Ovarian ectopic pregnancy

CASE REPORT ectopic pregnancy, ovarian; pregnancy, complication; pregnancy, ovarian ectopic

Ovarian Ectopic Pregnancy We present the case of a 27-year-old woman with left lower quadrant pain, tenderness, and rebound tenderness. Culdocentesis demonstrated non-clotting blood, and exploratory laparotomy showed an ovarian ectopic pregnancy. A wedge resection of the ovary was accomplished and the patient recovered completely. Ovarian ectopic pregnancy is an uncommon presentation of ectopic pregnancy. [Sturm JT, Hankins DG, Malo JW, Cicero JJ: Ovarian ectopic pregnancy. Ann Emerg Med May 1984;13:362-364.]

INTRODUCTION The pathological diagnosis of ovarian ectopic pregnancy requires documentation by Spiegelberg's four criteria 1 to establish that the pregnancy arises in the ovary and does not involve the Fallopian tube. These criteria are the following: 1) the tube on the affected side must be intact; 2) the fetal sac must occupy the position of the ovary; 3) the ovary must be connected to the uterus by the ovarian ligament; and 4) ovarian tissue must be located in the sac wall. Ovarian pregnancy must be distinguished from primary peritoneal implantation because different problems arise with the diagnosis and surgical management of these two conditions. The rich vascularity of the ovary results in maternal hemorrhage early in the first trimester, usually requiting emergency operation. Ovarian pregnancy ruptures in the ovary early in the course of the pregnancy, and the condition is commonly misdiagnosed at operation. The operative diagnosis of corpus luteum cyst or hemorrhagic corpus luteum is often made. z We discuss and illustrate the intraoperative diagnosis of ovarian ectopic pregnancy in a patient suspected of having a tubal ectopic gestation.

James T Sturm, MD* Daniel G Hankins, MD* John W Malo, MDt James J Cicero,MD* St Paul, Minnesota From the Departments of Emergency Medicine* and Obstetrics and Gynecology,I- St PauI-Ramsey Medical Center, St Paul, Minnesota. Received for publication April 18, 1983. Accepted for publication September 6, 1983. Supported in part by the St PauI-Ramsey Medical Education and Research Foundation. Address for reprints: James T Sturm, MD, Emergency Medicine Department, St PaulRamsey Medical Center, 640 Jackson Street, St Paul, Minnesota 55101.

CASE REPORT A 27-year-old woman presented to the emergency department complaining of left lower quadrant pain for 12 hours. The patient had been eating normally without nausea or vomiting. Her parity was 1-0-0-1 and she was sexually active without contraception. She had been treated for gonorrhea once in the past without complications, and had not used contraception previously. Her last menstrual period was two weeks prior to becoming ill, but it was not normal. There was a decreased amount of bleeding with that menses. Abnormalities on physical examination consisted of localized left lower quadrant tenderness and rebound tenderness in the left and right lower quadrants. Bowel sounds were normal and pelvic examination revealed a cervix exquisitely tender to motion. The left adnexae were extremely tender, but no adnexal masses were palpated. Rectal examination showed tenderness when directed toward the left lower quadrant. The blood pressure was 110/70 m m Hg and the pulse was 76; no postural changes were demonstrated. The patient's temperature was 37 C. Laboratory values included a white blood cell count of 12,300/mm3 with a normal differential, and a normal urinalysis. The hemoglobin was 13.7 g/dL. A serum pregnancy test was positive. An intravenous line was established with lactated Ringer's solution. Culdocentesis revealed 10 mL of non-clotting blood. Laparotomy performed under general anesthesia revealed 600 mL of blood in the peritoneal

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OVARIAN ECTOPIC PREGNANCY Sturm et al

