An ovarian pregnancy with delivery of a live infant

Objective

Ovarian ectopic pregnancy occurs very rarely.Most of them are terminated before reaching viability.

Case(s)

Failed termination at early pregnancy and repeated failed labor induction especially if the fetus has an abnormal lie or an abnormal presentation are the most important signs.By our case the findings at ultrasonograpy were like an abdominal pregnancy at 32 weeks gestation.At laparotomy the diagnosis of ovarian pregnancy was made and a live female infant,weighing 1400g was delivered.

Conclusion

After salpingoophorectomy,the patient made an uneventful recovery.

Keywords

Ovarian pregnancy, laparotomy, ultrasonography, abdominal pregnancy.

Introduction

The reported incidence of ovarian ectopic pregnancy is only 1:7000-40,000 deliveries, and in 0.7% or 0.4% of ectopic pregnancies. Approximately 75% are terminated in the first trimester; 12.5%, in the second trimester; 12.5%, in the third trimester.1 Nicholls, in 1941, stated that 38 ovarian pregnancies have been recorded to reach the age of viability with 12 living babies and 22 living mothers.(2) In the 32 years since this report, a search of the world literature has revealed 10 cases that have been reported as examples of ovarian pregnancy reaching viability.(3) 1982 and 1991 two more cases were reported.(4,5) This case report describes the clinical and sonographic pattern of an advanced ovarian pregnancy with the aim of emphasizing the most important features. 

Case(s)

N.K., a 22-year-old woman, para 1, gravida 2, admitted to the hospital at 32 weeks’ gestation, with some abdominal discomfort. She mentioned of a failed termination at 8 weeks of gestation and has never used an intrauterine contraceptive device. Abdominal examination revealed an oblique lie. Fetal heart tones were 135 bpm and regular. On vaginal examination, the cervix was thick and closed; the presenting part was high.
The findings at ultrasonography were: a 32 weeks fetus separate from the uterus, an ectopic placenta, oligohydramnios and amniotic bands (Figure 1). The first diagnosis was abdominal pregnancy and we decided to terminate the pregnancy because of signs of the acute abdomen.
The abdomen was entered through a midline incision. At laparotomy, the uterus was approximately 12 weeks’ size. The amniotic sac containing the fetus and placenta occupied the position of the right ovary; it was adherent to the lateral pelvic wall and attached to the uterus by the utero-ovarian ligament. A diagnosis of an ovarian pregnancy was made. The thin ovarian wall was opened and a female infant, weighing 1400g was delivered. The amniotic fluid was brown colored. The infant had no discernible congenital abnormalities and had Apgar scores of 6, 8, and 9.
By blunt and sharp dissection the amniotic sac and placenta were removed from the lateral pelvic wall. Salpingooforectomy was performed. The penrose drain was placed in posterior cul-de-sac and removed at postoperative second day. The patient had an uneventful recovery and was discharged from the hospital on the seventh postoperative day.
The spontaneous breathing baby was exchange transfused because of hyperbilirubinemia and followed up at an intensive care unite.
The surgical specimen measured 28x17x5 cm, had a bright surface and a vasculated surface with umbilical cord. The placenta had two parts. Sections of umbilical cord were unremarkable. The tube was intact and distinctly separate from the ovary. Chorionic villi with intact ovarian stroma are demonstrated on microscopic specimens (Figure 2). Diagnosis was placenta, with ovarian tissue and ovarian pregnancy.

Discussion

Primary ovarian pregnancy is very rare. This rare ectopic pregnancy is difficult to diagnose prior to surgery. Earlier diagnosis is now possible, owing to the availability of highly specific radioimmunoassay for human chorionic gonadotrophin and the development of transvaginal ultrasonography. At the beginning of pregnancy , ovarian pregnancies are usually considered as tubal pregnancies, the advanced cases are diagnosed as abdominal pregnancies.
Spiegelberg outlined four criteria for the diagnosis of primary ovarian gestation:6 1.The fallopian tube with its fimbriae should be intact and separate from the ovary, 2. Gestational sac should occupy the normal position of the ovary, 3. The gestational sac should be connected to the uterus by the uterine ovarian ligament; and 4. Ovarian tissue must be present in the specimen attached to the gestational sac. The Spiegelberg criteria were met in this case.
By first trimester pregnancy terminations like in our case, one must insure that tissue obtained at suction curettage is evaluated thoroughly. If pathologic study of the endometrial tissue reveals no chorionic villi, additional diagnostic evaluation is required.7
In cases of repeated failed labor induction especially if the fetus has an abnormal lie or an abnormal presentation, the possibility of abdominal pregnancy should be kept in mind.
To the practicing physician, it is of greater importance to reach a decision regarding the necessity for laparotomy than to attempt distinguishing preoperatively between forms of ectopic pregnancy.
Ovarian pregnancy must be distinguished from primary peritoneal implantation, which can involve any intraperitoneal site with different problems of diagnosis and management related to the organs involved. The ovary has no peritoneal covering and the implantation within the ovary results in a predictable sequence of events because of the consistent vascular anatomy of the ovary.

Conclusion

The management is laparotomy. Hysterectomy is justified when the ovary cannot be removed alone, when there is other pathology or for sterilization.
 

References

1. Vulgaris W, Reich W. Primary ovarian pregnancy. IMJ 1974; 146: 185.
2. Nicholls RR. Ovarian pregnancy with living child and mother. Am J Obstet Gynecol 1941; 42; 341.
3. Pratt- Thomas HR, White L, Messer HH. Primary ovarian pregnancy, presentations of 10 cases including one full term pregnancy. South Med J 1944; 67: 920.
4. Williams PC, Malvar TC, Kraft JR. Term ovarian pregnancy with delivery of a live female infant. Am J Obstet Gynecol 1982; 142: 589.
5. Belfar H, Heller K, Edelston DI, Hill LM, Martin JG: Ovarian pregnancy resulting in a surviving neonate. Ultrasound findings. J Ultrasound Med 1991; 10 :465.
6. Spiegelberg O.: Zur casuistic der ovarialschwangerschaft. Arch Gynaekol 1878; 13, 73-6.
7. Grimes HG, Nosal R, Gallagher JC: Ovarian pregnancy. A series of 24 cases. Obstet Gynecol 1983; 61: 174.

	File/Dsecription
	Figure 1. Microscopic section of ovarian tissue and chorionic villi.
	Figure 2. On abdominal ultrasonography, the uterus (U) is separete from the placenta (P) and the fetus.