Ovarian pregnancy-a 12-year experience of 19 cases in one institution

Ovarian ectopic pregnancy: clinical characteristics, ultrasound diagnosis and management

OBJECTIVE

To compare the clinical, ultrasound and biochemical characteristics of ovarian ectopic pregnancy (OEP) with those of tubal ectopic pregnancy (TEP).

METHODS

This was a retrospective case-control study of women with OEP and those with TEP seen at a single center between December 2010 and February 2021. OEP was defined as a pregnancy located completely or partially within the ovarian parenchyma, seen separately to a corpus luteum, if a corpus luteum was present within the ipsilateral ovary. We compared demographic features, risk factors, clinical presentation, ultrasound findings and outcomes, such as blood loss at surgery, need for blood transfusion, length of hospital stay, follow-up and future pregnancy outcome, between cases of OEP and TEP.

RESULTS

Overall, 20 women with OEP were identified and compared to 100 women with TEP. A total of 15/20 (75%) OEPs were diagnosed correctly on the first ultrasound scan. There was no difference between the groups in terms of maternal age, gestational age, gravidity, parity or risk factors. Compared with TEP, OEP was more likely to present with abdominal pain without vaginal bleeding (12/20 (60%) vs 13/100 (13%); odds ratio (OR), 10.0 (95% CI, 3.45-29.20); P < 0.01), contain an embryo with cardiac activity (3/20 (15%) vs 2/100 (2%); OR, 8.7 (95% CI, 1.34-55.65); P = 0.02) and have severe hemoperitoneum on ultrasound (9/20 (45%) vs 8/100 (8%); OR, 9.4 (95% CI, 3.01-29.40); P < 0.01), and had a higher volume of blood loss at surgery (median, 700 mL vs 100 mL; P < 0.01). All surgically managed OEPs had successful laparoscopic treatment (18 excisions, one wedge resection) with preservation of the ovary. Only one (5%) case of OEP required a blood transfusion.

CONCLUSIONS

OEP is more likely than TEP to contain an embryo and to present with severe hemoperitoneum. In a dedicated early pregnancy setting, the majority of OEPs were detected on an ultrasound scan at the initial visit, facilitating optimal minimally invasive surgical management, reducing the risk of blood transfusion and oophorectomy. Our findings can be used as a reference for clinicians who may not otherwise encounter this rare condition. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Unruptured ovarian ectopic pregnancy: Two case reports and literature review

In clinical practice, ovarian pregnancy is extremely rare and is always found to be ruptured. A definitive diagnosis for ruptured ovarian pregnancy is difficult to obtain. We present two cases of unruptured ovarian pregnancies detected during laparoscopy and review existing literature to better understand the clinical characteristics of ectopic pregnancies in this rare site. Intrauterine devices, assisted reproductive technology, and intrauterine operations are all high-risk factors in ovarian pregnancy. Moreover, menopause, abdominal pain, and vaginal bleeding are clinical manifestations. Ovarian pregnancy can be diagnosed using serum hCG, transvaginal ultrasound, and magnetic resonance imaging. Laparoscopy is the treatment of choice for ovarian pregnancy. It is recommended that the intact gestational sac be excised and the ovarian function be protected to the greatest extent possible during the operation. More definitive diagnosis of ovarian pregnancy must be reported in order to gain a better understanding of ovarian pregnancy.

Clinical analysis of women with ovarian pregnancy: a retrospective case-control study

Background

To address the clinical features and potential risk factors of ovarian pregnancy (OP).

Methods

In this retrospective case–control study performed in West China Second University Hospital from March 17, 2005 to December 8, 2018, 146 OP patients were selected as a case group, 292 patients with tubal pregnancy (TP) and 292 women with intrauterine pregnancy (IUP) were matched as controls at a ratio of 1:2:2.

Results

When compared with TP patients, OP patients tend to have worse clinical complications (hemorrhagic shock (7.41% vs 2.89%), rupture of pregnancy sac (54.07% vs 37.78%), hemoperitoneum (363.1 ± 35.46 ml vs 239.3 ± 27.61 ml) and increased need for emergency laparotomy (9.60% vs 3.97%) at an early gestational age. Assisted reproductive technology (ART) (adjusted OR1 2.08, 95%CI 1.04 to 4.18; adjusted OR2 2.59, 95%CI 1.25 to 5.37) and intrauterine contraceptive device (IUD) use (adjusted OR1 2.19, 95%CI 1.10 to 4.36; adjusted OR2 2.77, 95%CI 1.74 to 5.71) may be risk factors for ovarian ectopic pregnancy as compared to the control groups of TP and IUP patients.

Conclusions

OP patients tend to have more severe clinical complications and this study has identified ART and IUD use as potential risk factors for OP. Results of this study may contribute to improve the understanding of OP and promote early surgical intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05099-8.

