Primary ectopic ovarian pregnancy (report of three cases).
Primary ectopic ovarian pregnancy is seen rarely. The incidence of such pregnancies, as stated in Indian literature, varies from 0.001% to 0.013%of normal pregnancies and from 0.17%to 1% of ectopic pregnancies. We had at our institution, three cases of primary ovarian pregnancy during 1966-1983, which gave us an high incidence of 1.8% of ectopic pregnancies and this prompted us to present these three cases over here.
A 25 year old female, with 45 days' amenorrhoea, complained of severe pain of sudden onset, in the right iliac fossa and suprapubic region. The pain was present for 5 days and was associated with vomiting, fainting, difficulty in micturition and defaecation. No associated vaginal bleeding was observed.
The present pregnancy was fifth; the four earlier ones had been full term and normal. The last child had been born three and a half years earlier. No contraceptive agent had been used by her nor had her menstrual cycles been irregular.
On examination, the patient looked pale and restless with the pulse rate of 128/minute and the blood pressure of 90/60 mm Hg. On per vaginum examination, the cervix and vagina were found healthy and the uterus was enlarged to 8 weeks' size. All the fornices were tender and a tender mass was felt in the left fornix. The cervical movements were tender. The clinical diagnosis of 'disturbed' ectopic pregnancy was made after finding altered blood during colpocentesis.
Nine hundred ml of altered blood was removed from the peritoneal cavity at laparotomy. The right tube appeared normal but the right ovary was enlarged and haemorrhagic, showing rupture of the tunica albuginea. Since the left tube appeared slightly thickened, a bilateral salpingectomy and right oophorectomy were done.
The ovarian mass removed weighed 30 gm. The placental tissue and blood clots were seen grossly and were surrounded by ovarian stroma and some yellow corpus luteum. No embryo was detected. The fallopian tubes showed no evidence of any products of conception. The ovarian tissue microscopically showed ovarian stroma, corpus luteum and products of conception[Fig. 1].
A 26 year old female patient was admitted with a history of 49 days' amenorrhoea, abdominal colic, pain on defecation and intermittent fever of 8 days' duration. No dysuria was observed.
She had 4 earlier, full term and normal deliveries, the last being 3 years earlier. No contraceptive agents had been used by her nor had her previous menstrual cycles been irregular.
Clinically, she was pale with the pulse of 88/minute and the blood pressure of 120/80 mm Hg. The abdomen was slightly distended and both the iliac fossae were tender. The vaginal examination revealed tenderness in all the fornices. The clinical diagnosis of a possible ruptured ectopic pregnancy or an acute pelvic inflammatory disease was made.
The exploration showed 20 ml of old blood in the peritoneal cavity and fresh bleeding in the left adnexal site. Though the left fallopian tube was normal, a gestational sac with an embryo involving the left ovary was seen. A left salpingo-oophorectomy was done.
The specimen showed 3 cm of fallopian tube to which a round mass of 3.5 cm diameter was attached. The mass was covered on one side by a thin, translucent membrane through which an embryo could be seen. The cut section of the mass, showed the wall containing a yellow corpus luteum, ovarian tissue with chorionic villi and blood clots. The embryo had well defined limbs and eyes and measured 20 mm in crown-rump height equivalent to 50 days' gestation[Fig. 2].
Histologically, ovarian tissue with corpus luteum, many chorionic villi covered by trophoblastic cells, decidua with fibrin and polymorphs were seen. The fallopian tubes showed no evidence of products of conception.
A 26 year old female was admitted with 45 days' amenorrhoea; A clinical diagnosis of ruptured ectopic tubal gestation was made.
The section through the brown mass of 5 cm size, remove" at the operation, showed ovarian tissue with blood clot. On histology, occasional necrosing chorionic villi were observed in the clot.
The conditions most commonly confused with ectopic ovarian pregnancy, both clinically and pathologically are ruptured haemorrhagic corpora lutea, "chocolate" cysts and ruptured tubal ectopic pregnancies. Therefore, the Spiegelberg criteriaare important to diagnose ovarian pregnancy. All these criteria were fulfilled by the three cases presented here.
Both tubal and ovarian pregnancies are believed to occur more frequently in the users of intrauterine contraceptive devices. Though the uterine implantation of the fertilized ovum is sharply reduced by the use of such device, there is no protection against pregnancies occurring elsewhere. None of the patients presented here had used IUCD. However, among 22 patients presented in Indian literature, two had used IUCD.,
Review of the Indian literature.,,,,,,,,,,,,,,,, shows no definite age group, the range being between 21 and 43 years in the 22 reported cases of primary ectopic ovarian pregnancy. The mean parity of 3 was observed with only two ovarian pregnancies, occurring at first time and four at second time.,No predilection to any side was seem. The period of amenorrhoea varied from none,,,,,to 14 months.In the two instances, the pregnancy continued to full term with one healthy newborn being delivered.,No definite relationship as regards the interval from an earlier pregnancy was observed. It is, therefore, obvious that primary ectopic ovarian pregnancy is probably a random and a chance occurrence.
Out of the modern methods, ultrasonography, laparoscopy and estimation of human chorionic gonadotrophic (HCG) levels have been used in conjunction with repeated clinical evaluation in the diagnosis and management of extrauterine pregnancies.,,,
Bradley et al reported the 'classic' findings which differentiated the double ring of the decidua parietalis and capsularis of an intrauterine, pregnancy-gestational-sac from that of a single ring of the pseudogestational sac of an ectopic pregnancy. Subsequent studies suggested that these 'classic' findings were not specific for ectopic pregnancy as they were often proved surgically to be tuba-ovarian or appendicial abscesses.It became clear that actual definitive demonstration of extrauterine gestational sac was rare and neither specific nor sensitive enough to be relied on to diagnose this life-threatening process.,
The HCG levels of over 6500 m IU/ml with ultrasonographic suggestion of presence of a gestational sac indicates continuing intrauterine pregnancy since the coexistence of an intrauterine pregnancy and an ectopic pregnancy is very rare, the current approach of many sonographers is to virtually exclude an ectopic pregnancy by demonstrating an intra-utrine, pregnancy. Therefore, if the patient is acutely ill, laparoscopy may be the procedure of choice. If the patient's condition is stable, the clinician may choose to observe the patient, follow serial quantitative Ii-HCG levels and obtain a follow-up sonogram to sac if definitive signs of an intrauterine pregnancy appear.