Fig. 1. The intra-operative photograph

(A) depicts the ovary (arrow) and the gestational sac rupturing from the surface of the ovary. The line drawing (B) illustrates the important features of the photograph. Fig. 2. The photograph demonstrates the microscopic findings. The large arrow points out the hemorrhagic ovarian surface and the smaller arrows point to chorionic villi. cavi~ The right ovary and tube were normal. The left Fallopian tube was normal. The left ovary was enlarged, and on its antimesenteric side there was a 0.5-cm circular defect that was bleeding actively. A portion of a gestational sac with villi was seen extruding from the ovarian surface and the defect (Figures 1A and 1B). The remainder of the exploratory examination was normal. Using fine needle cauter~, an elliptical incision was made on the surface of the ovary surrounding the ovarian defect. A 1.5-cm wedge of ovarian tissue was resected and sent for histologic sectioning. Hemostasis was secured and the operation was completed. Pathologic sectioning demonstrated ovarian tissue and pieces of chorionic villi that were poorly vascularized and covered by syncytial and cytotrophoblastic layers. Corpora albicans and primary follicles also were noted (Figure 2). The patient made an uneventful postoperative recovery.

Gestational sac

Ovary

- - -

Line of wedge resection

lb

DISCUSSION The anatomic development of an ovarian pregnancy probably occurs because the ovulated ovum adheres to the ovarian operculum and remains entrapped within the ruptured ovarian follicle. Spermatozoa enter the peritoneal cavity within 15 minutes of deposition in the cervical mucus. 3 Fertilization occurs when sufficient spermatozoa reach the entrapped ovum to lyse the radiata and expose the zona pelluCida to sperm penetration. The fertilized o v u m undergoes division and proliferation within the corpus luteum and implants by day 6. I m p l a n t a t i o n occurs w i t h i n the ovary and on the corpus luteum, which is in the vascular stage of development. By the 40th day of gestation, trophoblastic invasion of maternal ovarian arteries occurs with resultant hemorrhage into the ovary and gestational sac. The hemorrhage disrupts the pregnancy and usually ruptures 90/363

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the capsule of the ovary, which has covered the implantation site. It probably is not possible for a pregnancy to develop within a corpus luteum that is well developed before implantation occurs. If there is not hemoperitoneum, there may be only transient pain followed by resorption of the dismpted pregnancy. Hibbard 4 reported that one-third of patients with ectopic pregnancy do not require operation but undergo complete resorption of the pregnancy. The frequency of resorption of ovarian pregnancies is unknown, but has been documented histologically in a case report from an asymptomatic patient who underwent a Hodgkin's staging operation. 4 Patients with ovarian pregnancy may be asymptomatic or misdiagnosed at operation. Therefore the true incidence of this rare anomaly of h u m a n r e p r o d u c t i o n remains unknown. Ovarian pregnancy accounts for 1% of all diagnosed ectopic pregnancies. 4

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There has been an apparent increase in the number of ovarian pregnancies that have been attributed to the widespread use of the intrauterine contraceptive device (IUD).S The IUD does not prevent ectopic implantation, but prevents intrauterine implantation. This selection results in an apparent increase in the frequency of ectopic pregnancies compared to the frequency of intrauterine pregnancies. A pregnancy that occurs with an IUD in place will be ectopic in 10% of instances. 5 However, the IUD does not increase the true risk of ectopic pregnancy. Women who use IUDs have no greater incidence of ectopic pregnancy when they are compared to all women at risk for pregnancy.S To date, 44 cases of ovarian pregnancy have been reported in association with use of the IUD.6 The high incidence of tubal and ovarian pregnancy associated with the IUD probably reflects the true incidence of ectopic pregnancy in the unprotected

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predisposed patient. It also reflects the chance of occurrence of ovarian pregnancy in the unprotected, multiply ovulating patient.

REFERENCES 1. Spiegelberg O: Zur Cauistik der ovarial Schwangerschaft. Arch Gynek 1878;13:73. 2. Settlage DSE, Motoshima M, Tredway DR: Sperm transport from the external cervical os to the Fallopian tube in women: A time and quantitative study. Fertil Steril 1973;24:655. 3. Rengachary D, Fayez JA, Jonas HS: Ovarian pregnancy. Obstet Gynecol 1977;49[Suppl):76. 4. Hibbard LT: Corpus luteum surgery. Am J Obstet Gynecol 1979;135:666. 5. Hallatt JG: Primary ovarian pregnancy: A report of 25 cases. Am J Obstet Gynecol 1982;143:55-60. 6. McMorries K, Lofton RH, Stinson JC, et al: Is the 1UD increasing the number of ovarian pregnancies? Contemp Ob/Gyn 1979;13:165.

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