Uncommon Ectopic Pregnancies—Challenges in the Management

Background

The risk factors for ectopic pregnancy are on the rise. Despite the progress (availability of serum βhCG, USG and MRI), there are diagnostic and therapeutic challenges in the management. Up to 50% of ectopic pregnancies go undetected. Furthermore, cases seen as emergency with hemodynamic instability need urgent intervention with simultaneous arrangement of transport, blood transfusion and at times multidisciplinary team involvement. This is more challenging in a setting where resources are limited.

Objective

To evaluate the outcome of women presenting with uncommon ectopic pregnancies as life-threatening emergency. Challenges encountered in diagnosis, pre-operative evaluation, decision for surgery and the procedure are presented.

Patients and Methods

This is a series of twelve cases of uncommon ectopic pregnancies belonging to eight different types. These were managed under the first author during the period 2001 to 2019. Subjects were analyzed retrospectively.

Results

Diagnostic dilemma was faced in majority of the cases even with the use of ultrasonography. All the conceptions were spontaneous. Emergency surgical interventions were made on the basis of clinical evaluation. Five cases presented with massive hemoperitoneum. Blood transfusion was needed in nine cases. There was no mortality. One woman (case 4), with abdominal pregnancy, went home with a live baby, after the second laparotomy.

Conclusion

Uncommon ectopic pregnancies are life-threatening conditions. Clinical acumen and an alert mind are of superior value in diagnosis. Investigations are supportive. Early diagnosis and intervention are lifesaving.

Concurrent Ovarian and Tubal Ectopic Pregnancy After IVF-ET: Case Report and Literature Review

Ovarian pregnancy (OP) coupled with tubal ectopic pregnancy is rare. We present a case of coexistent ovarian and tubal ectopic pregnancies in the same adnexa resulting from in vitro fertilization and embryo transfer (IVF-ET) for tubal occlusion. The patient presented with mild vaginal bleeding without abdominal pain. OP was diagnosed via sonographic findings of an ectopic gestational sac (GS) and yolk sac that seemed to be inside her left ovary. Laparoscopic exploration confirmed this diagnosis, and ipsilateral tubal ectopic pregnancy was suspected during surgery. The patient underwent left salpingectomy and resection of the ovarian lesion. A subsequent histopathological examination verified the diagnosis of coexistent ovarian and tubal ectopic pregnancy. Though the mechanism underlying concurrent OP and tubal ectopic pregnancy is still unclear, clinicians should be cautious of potential combined ectopic pregnancy when dealing with patients who have received more than one embryo transfer.

Similar but different: A comparison of rare site ectopic pregnancies

OBJECTIVES

A comparative examination of the clinical, laboratory, ultrasound findings, and operative characteristics of rare site located ectopic pregnancies.

METHODS

Retrospective analysis of all department cases of rare site located ectopic pregnancies diagnosed and treated from December 2006 to December 2019.

RESULTS

Thirty rare ectopic pregnancies were identified. Of these, 11 were ovarian, 10 were interstitial and 9 were tubal stump. The patients treated for ovarian pregnancy had significantly lower human chorionic gonadotropin (hCG) levels than patients treated for interstitial or stump pregnancies (2025 ± 1105 mIU/ml, 18,424 ± 2579 mIU/ml and 11,204 ± 9221 mIU/ml, respectively, p = 0.003). The main presenting symptom in patients with an ovarian pregnancy was abdominal pain (90.9%, 60.0% and 44.4%, respectively, p = 0.031). Signs of abdominal peritoneal irritation (i.e., rebound tenderness and guarding) were more frequent upon physical examination in patients with an ovarian pregnancy (72.2%, 30.0% and 22.2%, respectively, p = 0.044) who also exhibited the highest rates of syncope and hypovolemic shock upon admission compared to patients with an interstitial or stump pregnancy (54.5%, 10.0% and 11.1%, respectively, p = 0.031). Ovarian pregnancies were associated with the lowest sonographic detection rates (9.1%, 80.0% and 100%, respectively, p = 0.0001) and with free fluid in the pouch of Douglas (72.7%, 20.0% and 22.2%, respectively, p = 0.02). Ovarian pregnancies experienced the highest rupture rate during surgery compared to interstitial or stump pregnancies (66.9%, 16.7% and 44.4%, respectively, p = 0.028), had a significantly higher estimated blood loss (1081 ± 647 ml, 760 ± 597 ml and 343 ± 318 ml, respectively, p = 0.003) and required blood transfusions in the perioperative period (63.6%, 20.0% and 11.1%, respectively, p = 0.025) significantly more often.

CONCLUSIONS

Ovarian pregnancy remains the most challenging diagnosis compared to interstitial and tubal stump ectopic's. Health care providers should recognize these rare site ectopic pregnancies and to handle these gynecological emergencies promptly.

