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Solangon SA, Naftalin J, Jurkovic D. Ovarian ectopic pregnancy: clinical characteristics, ultrasound diagnosis and management. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:815-823. [PMID: 38031189 DOI: 10.1002/uog.27549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/23/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
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.
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Affiliation(s)
- S A Solangon
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - J Naftalin
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - D Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
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Advanced Ovarian Pregnancy: A Case Report of Misdiagnosis and Surgical Outcomes. Case Rep Obstet Gynecol 2022; 2022:8856078. [PMID: 36569640 PMCID: PMC9788897 DOI: 10.1155/2022/8856078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Background Ovarian pregnancy is rare and difficult to diagnose preoperatively, especially in advanced gestational age. Misdiagnosis can increase the chance of emergent complications. Case A misdiagnosed case of a 33-week ovarian pregnancy woman who underwent surgery due to a preoperative diagnosis of a dead fetus in utero, and transverse lie was reported with eventful surgical outcomes. This case resulted in the delivery of a dead fetus and a sudden massive hemorrhage that occurred after placental detachment. Oophorectomy could not be performed due to severe bowel adhesions and multiple feeding vessels from the bowel at the posterior part of the left ovary. The placental site was sutured at multiple sites, and local hemostatic agents were placed for hemostasis. Postoperatively, she received multiple transfusions and was safely discharged after 10 days. Conclusion Obstetricians must be acutely aware of this condition, especially while performing sonography preoperatively, for better outcomes.
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Ren F, Liu G, Wang T, Li M, Guo Z. Unruptured ovarian ectopic pregnancy: Two case reports and literature review. Front Physiol 2022; 13:1036365. [PMID: 36388130 PMCID: PMC9641050 DOI: 10.3389/fphys.2022.1036365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/05/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Fang Ren
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Gang Liu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Tifang Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meijun Li
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhiqiang Guo
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Zhiqiang Guo,
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Li H, Liu Y, Yang Y, Zhao X, Qi X. Clinical analysis of women with ovarian pregnancy: a retrospective case-control study. BMC Pregnancy Childbirth 2022; 22:768. [PMID: 36229794 PMCID: PMC9560037 DOI: 10.1186/s12884-022-05099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Hongyi Li
- Department of Gynecology and Obstetrics, Development and Related Disease of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, 20 South Renmin Road, Block 3, Chengdu City, 610041, Sichuan Province, People's Republic of China
| | - Yu Liu
- Department of Gynecology and Obstetrics, Development and Related Disease of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, 20 South Renmin Road, Block 3, Chengdu City, 610041, Sichuan Province, People's Republic of China
| | - Yang Yang
- Department of Gynecology and Obstetrics, Development and Related Disease of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, 20 South Renmin Road, Block 3, Chengdu City, 610041, Sichuan Province, People's Republic of China
| | - Xia Zhao
- Department of Gynecology and Obstetrics, Development and Related Disease of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, 20 South Renmin Road, Block 3, Chengdu City, 610041, Sichuan Province, People's Republic of China.
| | - Xiaorong Qi
- Department of Gynecology and Obstetrics, Development and Related Disease of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, 20 South Renmin Road, Block 3, Chengdu City, 610041, Sichuan Province, People's Republic of China.
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Kasraei S, Seifollahi A, Aghajani F, Nakhostin-Ansari A, Zarei N, Tehranian A. Successful management of a patient with ovarian ectopic pregnancy by the end of the first trimester: a case report. J Med Case Rep 2022; 16:175. [PMID: 35491424 PMCID: PMC9059382 DOI: 10.1186/s13256-022-03403-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 04/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among all ectopic pregnancies, between 0.5% and 3.5% are ovarian ectopic pregnancies, a potentially life-threatening condition when ruptured due to its serious potential for hemorrhaging. A majority of ovarian ectopic pregnancies are diagnosed by the 7th week of pregnancy when the patient becomes symptomatic, and ultrasound can be used to diagnose this condition. CASE PRESENTATION We present the case of a 39-year-old Persian woman in the 12th week of gestation who presented with vaginal bleeding and abdominal pain and was diagnosed with ovarian ectopic pregnancy. Her notable laboratory finding was β-human chorionic gonadotropin > 15,000, which indicates definite pregnancy. Transvaginal ultrasound (TVS) revealed no evidence of intrauterine pregnancy, but a well-circumscribed gestational sac in the left ovary. The patient was successfully treated with resection of the gestational sac and partial left salpingo-oophorectomy. Histopathological studies confirmed the diagnosis of ovarian ectopic pregnancy. CONCLUSION The case emphasizes the ability of ovarian ectopic pregnancy to develop asymptomatically through the course of pregnancy and points to the necessity for high-quality prenatal care and the importance of determining the fetal site during pregnancy.
