Ovarian ectopic pregnancy: a case report with review of literature

Background: Ectopic pregnancyis a major health issue in reproductive age group female. Incidence of primary ovarian ectopic pregnancy as mentioned in literature of India is variable from 0.001% to 0.014% of normal pregnancies.Only 0.15% to 3.0% of all ectopic pregnancy occurs in ovary and it is 2 m/c site of ectopic pregnancy after fallopian tube. Annual incidence ofextra uterine cavity pregnancyis rising over past 3 yrs. Aim and Objective: Aim of this review article is basically to describe a case of ovarian pregnancy and to study by a review of literature, the clinical sign &symptoms, diagnostic criteria and management of particular pathlogy accordingly, promote conservative surgical management. CASE-Here we report a case of 28 years old women, G5P3L3A1, presented to our hospital withlower abdomen pain with one and half month pregnancy with clinical feature of shock. Diagnosis was confirmed by transvaginal ultrasound, patient was prepared & taken for laparotomy in view of ruptured ovarianectopic pregnancy. Her intraoperative findings were 200 cc hemoperitoneum present, salpingo-oophorectomydone on Rt side. Tubal ligation done on left side by modified pomeroy method. Postoperative period was uneventful. Her histopathological report shows ovarian tissue in wall of gestation sac. Conclusion: According to spigelbergcriteria,it is a diagnostic challenge to obstetrician. Diagnosis can be missed radiologically and intraopertively. It Should be suspectedinpatients presented with rupturedec topic pregnancy, ultrasound features suggestive of normal b/lfallopian tubewith hemoperitoneum with breached ovarian surface. Conservative surgical approach is preferred, Now days Medical management is preferred for unruptured ectopic pregnancy. Confirmation of ovarian pregnancy done only after histopathologicalreport


Introduction
The Incidence of ectopic pregnancy is 1.2 -1.4%. Incidence of primaryovarian ectopic pregnancy as mentioned in literature of India is variable from 0.001% to 0.014% of normal pregnancies. Only 0.15% to 3.0% of all ectopic pregnancy occurs in ovary and it is 2 nd m/c site of ectopic pregnancy after fallopian tube [1]. Extra-iterine pregnancy or ectopic ovarian pregnancy a greek word originated from "EKTOPOS" which means out of place. Ektopos refer toimplantation of blastocyst outside of uterine cavity [1]. Primary ovarian ectopic pregnancy is very rare clinical presentation of extrauterinepregnancy & very dangerous lifethreatening emergency if not diagnosed timely. Fallopian tube is most common site of ectopic pregnancy, comprises to 95% of total ectopic pregnancies. Incidence increasing with ART proceduresand IUCD insertion. Ovarian pregnancy is

Case Report
-28 years old female, she is G5P3L3A1 presented to our NIMS hospital emergency with complaints of amenorrhea of one and ½ months corresponds to 6 weeks and 3 days of gestation. According to patient her previous menstrual history was normal. There was no history of PID, ART procedure, Infertility treatment, Tuberculosis. Onher examination, vitals were BP-90/60 mm of Hg, PR-110 /min, clinical features suggestive of haemorrhagic shock were present. On P/A soft distension present and tenderness in RIF.P/V examinationrevealed -uterusmobile and non-tender, cervical motion tenderness present, 2.8x2.8 cm adnexal mass felt in right fornix.Patient investigated, her UPT +ve, Hb% 8gm, TLC 10,600/cumm, rest hemogram was normal, USG findingswere uterine cavity Empty & bulky ET-19 mm, 2.8x2.8 cm with out fetal pole, freefluid was present in POD.

Figure-1: Ultrasound showing ovauran ectopic pregnancy
Our provisional diagnosis was ruptured ectopic pregnancy & patient was prepared for laparotomy, her intraoperative findings- Hemoperitoneum of 200 cc was present  Uteruswas bulky  B/L fallopian tubes normal &left ovary normal  Rt ovary enlarged with 2.8 ×2.8 cm size adnexal mass in situ, bluish red in color with bleeding frombreached ovarian surface.
Right salpingo-ooporectomy done.Left side tubal ligation done by modified pomeroy , s method and tissue sent for histopathologicalexamination. Her postoperative period was uneventful. Her histopathological report shows corpus luteum with trophoblastic villi in the ovarian tissue.Histopathological report of her D&C tissueshowsabsence of villous or fetal tissue.

Figure 2: Intraoperative finding showing ovarian pregnancy
Histopathology report & her intraoperativefindings were satisfied with the spigelberg criteria. Her immediate and long term postoperative course was uneventful .Patient followed up in OPD after 1 week of surgery. Her serial β hcg was on D5 -500miu/ml, D12 -30miu/ml, D19-undetectable.