Dual extrauterine ectopic pregnancy: double management

A 30-year-old nulliparous woman was referred with suspected left ovarian ectopic pregnancy. She had undergone laparoscopic left salpingectomy for ruptured tubal ectopic pregnancy 3 weeks earlier, following treatment with medications for ovulation induction. Sonological examination revealed a left ovarian ectopic pregnancy corresponding to 8 0/7 weeks with cardiac activity. She underwent ultrasound-guided intrasac therapy with intrasac instillation of 3 mEq of potassium chloride followed by 50 mg of methotrexate. She was followed with weekly measurements of serum beta human Chorionic Gonadotropin (hCG) which returned to baseline after 65 days of the intrasac therapy. This case not only highlights the need for continued follow-up of the serum beta hCG after definitive management of an ectopic pregnancy in cases with multiple ovulations, but also the option of medical management in cases of advanced ovarian ectopic pregnancy. It also accentuates the necessity for adequate counselling to avoid conception in a multiple ovulation cycle.

Ovarian pregnancy rupture following ovulation induction and intrauterine insemination: A case report

BACKGROUND

Ovarian pregnancy after assisted reproductive technology treatment has rarely been reported; ovarian pregnancy following intrauterine insemination (IUI) is even rarer, and only nine cases have previously been reported.

CASE SUMMARY

We report a case of ovarian pregnancy rupture after ovulation induction and IUI. The patient presented with bilateral lower abdominal pain and was referred to the emergency department. Ultrasound examination revealed ovarian pregnancy and intraperitoneal bleeding. Laparoscopy revealed an ovarian pregnancy with hemoperitoneum, which was subsequently removed. Pelvic adhesions were detected intraoperatively, which were treated immediately. The patient spontaneously conceived an intrauterine pregnancy 3 mo later, which was ongoing at the time of writing this study.

CONCLUSION

Close attention should be paid to any history of pelvic inflammatory disease before commencing IUI treatment,and patients with such a history should be closely followed up after IUI. Early measurement of serum β-human chorionic gonadotropin levels and ultrasonic examination are essential for timely diagnosis of ovarian pregnancy after ovulation induction and IUI to avoid more serious complications.

Catch Me While You Scan: Primary Ovarian Pregnancy

Primary ovarian pregnancy is rare, accounting for 0.5%–3.0% of all ectopic gestations. It was earlier diagnosed by the classical Spiegelberg's criteria. Ultrasonographic diagnostic criteria have now been described for preoperative diagnosis. We report a case of primary ovarian pregnancy in a 30-year-old woman, where the diagnosis was made preoperatively, and discuss the challenges in diagnosis and management for optimal patient outcomes.

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies

OBJECTIVE

To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy.

TARGET POPULATION

All patients of reproductive age.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with positive β-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Analysis of Surgical Procedure of Four Cases of Ovarian Pregnancies Treated with Laparoscopic Surgery

Ovarian pregnancy is a rare disease, accounting for 0.5%–3% of ectopic pregnancies. Ovarian pregnancy risk factors and preoperative diagnosis have been extensively reported. However, its histopathology and surgical findings have been poorly studied. To examine appropriate surgical procedures, we investigated the clinical features, surgical findings, and histopathological examinations of four ovarian pregnancy cases treated in our hospital. In histopathological examination, most specimens did not contain ovarian tissues; in some cases, villous tissues were buried in a clot. Therefore, evaluating the appropriateness of surgical resection range from histopathological images was difficult. However, the postoperative course was favorable; no cases manifested complications. Considering all these facts, we regarded the surgical procedures of the four cases in this study as appropriate. For the treatment of ovarian pregnancies, especially for the outward development type, a sufficient therapeutic effect may be achieved even without extensive excision of the ovarian tissues by laparoscopic surgery.

Directive clinique no 414 : Prise en charge des grossesses de localisation indéterminée et des grossesses ectopiques tubaires et non tubaires

OBJECTIF

Fournir un algorithme fondé sur des données probantes pour orienter le diagnostic et la prise en charge de la grossesse de localisation indéterminée et de la grossesse ectopique tubaire ou non tubaire.

POPULATION CIBLE

Toutes les patientes en âge de procréer. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive a pour objectif de bénéficier aux patientes ayant obtenu un résultat positif pour la sous-unité bêta de la gonadotrophine chorionique et de fournir aux médecins un algorithme normalisé pour l'expectative et le traitement pharmacologique ou chirurgical en cas de grossesse de localisation indéterminée et de grossesse ectopique tubaire ou non tubaire. DONNéES PROBANTES: Les termes de recherche suivants ont été entrés dans les bases de données PubMed-Medline et Cochrane en 2018 : cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography et prenatal. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des publications supplémentaires ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Obstétriciens-gynécologues, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

A rare case of ovarian ectopic pregnancy with IUD in situ: A case report from Nepal

High index of suspicion of ectopic (much likely ovarian) pregnancy should be considered if a woman with IUD in situ presents with abdominal pain, vaginal bleeding, and positive urine pregnancy test.