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Affiliation(s)
- Sara Kasraei
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Rashid Ave, Resalat Highway, Tehranpars, Tehran, Iran
| | - Akram Seifollahi
- Department of Pathology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Faezeh Aghajani
- Research Development Center, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amin Nakhostin-Ansari
- Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Zarei
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Rashid Ave, Resalat Highway, Tehranpars, Tehran, Iran
| | - Afsaneh Tehranian
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Rashid Ave, Resalat Highway, Tehranpars, Tehran, Iran.
- Research Development Center, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Konar H, Konar L, Konar C, Halder A, Saha A, Khamaru J. Uncommon Ectopic Pregnancies—Challenges in the Management. J Obstet Gynaecol India 2022; 72:224-234. [PMID: 35928092 PMCID: PMC9343554 DOI: 10.1007/s13224-021-01605-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/15/2021] [Indexed: 10/18/2022] Open
Abstract
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.
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Huang Y, Huang Q, Liu J, Guo M, Liu Y, Lai D. Concurrent Ovarian and Tubal Ectopic Pregnancy After IVF-ET: Case Report and Literature Review. Front Physiol 2022; 13:850180. [PMID: 35444560 PMCID: PMC9013932 DOI: 10.3389/fphys.2022.850180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Yating Huang
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qin Huang
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jinglan Liu
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Mengxi Guo
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yuan Liu
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Dongmei Lai
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- *Correspondence: Dongmei Lai,
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8
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Lijuan SMD, Hui LMS, Juhong LMS, Cuixia GMS, Qingqing WMD. Preoperative Diagnosis of Ovarian Pregnancy by Transvaginal Ultrasound: A Case Report. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2021. [DOI: 10.37015/audt.2021.200015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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9
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Ribeiro K, El Shamy T, Miskry T. Ovarian ectopic pregnancy after in vitro fertilisation treated by laparoscopic excision with ovarian preservation. BMJ Case Rep 2020; 13:13/11/e236680. [PMID: 33139361 DOI: 10.1136/bcr-2020-236680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Kelly Ribeiro
- Obstetrics and Gynaecology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Tarek El Shamy
- Obstetrics and Gynaecology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Tariq Miskry
- Obstetrics and Gynaecology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Agarwal N, Shekhar S, Goyal M, Singh P, Yadav T. Successful outcome in a rare case of live post-term ovarian pregnancy. J Obstet Gynaecol Res 2020; 46:2691-2695. [PMID: 33006211 DOI: 10.1111/jog.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/02/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
Ovarian ectopic is a rare form of ectopic pregnancy and reaching up to term is an extreme rarity. It is usually diagnosed incidentally when a cesarean section is done for other obstetric causes. Being highly vascular, it may result in obstetric catastrophes. We report first live post-term ovarian pregnancy well managed with multidisciplinary approach. A 35-year multigravida at 44 weeks presented with a diagnosis of placenta percreta. Magnetic resonance imaging suggested abdominal pregnancy with a live fetus. On laparotomy, it was live ovarian ectopic with placenta attached to left infundibulopelvic vessels and later confirmed on histological examination. Ovarian ectopic is best diagnosed in the first trimester by ultrasound and managed by laparoscopy or laparotomy. It is usually misdiagnosed as an abdominal pregnancy at term even with the use of high-end technology. It always poses a dilemma for clinicians. Preoperative magnetic resonance imaging helps in the planning of surgery with all precautionary measures and counseling of patients.