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at : www.medresearch.in 27 | P a g e

Discussion and Review of Literature
Clinical presentation of primary ovarian ectopic pregnancy is variable. This is a life-threatening emergency. Etiology of ovarian ectopic pregnancy still remain obscure. A study done by goyal et. al concluded that incidence of ovarian pregnancy is 4.8% of all pregnancies. 94% patients diagnosed in first trimester, in 11% cases preoperatively diagnosed only [3,4]. Increase incidence with ART procedures [due to increase progesterone from corpus luteum, ovarian hyper vascularity due to hyper stimulation], PID, previous pelvic surgery, PCOD, fibroid uterus. IUCD is found in 15-32% of patients of non ovarian ectopic pregnancy. 60-92% of patient of ovarian ectopic pregnancy. Grimes et. al studied 24 case of ovarian pregnancy & concluded greater then 50% cases had infertility or failed ART (4,5).
Cigarette smoking also interferewith tubal motility and ovum pickup. There is usually delay in diagnosis because Gestation sac of ovarian ectopic pregnancy in ultrasound mimic to haemorrhagic cyst of ovary, corpus luteal cyst, endometrioma of ovary. Diagnosis confirmed by TVS and CT scan. Ovarian pregnancy carries higherriskof morbidity and mortality then tubal pregnancies because ovarian pregnancy located at the most vascularised site of female pelvis. Uteroovarian anastomosis of blood vessels eroded by developing chorionic villi, leads to severe haemorrhage and patient went into haemorrhagic shock [6,7].
Ovarian ectopic pregnancies diagnosed intraoperatively &histo-pathologically fewexceptions according to spigelberg criteria. ovarian ectopic pregnancy should be differentiated from ampullary /infundibulam tubal pregnancy, in these cases ovaries may involve secondarily after tubal abortion or rupture [8].
Criteria includes: 1. Gestation sac should occupy the normal position of the ovary.
2. Gestation sac and uterus connected with each other by utero-ovarian ligament.
3. Affected side fallopian tube with its fimbria should be intact andseparate from ovary.
4. Ovarian tissue (tunica albugenia) must be present in the specimen or in the wall of gestational sac.
5. Empty uterine cavity and evidence of amniotic cavity within follicle.
Sensitivity is 85%-92% and specificity is 99.98% 1. Double echogenic ring found within hypoechoic latero-uterine mass&echogenecity of ring is more then ovary itself (inhomogenous mass). Wideechogenic ring with an internal echolucent areas on superficial ovarian surface are also found.
2. Gestational sac found very adjacent to the ovary. Gestation sac visualizedby trans-abdominal scan at β-hCG discriminatory zone ≥6500miu/ml in 1981.Discriminatory zone for Transvaginal ultrasound upto 1000 to 2000 miu/ml. Com shock et. al studied ultrasonographic appearance of ovarian ectopic pregnancy and they concluded ovarian pregnancyis rarely identified correctlyby sonographyandit is evenvery difficultto diagnose intra operatively [8,9]. Ectopic pregnancy may coexist with an intrauterine pregnancy but it is very rare with incidence 1/40000, diagnosis is very difficult. It is common with assisted conception. Benauereaf et. al suggested that transducer frequency from 7MHZ to 10MHZ is helpfulin improving diagnostic accuracy [9]. Ovarianectopic pregnancy classifiedinto two types -  It is most useful when initial β-hCGlevel is ≤1000 iu/l with unruptured ectopic pregnancy. Success rate is b/w 50-80%. According to a prospective observational study, 118 patients are on expectant management out of them 88% recovered successfully. They hadβ-hCG ≤ 200 mIU/mL andpatients with β-hCG level≥ 2000 mIU/ml only 26% recovered. Favorable factors for success of expectant management areserum β-hCG level≤200, gestational age ≤ 6 weeks & progesterone level below 10 nmol/L. Patient selection is very important. Methotrexate is antagonist of folic acid that impairs cellreplication & DNA synthesis. In 1982 first time used for medical management and mode of action by killing rapidly dividing cytotrophoblasts cells at implantation [11,12]. i. Β-hCG>5000miu/ml ii. Ectopic mass > 4 cm iii. Fetal cardiac activity present iv. Poor complaint patient Patient should instruct to stop taking prenatal vitamins, Alcohol, nonsteroidal anti-inflammatory drugs & avoid excessive sunlight (to avoid MTX induced dermatitis) and folate supplementation, as folate will counteract action of injection methotrexate.Rh status of patient must be known to determine further need of immunoglobin therpy in Rh negative patient. A meta-analysison single and multiple dose regimens done by Barnhart et al. They concluded multidose regimen is more effective (90 % ) then single dose (80%) [13,14,15].
Single dose of methotreaxate-Levin et al. done a study and concluded, out of 69 women of study group 45 patient was treated successfuly withsingle dose of injection methotrexate. before single dose of methotrexategood predictorsof successful treatment are-If β-hCG level≤ 1600 iu/landincrease ≤14%, in a day or 24 hr.
Single dose regimen associatedleast side effects.

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at : www.medresearch.in 30 | P a g e  [16,17].  If βhcg decrease< 15% between day 5 to day 7. Give methotreaxate.

L E U
Sucess rate of treatment with β-hCG ≤1000miu/ml is 87% . Failure rate is 40 % with level ≥5000miu/ml.