Ovarian ectopic pregnancy after in vitro fertilisation treated by laparoscopic excision with ovarian preservation

A 42-year-old woman presented with lower abdominal pain and fainting episodes 36 days after in vitro fertilisation and embryo transfer. Transvaginal ultrasound revealed a large amount of free fluid in the pouch of Douglas and no evidence of an intrauterine gestational sac or adnexal mass suggestive of ectopic pregnancy. A presumed haemorrhagic corpus luteal cyst was seen in the left ovary. Laparoscopic exploration revealed a left ovarian haemorrhagic mass, which was excised with preservation of the ovary. Histopathological examination confirmed an ovarian ectopic pregnancy (OEP). OEP is rare but potentially life-threatening, as it can lead to internal haemorrhage. Its diagnosis is challenging as preoperative and intraoperative findings can be evocative of the far more frequent haemorrhagic corpus luteal cyst and histopathology is often necessary to confirm the diagnosis. Early recognition of OEP is crucial to reduce maternal morbidity and mortality, and allow treatment that preserves fertility as much as possible.

Ovarian ectopic pregnancy: the role of complex morphopathological assay. Review and case presentation

Ovarian ectopic pregnancy (OEP) represents the rarest type of ectopic pregnancy, accounting for 1-3% of this pathology. The diagnosis of this pathology is challenging due to the non-specific clinical aspects and the ultrasound examination hampered by the lack of visible gestational sac in the presence of hematocele and hemoperitoneum. The purpose of the extended histopathological (HP) examination was to identify particular aspects of the OEP trophoblast and to highlight potential local ovarian modifications which can determine pregnancy fixation at this level. The patient presented local favorable conditions for intraovarian nidation, conditions confirmed by the HP classical examination and by the immunohistochemical evaluation. We identified, using classical Hematoxylin-Eosin, Masson's trichrome and Periodic Acid-Schiff (PAS)-Hematoxylin, necrotic hemorrhage, accentuated vascular thrombosis and high density lymphoplasmocytary infiltrate. These modifications increased local adhesivity and cell destruction through hypoperfusion. Anti-cluster of differentiation antibodies (CD34, CD38, tryptase) revealed the low number of intravillous vessels and the high number of macrophages and mastocytes involved in the local inflammatory process heighten. We identified the presence of trophoblast tissue in the ovarian structure using anti-cytokeratin AE1∕AE3 (CK AE1∕AE3)/anti-cytokeratin 7 (CK7) antibodies. The anti-alpha-smooth muscle actin (α-SMA) and anti-vimentin (VIM) antibodies displayed the density of myofibroblasts and intravillous stromal cells and with the aid of anti-progesterone receptor (PR) antibody, we identified the corpus luteum hormonal response in the OEP. The placental villosities present a blocked multiplication process at the anti-apoptotic B-cell lymphoma 2 (BCL2) protein, confirmed by the Ki67 cell proliferation and tumor protein 63 (p63) immunomarkers. Anti-neuron specific enolase (NSE), anti-calretinin and anti-inhibin A antibodies showed the particular aspects of the granulosa and internal theca cells, which may be involved in oocyte release blockage, intraluteal and extraluteal fecundation of the OEP.

MRI of Acute Gynecologic Conditions

Although usually not a first-line imaging modality in the setting of acute pelvic pain, magnetic resonance imaging (MRI) is able to depict and characterize a wide range gynecologic diagnoses with high accuracy. Lack of ionizing radiation renders MRI particularly useful for assessment of pregnant women and children. Furthermore, inherent high soft-tissue resolution of MRI allows accurate diagnosis without intravenous contrast use, which is advantageous for patients with renal insufficiency and pregnant patients. Familiarity with the typical MRI appearance of various acute gynecologic conditions helps establish the correct diagnosis. This article reviews the common MRI findings of acute gynecologic processes, in both pregnant and nonpregnant patients. Level of Evidence: 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1291-1309.

