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Prımary Ovarıan Pregnancy : A Case Report And Revıew Of The Lıterature
MAKALE #5560 © Yazan Dr.Özge İŞCAN | Yayın Eylül 2010 | 3,995 Okuyucu
PRIMARY OVARIAN PREGNANCY : A CASE REPORT AND REVIEW OF THE LITERATURE
PRIMER OVARIAN GEBELIK: OLGU SUNUMU VE LITERATÜR DERLEMESI

Ismail Mete ITIL Özge ÖZCAN Mustafa Coan TEREK Senay AYGÜL
Department of Obstetrics and Gynecology, Ege University Faculty of Medicine, Izmir, Turkey
Anahtar Sözcükler :
Ovarian ectopic pregnancy

Key Words :
Ovarian ektopik gebelik

SUMMARY
Ovarian pregnancy is the most common type of non-tubal ectopic pregnancy. The diagnostic criteria for ovarian pregnacy
were described by Spiegelberg. We report a 31-year-old patient with secondary amenorrhea after a first trimester
pregnancy termination. The patient underwent laparoscopic operation for the right ovarian cyst and the mass on the
posterior surface of the uterus. Subsequently histopathologic examination of the laparoscopically extirpated cyst revealed
an ovarian pregnancy.
ÖZET
Ovarian gebelik en sık görülen non-tubal ektopik gebeliktir. Ovarian gebeliğin tanı kriterleri Spiegelberg tarafından tanımlanmışır. 31 yaında bayan hasta ilk trimester gebelik vonlanması sonrasında sekonder amenore ile kliniğimize bavurdu.
Hastaya sağ overde mevcut olan sağ over kisti ve uterus arkasındaki lezyon için laparoskopi uygulandı.

Laparoskopik olarak çıkarılan kistin histopatolojik incelemesi ovarian gebelik olarak geldi.
INTRODUCTION
Ectopic pregnancies are most commonly seen in fallopian
tubes. The frequency of ovarian pregnancy is less than a
tubal pregnancy and constitutes 0.5-1% of all ectopic
pregnancies (1). Pelvic pain, amenorrhea and vaginal
bleeding are the foremost classical symptoms found in
these cases. Abdominal pain is the most common
presenting complaint, but the severity and nature of the
pain varies widely. Ovarian pregnancies could be
misdiagnosed because they are mostly and easily
confused with a ruptured corpus luteum.
Here, we report a patient with an ovarian pregnany who
was diagnosed after the laparoscopic extirpation of an
ovarian cyst.
CASE REPORT
A 31-year-old nulliparous woman admitted to gynecology
clinic with the complaint of secondary amenorrhea. Her
last menstrual period was six weeks ago.


Makalenin geliş tarihi : 13.10.2003 ; kabul tarihi : 11.06.2004

She had a history of termination of an undesired first
trimester pregnancy by D&C two weeks ago. Her main
complaint was the delay of menstrual period after
D&C.Pelvic examination revealed a mass on the posterior
wall of uterus which was two cm in diameter. She had no
abdominal tenderness. A pelvic Doppler sonographic
examination revealed a tumoral lesion which was 27 x 17
mm in diameter – resembling a mural or a subserous
myoma on the posterior wall of the uterus. This
sonographically heterogenous mass showed
hyperechogenic regions which were identified as
increased vascularity at Doppler sonographic examination.
Endometrial thickness was 5 mm and was irregular.
There were physiologic follicules in both ovaries and a
ruptured cyst of 14 mm in diameter at the right ovary.
b-human chorionic gonadotropin level 2675 mIU/ml. The

patient underwent a diagnostic laparoscopy. Laparoscopic
examination revealed a hemorrhagic mass of
approximately 2 cm in diameter on posterior surface of the
uterus. This mass seemed to be an organised hematoma
occured after the possible perforation of the uterine wall
during aspiration curettage and it started to bleed readily
with a single touch of laparoscopic forceps (Figure 1).
114
Ege Tıp Dergisi

Figure 1.
The laparoscopic appearance of üterine perforation site

healing with granulation tissue
During the operation a cyst of approximately 15 mm in
diameter on right ovary was removed by partial
oopherectomy and subsequently a revisional curettage
was performed (Figure 2).
Figure 2
. The laparoscopic appearance of ovarian pregnancy

