International Journal of Current Medical And Applied Sciences, 2018, July, 19(2), 57-59

IJCMAAS, E-ISSN: 2321-9335,P-ISSN:2321-9327. Page | 57

Ruptured Ovarian Pregnancy: A Case Report U. Yashila Prithika1 & K. Saraswathi2

1Post Graduate, 2Professor, Department of Obstetrics and Gynaecology, Sree Balaji Medical College and Hospital, Bharath University, Chromepet, Chennai [TN], India-600044.

------------------------------------------------------------------------------------------------------------------------ Abstract: - Ovarian Pregnancy occurs quite rarely and that too usually in young highly fertile multiparous women using Intra-uterine device. We present a case where an elderly G3P1L1A1 presented with abdominal pain and was diagnosed as ectopic pregnancy and was confirmed intra-operatively and histopathological as ovarian pregnancy, managed with salphingo-oopherectomy. Ovarian pregnancies are rare and can be missed radiologically and diagnosed intraoperatively. Making preoperative diagnosis of OEP is still challenging due to its similar appearance to corpus luteal hematoma or hemorrhagic cyst of ovary before rupture and to ruptured tubal ectopic pregnancy after rupture. Therefore, better investigations and expertise in imaging techniques are urgently required for early diagnosis to gain time for conservative nonsurgical management to reduce morbidity secondary to blood loss and surgery. Keywords: Ectopic pregnancy, Ovarian Pregnancy, salphingo-oopherectomy.

Introduction: Ectopic pregnancy is one of the most common gynecological emergencies. Ectopic pregnancy occurs in 2% of all pregnancies, the myriad of locations have a hierarchy of prevalence as well as associated mortality and morbidity. The most common location of the ectopic pregnancy continues to be fallopian tubes (accounting for 95% of all ectopic pregnancies) followed by far less common ovarian ectopic which comprises 0.3 - 3% of extra uterine cavity pregnancies. Primary ovarian pregnancy results, when an ovum not released from the ovary is fertilized or following a primary implantation of fertilized ovum in the ovary after reverse migration from fallopian tube. In secondary ovarian pregnancy there is a tubal abortion or rupture with secondary implantation of gestational sac on the surface of ovary. The diagnosis can be established by Trans vaginal sonographically and Serum Beta HCG but it is inconclusive to differentiate between Tubal ectopic and ovarian ectopic pregnancy. Mostly, Patients present with ruptured ectopic pregnancy with haemodynamic instability or shock.

Diagnosis is by Emergency laparotomy, Spiegelberg’s Criteria and Histo-Pathological Examination.

Case Report: - A 37 year old lady presented to OBG department with 45days Amenorrhea and lower abdominal pain for past 3 days. UPT Positive. LMP – 25/1/2018 with Gestational age of 6 weeks + 2 Days. No history Spotting PV / Bleeding PV. She is Gravida 3 Para 1 Live 1 and Abortion 1, with previous cesarean section done in view of PROM, Oligohydramnios with fetal distress and a spontaneous abortion at 2 months gestation for which Dilatation and Curettage done one year back. History of Previous regular cycles with bleeding for 3-5 days once in every 30 days. She was married for 4 years. On examination she was hemodynamically unstable with anemia (Hb-7.5 gm%), Tachycardia with Pulse rate 94bpm and Blood pressure of 110/70 mm Hg. Per abdominal examination Soft, No Distension, Non-tender, Suprapubic trans-versescar.

Address for correspondence: Dr. U. Yashila Prithika, Post Graduate,

Department of Obstetrics And Gynaecology, Sreebalaji Medical College And Hospital, Bharath University, Chromepet, Chennai, India-600044.

Email ID: yashilaudaya@gmail.com

A CASE REPORT

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How to cite this article: U. Yashila Prithika & K. Saraswathi: Ruptured Ovarian Pregnancy – A Case Report. International Journal of current Medical and Applied sciences; 2018, 19(2), 57-59.

U. Yashila Prithika & K. Saraswathi

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Figure 1- usg showing right ectopic Figure 2: Breached surface of right ovary Figure 3: Inflamed Appendix Speculum examination: Cervix healthy, No significant discharge. Vaginal examination – Cx Pointing Downwards, uterus Anteverted, Normal size, Mobile, right forniceal tenderness, no Cervical motion tenderness Ultrasonography of Pelvis revealed the following Thick walled echogenic ring shaped lesion with irregular central anechoic area approx – 5.1 x 3.8 cm noted in right adnexa with peripheral vascularity. Right ovary could not be visualized, Left ovary appeared normal – 2.7 x 2.1 cm Endometrial Thickness – 6mm. Free fluid in Pouch of douglas and right paracolic gutter noted Thin rim of fluid noted in Morrison’s pouch An Emergency Laparotomy was done with a pre-operative diagnosis of Ruptured right tubal ectopic pregnancy. Intraoperatively, uterus was normal in size with bilateral normal fallopian tubes. Ruptured right ovarian ectopic was found.Right ovary was enlarged with a breach of its surface and an active bleeder seen on its ruptured surface. Haemoperitoneum about 500ml of fresh clots were seen. Left ovary was normal. Right salphingo-oopherectomy was done. Left side tubectomy was done by modified Pomeroy’s technique as per Patient’s request. Incidentally, appendix was found inflamed, Surgeons called over and Appendectomy done in usual way. 2 packed cells were cross matched and transfused intra-op. Complete Hemostasis secured. Procedure was uneventful. Postoperative period was uneventful. HPE examination: showed the presence of hyperplastic villi, Syncytiotrophoblast and cytotrophoblast. Shows congested serosa, circular bands of muscle fibres and fat with thick walled blood vessels within. Postoperative Diagnosis of Right Primary Ovarian Ectopic Pregnancy was made.