Primary Ovarian Pregnancy: A Case Series and Analysis

The preoperative diagnosis of primary ovarian pregnancy (POP) remains elusive and the final diagnosis relies heavily on histologic findings. The diagnostic criteria for POP, established in 1878 by Spiegelberg, are based primarily on the identification of an embryonic sac within the ovary and the localization of conception products therein. However, these diagnostic criteria may be overly strict, which may not only significantly underestimate the prevalence of POP, but also potentially mislead patient management. In this series, we present 7 cases that showed no embryonic sac within the ovary (thus not meeting the Spiegelberg criteria for POP), but were nonetheless classified by the authors as POP based on the unequivocal presence of chorionic villi and implantation sites within the ovary. Immmunohistochemical studies for beta-human chorionic gonadotropin, human placental lactogen, and inhibin highlighted the trophoblastic populations. These findings indicate that POP may occur even if no embryonic sac is pathologically demonstrable. Accordingly, we propose the following modified diagnostic criteria for POP: (1) no pathologic evidence of ipsilateral fallopian tube involvement is present; and (2) evidences of gestation, including presence of chorionic villi and/or implantation site are present within the ovary. If both criteria are met, the diagnosis of POP should be rendered. These proposed diagnostic criteria should lead to more accurate diagnoses of POP, provide more contemporary insights into its true prevalence, heighten clinical awareness of the disease, and ultimately, optimize its clinical management.

Ultrasound classification and clinical analysis of ovarian pregnancy: A study of 12 cases

OBJECTIVE

To evaluate the clinical significance of preoperative ultrasound diagnosis and classification of ovarian pregnancy (OP).

METHODS

The ultrasonographic reports, medical records, and operative summaries were reviewed for twelve women with a confirmed diagnosis of OP. According to the ultrasonographic appearance, OP was classified into two types. For every type, we analyzed the possibility and clinical significance of preoperative ultrasound diagnosis, combining with its clinical manifestations and treatments.

RESULTS

According to sonographic features, twelve cases of OP can be classified into ruptured type (n = 6) and unruptured type (n = 6), the latter was subclassified into embryo sac type (n = 2) and non-homogeneous mass type (n = 4). All the unruptured OP have the characteristic solid hyperechoic rings or masses, and 66.7% (4/6) were correctvly diagnosed by preoperative ultrasound. No characteristic ultrasonogram was detected in ruptured OP which were all diagnosed as ruptured ectopic pregnancy (EP) or corpus luteum by preoperative ultrasound. The diagnostic and surgical procedures of four cases diagnosed by preoperative ultrasound were all laparoscopy and removal of the gestational products, and their average hemoperitoneum, operation time, hospital days was 313 ± 278 ml, 57 ± 9 min, and 4.25 ± 0.5days, respectively. While ruptured OP cases (6 cases diagnosed at first visit and 1 underdiagnosed but ruptured after 6 days), the diagnostic procedures was laparoscopy(3/7) or laparotomy(4/7), the surgical procedure was removal of the gestational products(2/7), wedge resection(3/7), or adenexectomy(2/7), and their average hemoperitoneum, operation time, and hospital days was 1914 ± 1059 ml, 93 ± 17 min, and 5.9 ± 1.3days, respectively.

CONCLUSIONS

Ultrasound plays a significant role in diagnosis of OP, and part of the unruptured OP based on the typical sonographic characteristics could be correctly diagnosed by an experienced sonographer, this is beneficial and effective in terms of the risk of patient's operation and life. Whereas ruptured OP were generally diagnosed as ruptured EP or corpus luteum because there were no characteristic ultrasound manifestations.

Magnetic resonance imaging of common, uncommon, and rare implantation sites in ectopic pregnancy

OBJECTIVE

To review the MRI appearances of tubal and non-tubal implantation sites in ectopic pregnancy.

CONCLUSION

Transvaginal ultrasound is the primary imaging modality in ectopic pregnancy and MRI is used as a problem-solving tool in selected indications as detailed in the article. MRI features of tubal, interstitial, cervical, cesarean scar, cornual, ovarian, abdominal, and heterotopic pregnancies are provided to familiarize the radiologists with their appearances thereby assisting them in making early and accurate diagnosis.

Coexisting ovarian and tubal pregnancies on opposite sides after intrauterine insemination: a case report

BACKGROUND

Ovarian pregnancy is very rare, and contralateral tubal pregnancy coexisting with ovarian pregnancy must be even rarer.

CASE PRESENTATION

A 33-year-old Korean nulliparous woman was referred to our hospital because she suffered lower abdominal pain and had missed her periods after controlled ovarian hyperstimulation and intrauterine insemination. We could not identify any normal gestational sac in the endometrium, or specific ectopic pregnancies, on an initial ultrasound scan. However, there was a large hematoma in the cul-de-sac and free fluid in the right paracolic gutter. We decided to perform emergent laparoscopic surgery. We found contralateral tubal and ovarian ectopic pregnancies.

CONCLUSION

To the best of our knowledge, this is the first report of a case in which a patient underwent laparoscopic right salpingectomy and left ovarian ectopic mass excision due to contralateral tubal and ovarian ectopic pregnancies after assisted reproductive technology.