Histopathologic examination of the specimen revealed
ovarian pregnancy. Revisonal curettage showed decidual
endometrium. Serum beta human chorionic gonadotropin
level was found to be decreased to 363 mIU/mL after one
week of the operation
DISCUSSION
Ovarian pregnancy is an uncommon presentation of
ectopic gestation being 0.5-1.0% of all ectopic
pregnancies (1). In 1950s the incidence of primary
ovarian pregnancy was one in 40,000 pregnancies and
increased further with an incidence of one in 7,000
pregnancies for the year 1983 (2,3). Usually it ends with
rupture before the end of first trimester. It is important to
distinguish primary ovarian pregnancy from tubal pregnacy
and hemorrhagic ovarian cyst, because they have same
symptoms. It has been reported that ovarian pregnancy is
diagnosed as a hemorrhagic corpus luteum in two-thirds of
cases (4,5).
Ovarian pregnancies can be diagnosed by the following
criteria of Spiegelberg (6,7) :
1- The fallopian tube on the affected side must be intact.
2- The fetal sac must occupy the position of ovary
3- The ovary must be connected to the uterus by the
ovarian ligament
4- Ovarian tissue must be located in the sac wall.
Bouyer et al reported that unlike tubal gestation, ovarian
pregnancy is neither associated with pelvic inflamatory
disease nor infertility (8). The only risk factor associated
with the development of ovarian pregnancy is the current
use of intrauterine device. Intrauterine device is effective
in preventing intrauterine and tubal pregnancies in 99.5%
and 95% respectively. However it has little effect on the
prevention of an ovarian pregnancy (9). The rate of
intrauterine device use in reported ovarian pregnancies is
17 to 25% (3). Raziel et al reported that 90% of ovarian
pregnancies occured in intrauterine device users (10).
In addition, De Seta et al reported that pelvic inflammatory
disease causes an increased risk of intrafollicular
pregnancy due to hampered follicular dehiscence by
inducing reduction in tubal motility and thickening of
ovarian albuginea (11). Grimes and Matseoane noted prior
history of pelvic inflammatory disease in 42% and 46% of
ectopic pregnancies, respectively (3,12).
Several theories have been suggested to explain ovarian
implantation such as reflux of the conceptus following a
normal fertilization from the fallopian tube along with blood
from the uterus (3) or fertilization occurs within the follicule
following defective ovum release at ovulation (4). Since
ovarian pregnancy may result from in vivo fertilization of
unrecovered oocytes, patients should be informed to avoid
intercourse near the time of ovulation (13).
Conservative treatment, as in tubal pregnancy, is of the
utmost importance if the patient is young and desires to
bear children in ovarian pregnancy. Methotrexate is an
effective therapeutic option in the management of
unruptured ovarian ectopic pregnancy. It permits to avoid
more invasive interventional surgery, with possible
complications such as hemorrhage, ovariectomy or later
pelvic adhesions (14).
In the past oophorectomy has been advocated as
treatment of ovarian gestations, but ovarian cystectomy,
mostly by laparoscopic techniques, is now the preferred
procedure (15,16). For selected ovarian pregnancies an
alternative therapy by the use of methotrexate or
prostaglandin may possibly minimize adhesion formation
and optimize future fertility. The first successful case of
treatment of unruptured ovarian pregnancy by
prostaglandin was reported in 1990 by Koite et al (17). It is
followed by the first successful case of treatment of
unruptured ovarian pregnancy by methotrexate by
Shamma and Schwarts in 1992 (18) These conservative
methods are questionable since histologic proof in
diagnosis does not exist meeting Spiegelberg’s criteria.
Recently, Mittal et al (14) reported the third case of
successful treatment of an ovarian pregnancy with
methotrexate. Similiarly Chelmow et al treated an ovarian
Cilt 43, Sayı 2, Mayıs – A
ustos 2004 115

pregnancy diagnosed by laparoscopy with methotraxate
(19). In our patient there was a history of 6 weeks
amenorrhea without any accompanying abdominal pain or
tenderness and vaginal bleeding. These symptoms did not
meet the classical triad of ectopic pregnancy symptoms.
Furthermore absence of intrauterine device in the present
patient resulted in a clinical dilemma. In our patient
laparoscopic exploration rather than medical treatment
with methotrexate was preferred because of the presence
of unidentified ovarian cyst. During laparoscopic
examination a cyst of 15 mm in diameter on right ovary
resembling to a ruptured corpus luteum was diagnosed as
the ovarian pregnancy after histopathologic examination.
This case demonstrates that ovarian pregnancy may be
diagnosed and treated effectively with cystectomy by the
use.of.operative.laparoscopy.
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