Discussion: - An ectopic pregnancy is characterized by implantation and development of an embryo outside of the uterine cavity. Ectopic pregnancies can occur in the ovary (3.2%), or abdomen (1.3%) [1]. There is often a delay in the diagnosis of ovarian pregnancy as the gestational sac mimics corpus luteum,

hemorrhagic cyst and endometriotic cyst of ovary [2]. Most often, it is an Intra-operative Diagnosis. Little is known about the incidence and risk factors. The etiological factors for the ovarian pregnancy are pelvic inflammatory disease, fibroids, previous pelvic surgery and use of ART procedures (Spiegel berg, 1878). Altered tubal motility as a result of increased progesterone secretion from multiple corpuralutea or ovarian hypervascularity following hyperstimulation could be a cause. A high number of transferred embryos, a transfer near the uterine horn, and excessive pressure on the syringe during the transfer or difficulties during the embryo transfer procedure increase the risk [3]. This condition seems to be strongly associated with intrauterine devices. Preoperative evaluation includes serum beta HCG levels and TVS [4]. Ovarian Ectopic Pregnancy can be classified as primary and secondary OEP. Primary OEP results from ovulatory dysfunction whereas secondary OEP results from secondary implantation in ovarian stromal tissue after tubal abortion or perforation [4]. Diagnostic tests include the sensitive beta-HCG radio immunoassay, culdocentesis and ultrasonography. Ovarian pregnancy is diagnosed with ultrasonographic criteria in presence of a positive HCG level indicating pregnancy [2]. USG showed a cyst with wide echogenic ring with an internal echoluent area as compared to a thin tubal ring with tubal pregnancies or corpus luteum cyst and occasionally a yolk sac or fetal heart motion were also identified. Three-dimensional ultrasound has been reported to distinguish ovarian pregnancy from corpus luteum cyst, which may improve detection [5]. Although there were case reports explained conservative management and methotrexate therapy. Our case was haemodynamically unstable with haemoperitoneum on USG so taken up for emergency laparotomy. Spiegelberg’s Criteria for intraoperative diagnosis of OEP include:

Intact fallopian tubes including fimbria, separate from the ovary

Ectopic pregnancy occupying normal position of the ovary

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International Journal of Current Medical And Applied Sciences [IJCMAAS], Volume: 19, Issue: 2. Page | 59

Ectopic gestational sac must be attached to uterus through the utero-ovarian ligament

Presence of ovarian tissue in the wall of gestational sac in specimen.

The delay in diagnosis of Ovarian Pregnancies has been attributed to the non-specific clinical presentation upto admission, while the massive intra-abdominal bleeding has been explained by the fragility and hypervascularity of the ovarian tissue [6-8]. The diagnosis is often made at surgery and requires histological confirmation. A correct diagnosis of ovarian pregnancy during surgery is only possible in 28% of the cases, because it is difficult to differentiate from a hemorrhagic corpus luteum intraoperatively [9]. Medical management is not feasible in most of the cases as patients present after rupture of OEP. In most of the cases, Classically Ovarian pregnancies are managed surgically – small lesions by wedge resection or cystectomy and large lesions by oophorectomy [10]. Due to majority of patients being brought with ruptured pregnancy and hemodynamic instability secondary to early rupture of friable nature and increased vascularity of OEP and radiological diagnostic dilemmas. There is lack of enough evidence on conservative nonsurgical management options. These options include methotrexate therapy (single or multiple doses) either given locally or systemic. With conservative management, Beta HCG levels should be monitored to exclude remnant trophoblast. No case of recurrent ovarian ectopic has been reported as contrast to 15% risk of recurrence of tubal ectopic pregnancy [11].

Conclusion: - Ovarian pregnancies are rare and can be missed radiologically and diagnosed intraoperatively. Making preoperative diagnosis of OEP is still challenging due to its similar appearance to corpus luteal hematoma or hemorrhagic cyst of ovary before rupture and to ruptured tubal ectopic pregnancy after rupture. Therefore, better investigations and expertise in imaging techniques are urgently required for early diagnosis to gain time for conservative nonsurgical management to reduce morbidity secondary to blood loss and surgery.

Hence obstetricians could diagnose them only after histopathological confirmation following excision according to Spiegelberg’s criteria.

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Conflict of interest: None declared Source of funding: None declared