Preoperative diagnostic clues to ovarian pregnancy: retrospective chart review of women with ovarian and tubal pregnancy

OBJECTIVE

To analyze the preoperative diagnostic clues to ovarian pregnancy (OP).

METHODS

This study conducted a retrospective chart review of 23 patients with OP and 46 patients with tubal pregnancy (TP) from October 1, 2003 to September 31, 2016 in Hanyang University Hospital.

RESULTS

There were no significant differences in demographic and clinical characteristics between the two groups. The presence of an ectopic gestational sac and hemoperitoneum was significantly higher in the TP group (13.0% vs. 95.7%, P=0.000; 13.0% vs. 54.3%, P=0.001, respectively) in preoperative ultrasonogram. The OP group had more ruptured ectopic gestational sacs than the TP group (73.9% vs. 45.7%, P=0.039) in surgical findings.

CONCLUSION

For the patients in whom a gestational sac is not detected in the uterus or the fallopian tubes, it is important to be aware of the possibility of OP and rupture of an ovarian gestational sac to promote early diagnosis and surgical intervention.

Diagnosing ectopic pregnancy in the emergency setting

Ectopic pregnancy is the implantation of a fertilized egg outside the uterine endometrial cavity. For women presenting to the emergency department with abdominal pain and/or vaginal bleeding, ectopic pregnancy is an important diagnostic consideration. The diagnosis is made based on laboratory values and ultrasound imaging findings. The ultrasound appearance of both normal early pregnancy and ectopic pregnancy are variable and often subtle, presenting diagnostic challenges for radiologists. This pictorial essay describes and illustrates the sonographic findings of ectopic pregnancy and reviews the differential diagnoses that can mimic ectopic pregnancy on ultrasound. With the possibility of medical management, the value of early detection and prompt initiation of treatment has increased in improving clinical outcomes and preventing the complications of ectopic pregnancy.

Ectopic ovarian pregnancy after intracytoplasmic sperm injection with testicular spermatozoa - a case report

Ovarian ectopic pregnancy is a rare event in both natural and assisted human reproduction settings. There are few reports of this event after in vitro fertilization. Diagnosis can be challenging, since it requires specific medical expertise. Patients with this condition call for careful management during treatment so as to not affect their fertility potential. This paper describes the case of a woman submitted to ICSI and embryo transfer who subsequently had an ovarian ectopic pregnancy and underwent a laparoscopic partial right oophorectomy

Case Report of Ectopic Ovarian Pregnancy Following Fresh Embryo Transfer

BACKGROUND

Ovarian pregnancy is a rare and challenging clinical phenomenon. Recent studies have identified assisted reproductive treatments and infertility as risk factors. However, neither a definite mechanism nor clear risk factors were identified and therefore prevention strategies are yet unavailable.

CLINICAL CASE

In this article, we present a case of ovarian pregnancy occurring following in vitro fertilization treatment and a fresh embryo transfer. The couple was diagnosed with unexplained infertility and no identifiable risk factors for extrauterine pregnancy. The diagnosis of ovarian pregnancy was made during explorative laparoscopy performed due to suspected extrauterine pregnancy. The patient had normal intra- and postoperative course.

CONCLUSION

Ovarian pregnancy is an infrequent and a challenging diagnosis. Yet, late diagnosis and lack of appropriate intervention may have long-term implications. Several mechanisms and risk factors are proposed, and their acknowledgment may improve early diagnosis and prevention of complications.

[Ovarian pregnancy: about 3 cases and review of the literature]

Ovarian pregnancy is a rare event among women with ectopic pregnancy in whom the ovary is the site of implantation. Its diagnosis requires a well codified approach. The peculiarities of the determining factors, of the histopathological and evolutionary features typical of ovarian pregnancies led us to focus on this form of ectopic pregnancy. We report 3 cases of ovarian pregnancy diagnosed in our Department. The three women were between 30 and 42 years, at 13 to 37 weeks of amenorrhea. All women had abdominal pain of varying intensity associated with shock. Anatomopathological examination of the right annex, normal site of implantation of ovarian pregnancies, confirmed the diagnosis. All women had juxtaposition ovarian cortical pregnancy. Ovarian pregnancy is a rare event among women with ectopic pregnancy, having specific peculiarities. Its diagnosis is difficult and is based on preoperative findings. The identification of the ovarian implantation on histopathological examination is ideal for confirming the diagnosis. Currently, it is assumed that ovarian pregnancy is the form of ectopic pregnancy which can develop to term or even result in a live birth.

Ovarian ectopic pregnancy in adolescence

Ovarian pregnancy is one of the rarest types of extrauterine pregnancy. Its preoperative diagnosis remains a challenge since it presents quite similarly to tubal pregnancy and complicated ovarian cysts. Although in most cases, histology is necessary to confirm the diagnosis, we present an ovarian pregnancy in a teenager, correctly diagnosed during ultrasound examination.

