A RARE CASE OF OVARIAN ECTOPIC PREGNANCY TREATED WITH OVARIAN CONSERVATIVE WEDGE RESECTION Amin Alqaisy, MD د. أمين القيسي Department of Gynecology and Obstetrics, Al-Karak Governmental Hospital/ Al-karak, Jordan مستشفى الكرك الحكومي

Introduction In this presentation, we present a case of ectopic ovarian pregnancy treated by wedge resection of ovarian tissue with ovarian conservation, this case was diagnosed and treated at the Gynecology and obstetrics department/ Al-karak Governmental Hospital

Case presentation A 32 years old P3+1 woman, presented to our gynecology clinic complaining of lower abdominal pain. Complete history revealed amenorrhea of 5 weeks duration, without use of any contraception method. She used to have regular menstrual cycles She gave history of three normal vaginal deliveries, the last one was 2 years ago.

Physical examination stable vital signs (with a blood pressure of 110/60mm Hg and pulse rate of 80/min ) abdominal examination revealed guarding. The abdomin is not distened, and no obvious palpable masses are felt. pelvic examination revealed multiparous cervix ,cervical os closed without motion tenderness, vaginal bleeding or discharge.

Ultrasonography Vaginal ultrasound showed increased right ovarian size, along with fluid collection in the pouch of Douglas. No intrauterine gestational sac was identified. Ectopic pregnancy is suspected, βHCG level was done and was 1400 ml U/ml. her Hb was 11.5 gm/dl she underwent laparatomy

Operative findings During laparatomy, the uterus was normal in size and shape. The left fallopian tube and ovary appeared healthy. The right fallopian tube was intact and healthy.there was no evidence of endometriosis or peritubal adhesions. However, the right ovary revealed a gestational sac measuring 1.5x 1.5 cm on the upper ovarian surface (Figure1).

The right ovary is exposed during laparatomy The right ovary is exposed during laparatomy. The gestational sac is identified and then resected with a small amount of ovarian tissue.

Treatment The gestational sac along with a small amount of ovarian tissue are removed by wedge resection, with preservation of the rest of the ovarian tissue. The resected tissues were sent to histopathology which confirmed ectopic ovarian pregnancy. βhCG level was measured 2 weeks post operation. and it was negative.

Histopathology findings in the ovary Gestational sac with first trimester chorionic villi and syncytiotrophoblasts surrounded by congested ovarian tissue and fibrin exudates.

Histopathological findings in the ovary: Gestational sac with first trimester chorionic villi and Syncytiotrophoblasts surrounded by congested ovarian tissue and fibrin exudates.

fibrin exudates

Syncytio-trophoblasts Chorionic villous

Discussion Ectopic pregnancy is an important health problem and accounts for 10% of all maternal mortality Ovarian pregnancy is one of the rarest forms of ectopic pregnancy. Ovarian pregnancy can be classified as primary and secondary.

Primary versus secondary It is called as primary when the ovum is fertilized while it is still within the follicle It is called as secondary when the fertilization takes place in the tube and when the concept is later regurgitated and implanted in the ovarian stroma

Incidence of ovarian ectopic Ovarian ectopic pregnancy is very rare, with an incidence of 1/7000-1/40,000 in live births and 0.5-3% of all ectopic pregnancies. Primary ovarian pregnancy may occur without any classical antecedent risk factors The incidence reported following In vitro fertilization (IVF) or embryo transfer (ET) is 0.27% per clinical pregnancy

Risk factors for ovarian ectopic previous pelvic inflammatory disease IUD use Endometriosis assisted reproductive technologies (including ovulation induction and intra uterine insemination in the preceding cycle) previous abdominal surgeries. Recently ovarian ectopic pregnancy has been reported after tubal ligation.

