinghAF0001
Tulon BorahAF0001
Departments of Obstetrics and Gynecology, North East Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
1Departments of Surgery, North East Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
Correspondence: Address for correspondence: Dr. Subrat Panda, Department of Obstetrics and Gynecology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India. E-mail: pandadrsubrat@rediffmail.com

INTRODUCTION

Primary ovarian pregnancy is a rare entity, the diagnosis of which continues to challenge the practicing clinicians. Since the first case reported by St. Maurice in 1689, many cases have been reported in the literature. Heartig estimated that ovarian pregnancy occurs in one in 25,000- 40,000 pregnancies.[1] Its frequency is 0.3-3.0 of all ectopic gestation.[2]


CASE REPORT

A 28-year-old primigravida with lower abdominal pain for 1 week with a history of 5 weeks amenorrhea was referred from the Department of Surgery. Her previous menstrual cycle was regular: average flow and no dysmenorrhea. On examination, no pallor, pulse 104/min, BP 100/70 mmHg and tenderness in the right iliac fossa were observed. Per vaginal examination showed normal uterine size and no cervical motion tenderness, but a palpable mass of size 4 cm ? 4 cm was seen in the fornix. On investigation, the urine pregnancy test was positive, Hb% was 9.4 gm%, total leucocyte count was 10,800/cu mm, platelet count was 2.6 lakh and the blood group was A positive. On ultrasonography, no gestational sac was seen inside the uterus but a right adenexal gestational sac 1.1 cm ? 0.5 cm ? 0.5 cm was seen without a fetal pole or free fluid in the cul de sac [Figure 1]. Provisional diagnosis was unruptured ectopic pregnancy. Medical management with a single dose of methotrexate was offered to the woman. Serum ? human chorionic gonadotropin (HCG) was 10,549 mIU/mL. On the fourth day of medical management, the patient complained of severe pain in the abdomen. The pulse rate was 120/min and the BP was 90/60 mmHg, following which a decision for laparotomy was taken because of the clinical features of shock (tachycardia, hypotension). However, in hemodynamically stable patients, such cases can be managed by laparoscopy if the facility and the expertise exist. Intra-operatively, the uterus was normal in size, with no hemoperitonium and both fallopian tubes were normal. The right ovary was enlarged with a bluish red mass of size 4 cm ? 4 cm, with oozing of blood from the surface of the mass [Figure 2]. Right-sided partial ovariectomy was performed and the contents were evacuated and sent for histopathology. The postoperative period was uneventful. On histopathological examination, trophoblastic villi and corpus luteum embedded in the ovarian tissue were seen, which were confirmatory of primary ovarian pregnancy [Figure 3]. Thus, the intra-operative findings and the histopathology examination satisfied the criteria for ovarian pregnancy as described by Spigelberg,[3] which is as follows: (a) intact fallopian tube on the affected side, (b) fetal sac must occupy the position of the ovary on the affected side, (c) ovary connected to the uterus by ovarian ligament, (d) ovarian tissue must be located in the sac wall, which was confirmed by histopathology.


DISCUSSION

Primary ovarian pregnancy is one of the rarest types of extra-uterine pregnancy. 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 Spigelberg criteria, establishing that the pregnancy is limited to the ovary and does not involve the tube.[3]

The cause of primary ovarian pregnancy remains obscure. Borrow concluded that chance is a reasonable explanation of ovarian pregnancies.[4] Other hypotheses have suggested interference in the release of the ovum from the ruptured follicle, malfunction of the tubes and inflammatory thickening of the tunica albugenia. Current intra uterine contraceptive device used may also be a cause.[5] The entity, empty follicle syndrome, where no oocytes are retrieved from the mature ovarian follicles with apparently normal follicular development and estradiol levels, after controlled ovarian hyperstimulation for an assisted reproductive technology cycle, despite repeated aspiration and flushing, can also be a cause for primary ovarian pregnancy.[6]

The signs and symptoms of ovarian pregnancy are similar to disturbed tubal pregnancy, conditions most commonly confused with ruptured hemorrhagic corpus luteum and chocolate cyst or tubal ectopic pregnancy.[5] Rupture in the first trimester is the usual rule in an ovarian ectopy, but the pregnancy may advance to full term.[7]