Unusual ectopic pregnancies: sonographic findings and implications for management

Ectopic pregnancy is a considerable source of morbidity and mortality for women of childbearing age. Improved detection and increased risk factors have led to a dramatic rise in the incidence of ectopic pregnancy in recent years. Early diagnosis is critical for the health of the patient as well as the success rate of future pregnancies. Besides laparoscopy, sonography is the mainstay for evaluating ectopic pregnancy. It is important to understand the sonographic features of ectopic pregnancies, including unusual cases that occur outside the fallopian tube.

Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass

Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy.

[Indications for methotrexate in gynecology outside the first-line treatment of ectopic tubal pregnancies]

The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.

Risk factors and clinical features of ovarian pregnancy: a case-control study

OBJECTIVE

To identify risk factors for ovarian pregnancy (OP) and compare clinical features between OP and tubal pregnancy (TP) patients.

DESIGN

Case-control study.

SETTING

University hospital.

PARTICIPANTS

A case-control study was conducted from January 2005 to May 2014. Women diagnosed with OP were recruited as the case group (n=71), 145 women with TP and 146 with intrauterine pregnancy (IUP) were matched as controls at a ratio of 1:2:2. Women who refused interviews or provided incomplete information were excluded.

RESULTS

OP risk was lower than TP risk in women with serological evidence of Chlamydia trachomatis infection (adjusted OR1 0.17, 95% CI 0.06 to 0.52), previous adnexal surgery (adjusted OR1 0.25, 95% CI 0.07 to 0.95), and current levonorgestrel emergency contraceptive use (adjusted OR1 0.24, 95% CI 0.07 to 0.78). In vitro fertilisation-embryo transfer (IVF-ET) carried a higher risk of OP (adjusted OR1 12.18, 95% CI 2.23 to 66.58) than natural conception. When Controlled by IUP women, current users of intrauterine devices (IUDs) carried a higher risk of OP than non-users of any contraceptives (adjusted OR2 9.60, 95% CI 1.76 to 42.20). β-Human chorionic gonadotropin (hCG) levels on the day of surgery were higher in OP patients than in TP patients (p<0.01). Women with OP were less likely to initially present with vaginal bleeding than those with TP (p=0.02). Moreover, shock (p=0.02), rupture (p<0.01), haemoperitoneum (p<0.01) and emergency laparotomy (p<0.01) were more common in the OP group than in the TP group.

CONCLUSIONS

IVF-ET and IUD use may be risk factors for OP, and OP patients tend to have high β-hCG levels and a poor clinical outcome (shock, rupture, haemoperitoneum and need for emergency laparotomy). Our findings may contribute to the prevention and early diagnosis of OP.

Ovarian pregnancy: uncommon mode of presentation

Ovarian pregnancy is very rare, and its incidence is 1 in 3000 live births. In this condition, common risk factors for ectopic pregnancy not usually found. It usually occurs in fertile women and more commonly with in-situ intrauterine device (IUD). Preoperative diagnosis is always not possible although the patient commonly presents with abdomen-pelvic pain, per vaginal bleeding and hypovolemic shock. High degree of suspicion with estimation of serum beta HCG, transvaginal ultrasonography by an experienced sonologist and laparoscopy is required for confirming the diagnosis. Though, the usual treatment is surgery, it can be managed by medical methods only in hemodynamically stable patients. In this case report, we describe the unusual mode of clinical presentation in an elderly woman with ovarian pregnancy.

Ultrasound imaging in the management of bleeding and pain in early pregnancy

Bleeding and pain are experienced by 20% of women during the first trimester of pregnancy. Although most pregnancies complicated by pain and bleeding tend to progress normally, these symptoms are distressing for woman, and they are also associated with an increased risk of miscarriage and ectopic pregnancy. Ultrasound is the first and often the only diagnostic modality that is used to determine location of early pregnancy and to assess its health. Ultrasound is an accurate, safe, painless and relatively inexpensive diagnostic tool, which all contributed to its widespread use in early pregnancy. Pain and bleeding in early pregnancy are sometimes caused by concomitant gynaecological, gastrointestinal, and urological problems, which could also be detected on ultrasound scan. In women with suspected intra-abdominal bleeding, ultrasound scan can be used to detect the presence of blood and provide information about the extent of bleeding. In this chapter, we comprehensively review the use of ultrasound in the diagnosis and management of early pregnancy complications. We include information about the diagnosis of gynaecological and other pelvic abnormalities, which could cause pain or bleeding in pregnancy. We also provide a summary of the current views on the safety of ultrasound in early pregnancy.