Incidence of ovarian pregnancy is rising, due to: better diagnostic modalities such as transvaginal ultrasonography wider use of intrauterine contraceptive device (IUCD), ovulatory drugs, assisted reproductive techniques such as in IVF or ET

Clinical presentation Most cases present during first trimester (almost 75% of all cases), only exceptional cases survive to third trimester or even term pregnancy (one case report). usually terminates in rupture during the first trimester (91% ), in 5.3% cases in the second trimester and in 3.7% cases in the third trimester (Kumar et al. IJPM. 2008 )

Clinical presentation Most common presenting complaints are reported as: acute pain in the abdomen Amenorrhea, followed by vaginal bleeding If ruptures, associated with evidence of circulatory collapse at presentation

Diagnosis of ovarian ectopic The Spielberg criteria are essential for confirmation of early ovarian pregnancy : a) fallopian tube at the affected site must be intact b) the gestational sac must occupy the normal position of the ovary c) the gestational sac must be connected to the uterus by ovarian ligament d) ovarian tissue must be located in the sac wall, which is essential for confirmation of early ovarian pregnancy

Diagnosis of ovarian ectopic other newer criteria combine biochemical and Ultrasound findings, and include: 1) serum βhCG level ≥1000 mIU/ml 2) no gestational sac in uterus by transvaginal ultrasound 3) ovarian involvement should be confirmed on exploration (bleeding, visualization of chorionic villi or presence of atypical cyst at the ovary) 4) normal tubes 5) absence of serum βhCG after treatment of ovary

Sonographic diagnostic criteria of ovarian ectopic The following criteria of an ovarian pregnancy have been suggested: a wide echogenic ring with an internal echo lucent area on the ovarian surface; the presence of ovarian cortex, including corpus luteum or follicles around the mass; the echogenicity of the ring usually greater than that of the ovary itself

Ovarian ectopic—thick echogenic ring with a faint yolk sac within the gestational sac (arrow). Note that the ring (R) is more echogenic than the ovary (O). Ovarian ectopic—thick echogenic ring (arrow) around a small echolucent area. Note the echolucent gestational sac (arrowhead). Comstock et al. Ultrasonography of Ovarian Ectopics. Obstet Gynecol 2005

Diagnosis of ovarian ectopic The diagnosis of ovarian ectopic can be difficult, as they are often confused with ovarian cysts usually misdiagnosed as corpus luteal haemorrhagic cysts. Preoperative diagnosis by transvaginal USG is superior to abdominal USG. All cases are confirmed by histopathology examination

Differential diagnosis hemorrhagic corpus luteal cyst “chocolate’’ cysts (endometriosis) Ovarian tumor producing HCG a ruptured distal tubal ectopic

Treatment of ovarian ectopic Treatment of ovarian pregnancy requires surgery [oophorectomy or wedge resection of the ovary]. Treatment of choice is resection of sac and hemostasis preferably with laparoscopy, or laparotomy A few reported cases and case series had patients treated with conservative ovarian surgery, with some case reports, subsequent pregnancy has been uncomplicated

Role of methotrexate Methotrexate has been used successfully to treat unruptured ovarian pregnancies in a few reports (Shamma FN et al.1992 ; Raziel A et al 1993; Chelmow D et al.1994)

Follow up of patients After successful conservative treatment of ovarian ectopic pregnancy, literature suggests that there is a high rate of successful subsequent pregnancy and a low rate of subsequent ectopic pregnancy or infertility

Conclusion Ovarian ectopic pregnancy should be kept in mind as a rare possibility in females of reproductive age presenting with amenorrhea, vaginal bleeding, and acute abdomen.

Our case is: An ovarian ectopic pregnancy, which is very rare. Patient had no risk factors for ectopic pregnancy Early diagnosis at 5 weeks duration of amenorrhea Treated by wedge resection, not oophorectomy Without complications

References 1- Comstock C, Huston K, Lee W. The ultrasonographic appearance of ovarian ectopic pregnancies. Obstet Gynecol 2005; 105(1): 42-46. 2- Marret H, Hamamah S, Alonso A M. Pierre F. Case report and review of the literature: primary twin ovarian pregnancy. Hum Reprod 1997; 12(8): 1813-1815 3- Grobman W A. Milad M P. Conservative management of a large cornual ectopic pregnancy. Hum Reprod 1998; 13(7): 2002-2004

References Ovarian ectopic pregnancy: A 10 years’ experience and review of literature. Lajya Devi Goya. Iran J Reprod Med Vol. 12. No. 12. pp: 825-830, December 2014. Thirteen -weeks ovarian pregnancy following in vitro fertilization for primary infertility treatment: A case report. Sara Defaee. Iran J Reprod Med Vol. 12. No. 11. pp: 779-784, November 2014. Diagnostic Dilemma in Ovarian Pregnancy: A Case Series. Sunita samal. Journal of Clinical and Diagnostic Research. 2015 Apr, Vol-9(4): www.jcdr.net