With the improvement in the ultrasonographic skill and instrumentation, especially with the use of vaginal probe, ovarian pregnancy can be diagnosed pre-operatively.[8]

No case of repeat ovarian pregnancy has been reported in contrast to approximately 15% recurrent tubal pregnancy.[9] Treatment consists of a single dose methotrexate protocol or conservative surgery. More preferred is partial overiectomy by either laparotomy or laparoscopy.[10] Methotrexate treatment in women with tubal ectopic pregnancy shows a success rate of > 82%, with the beta HCG level between 10,000 and 14,999 mIU/mL,[11] but according to the American Society of Reproductive Medicine guidelines, a beta HCG level more than 5000 mIU is a relative contraindication to medical therapy.[12] As in our case, the woman was a primigravida, with gestational sac size less than 2 cm, no cardiac activity, hemodynamic stability and no hemoperitonium. We had started medical therapy with methotrexate under strict supervision. Fertility after ovarian pregnancy remained unmodified.[13]


CONCLUSION

The diagnosis of ovarian pregnancy is difficult. Thus, it continues to challenge the practicing clinicians. Now, with ultrasonographic advances, it can be diagnosed early, leading to conservative treatment and preservative surgery.


Notes

Source of Support: Nil

Conflict of Interest: None declared.

REFERENCES
1. Hertig AT. Discussion of Gerin-Lojoie L. Ovarian pregnancyAm J Obstet and GynecolYear: 19516292014885275
2. Salas Valien JS,Reyero Alvarez MP,Gonzalez Moran MA,Garcia Merayo M,Nieves Diez C. Ectopic ovarian pregnancyAn Med InternYear: 1995121924
3. Spigelberg O. Casusistik der ovarialschwangerschaftArch GynecolYear: 18781373
4. Borrow RC,McElin TW,West RH,Bukingham JC. Ovarian pregnancy; Report of four cases and a thirteen-year survey of the English literatureAm J Obstet GynecolYear: 1965911095614280160
5. Mehmood SA,Thomas JA. Primary ectopic ovarian pregnancy, report of three casesJ Postgrad MedYear: 1985312193834088
6. Qublan H,Tahat Y,Al-Masri A. Primary ovarian pregnancy after the empty follicle syndrome: A case reportJ Obstet Gynaecol ResYear: 200834422418588619
7. Darbar RD,Reddy CC,Despande NR,Nagalotimath SJ. Primary Ovarian Pregnancy (a case report)J Obstet Gynecol IndiaYear: 197628310
8. Russel JB,Cutler LR. Transvaginal ultrasonographic detection of primary ovarian pregnancy with laparoscopic removalFertil SterilYear: 19895110552656305
9. Sergent F,Mauger-Tinlot F,Gravier A,Verspyck E,Marpeau L. Ovarian pregnancies: Revaluation of diagnostic criteriaJ Gynecol Obstet Biol ReprodYear: 2002317416
10. Chahtane A,Dehayni M,Rhrab B,Kharbach A,El Amrani S,Chaoui A. Ovarian pregnancy: Four cases with review of literatureRev Fr Gynecol ObstetYear: 1993883588441886
11. Lipscomb GH,McCord ML,Stovall TG,Huff G,Portera SG,Ling FW. Predictors of success of methotrexate treatment in women with tubal ectopic pregnanciesN Engl J MedYear: 19993411974810607814
12. Medical treatment of ectopic pregnancy: The practice committee of the American society of reproductiveFertil SterilYear: 200890S2061219007632
13. Portundo JA,Ochoa C,Gomez BJ,Uribaron A. Fertility and contraception of 8 patients with ovarian pregnancyInt J FertilYear: 1984292546152450

Figures

[Figure ID: F0001]
Figure 1 

Ultrasonogram showing ectopic gestation



[Figure ID: F0002]
Figure 2 

Intraop showing primary ovarian pregnancy



[Figure ID: F0003]
Figure 3 

Histopathology slide showing trophoblastic villi and corpus luteum embedded in ovarian tissue



Article Categories:
  • Case Report

Keywords: Ovarian pregnancy, partial ovariectomy, primigravida.

Previous Document:  Uterus didelphys with unilateral obstructed hemivagina with hematometrocolpos and hematosalpinx with...
Next Document:  The novel influenza A (H1N1) virus pandemic: An update.