Ovarian pregnancy: two case reports

Ovarian pregnancy is a rare event occurring in 1-3% of all ectopic pregnancies. Increased reporting might be due to the wider use of intra-uterine devices, ovulatory drugs and assisted reproductive techniques. Though ovarian pregnancy has a distinct pathology, it can be a source of clinical and intraoperative diagnostic difficulty. We report two cases of ovarian pregnancy - one primary and one secondary - that came to our notice within six months span. Unlike tubal ectopic and secondary ovarian pregnancies, patients with primary ovarian pregnancy are likely to experience success in future intra-uterine conception and negligible risk.

Twenty-one years of experience with ovarian ectopic pregnancy at one institution in Taiwan

OBJECTIVE

To review the experience with patients with ovarian ectopic pregnancy (OEP) at Chang Gung Memorial Hospital, Lin-Kou Medical Center, Tao-Yuan, Taiwan, between 1989 and 2009.

METHODS

A retrospective review of the presentation, prevalence, diagnosis, and trends in treatment of patients with OEP, and the use of assisted reproductive technology (ART) procedures and intrauterine devices (IUD). The incidence rate ratios (IRR) of ectopic pregnancies (EPs) per live births, OEPs per EPs, and OEPs per live births were analyzed.

RESULTS

The 110 OEPs diagnosed comprised 2.0% of all EPs (n=5408) and 1:1543 of all live births, leading to a mean OEP per year of 5.24. Seventy-eight patients were managed with laparoscopy and 32 underwent laparotomy. Twenty-six (23.6%) patients used an IUD and 12 (10.9%) had undergone ART. OEP associated with ART increased in the last 10 years of the study period. The IRR of EPs per live births, OEPs per EPs, and OEPs per live births all increased between 1989 and 2009. Management of OEP tended to favor laparoscopy in the later years.

CONCLUSION

There was a trend toward better management of OEP with laparoscopy. ART has become a risk factor for OEP. The IRR of EPs per live births, OEPs per EPs, and OEPs per live births all increased over the 21-year period.

Ovarian pregnancy resulting from cryopreserved blastocyst transfer

Ovarian pregnancy very rarely occurs and its exact mechanism is unclear. Here, we report a case of ovarian pregnancy resulting from cryopreserved blastocyst transfer. The patient was a 34-year-old woman who had undergone bilateral ovarian cystectomy for endometriosis. Both fallopian tubes indicated normal findings on laparoscopic surgery, and we removed the gestational product of the right ovary. Pathological analysis confirmed the diagnosis of right ovarian pregnancy. Ectopic pregnancy is one of the major complications of in vitro fertilization-embryo transfer. Although ovarian pregnancy is an extremely rare occurrence, the possibility of developing this event after cryopreserved blastocyst transfer should be recognized.

A pelvic mass on ultrasonography and high human chorionic gonadotropin level: not always an ectopic pregnancy

A 24-year-old patient with 7-week amenorrhoea consulted for vaginal bleeding without abdominal pain. Ultrasonography revealed a 7 × 4 cm solid right pelvic mass. There was no visible intrauterine gestational sac. The serum β-human chorionic gonadotropin (β-hCG) level was 11 998 IU/l. Emergency laparoscopy was performed for a presumptive diagnosis of ectopic pregnancy. At laparoscopy, the right ovary was enlarged with a non-haemorrhagic 7 × 4 cm solid lesion, which was resected. The histological diagnosis was a dysgerminoma with immunohistochemistry showing nests of syncytiotrophoblastic cells, which were the origin of the hCG production. There was no pregnancy, either intrauterine or ectopic. There was no evidence of metastasis from the dysgerminoma on the positron-emission tomography scanner. The patient underwent a second procedure for surgical staging of this ovarian germ-cell tumour. This ovarian dysgerminoma was staged FIGO 1A, and the patient did not receive adjuvant therapy. There was no recurrence at the last 8-month follow-up.

Ovarian ectopic pregnancy

The authors report the rare case of a 25-year-old female who suffered from an ovarian ectopic pregnancy. She presented at 10 weeks gestation with a 1-day history of vaginal bleeding and lower abdominal discomfort. β-human chorionic gonadotropin concentration was 8538 IU/ml. Ultrasound showed a right adnexal mass 4.0 × 3.8 × 5.5 cm with a 16 mm cystic area suggesting right ovarian ectopic pregnancy. Diagnostic laparoscopy confirmed a ruptured right ovarian ectopic pregnancy with haemoperitoneum. This was excised laparoscopically. She made a good postoperative recovery and was discharged on the second postoperative day. Histology confirmed a ruptured ovarian ectopic pregnancy. Ovarian ectopic pregnancy is a rare condition. There are two features that make this an unusual case; the relatively late gestation at which she presented and her mild presenting features. Unlike tubal ectopic pregnancies, which usually present at earlier gestations, this patient presented relatively late. She also presented with mild symptoms and signs.