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Affiliation(s)
- Neha Agarwal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Shashank Shekhar
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Manu Goyal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Pratibha Singh
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, India
| | - Taruna Yadav
- Department of Radiology, All India Institute of Medical Sciences, Jodhpur, India
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Investigation of clinical utility of contrast-enhanced MRI in the diagnosis of ectopic pregnancy. Clin Radiol 2020; 75:543-551. [PMID: 32209236 DOI: 10.1016/j.crad.2020.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/20/2020] [Indexed: 11/22/2022]
Abstract
AIM To investigate whether contrast-enhanced (CE)-magnetic resonance imaging (MRI) improves identification of implantation site of ectopic pregnancy. MATERIALS AND METHODS This retrospective study enrolled 63 patients in whom implantation sites had been confirmed at histopathology. Two expert radiologists for gynaecological imaging and two inexpert radiologists independently reviewed non-CE MRI and a combination of non-CE and CE-MRI (non-CE+CE-MRI), then determined implantation site with a confidence level. The following MRI features were also evaluated: extrauterine gestational sac (GS)-like structure (shape, signal intensities at T1-weighted imaging [WI], T2WI, and diffusion-weighted imaging [DWI], presence of the three rings appearance, and distinct low intensity areas at T2WI, presence of tree or dot-like components, degree of contrast enhancement), fallopian tube (dilatation, dilatation with haematoma, degree of contrast enhancement, enhanced components within the tube), and ascites. These findings were compared for non-CE and non-CE+CE-MRI data, and for expert and inexpert groups. RESULTS The expert group identified implantation sites correctly in 58/63 (92%) cases for non-CE and non-CE+CE-MRI. In the inexpert group, the correct identification was improved from 54/63 (86%) using non-CE MRI to 58/63 (92%) using non-CE+CE-MRI, but was not significant (p=0.29). In comparison between non-CE and non-CE+CE-MRI, dilation of the fallopian tubes was observed more frequently (p=0.004) and the confidence level was elevated significantly in the non-CE+CE-MRI (p<0.0001) in the inexpert group. Intergroup comparison revealed that confidence level was significantly higher in the expert group than in the inexpert group using non-CE MRI (p<0.0001), although the difference was not significant at non-CE+CE MRI (p=0.49). CONCLUSION CE-MRI did not significantly improve correct identification of ectopic pregnancy implantation sites, although the addition of contrast enhancement did enable inexpert radiologists to diagnose confidently.
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Abstract
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.
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Ge L, Sun W, Wang L, Cheng L, Geng C, Song Q, Zhan X. Ultrasound classification and clinical analysis of ovarian pregnancy: A study of 12 cases. J Gynecol Obstet Hum Reprod 2019; 48:731-737. [PMID: 30980997 DOI: 10.1016/j.jogoh.2019.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 03/31/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ling Ge
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Wenrong Sun
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Lihua Wang
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Lei Cheng
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Chenchen Geng
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Qian Song
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Xinfeng Zhan
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China.
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Early diagnosis of ovarian pregnancy – a case report. GINECOLOGIA.RO 2019. [DOI: 10.26416/gine.26.4.2019.2710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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15
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Gundabattula SR, Resapu P, Surampudi K, Surapaneni T, De Padua M. Ovarian apoplexy resulting from ruptured heterotopic pregnancy following intrauterine insemination. J Obstet Gynaecol Res 2018; 43:1222-1226. [PMID: 28718211 DOI: 10.1111/jog.13346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 03/05/2017] [Indexed: 01/24/2023]
Abstract
Heterotopic pregnancy is on the rise with the use of assisted conception and commonly involves the fallopian tube. Ovarian heterotopic pregnancy is rare, with fewer than 40 reported cases in PubMed/Medline; cases of ovarian ectopic pregnancy after intrauterine insemination are even rarer, with only seven published reports. We report here a case of ovarian heterotopic pregnancy following intrauterine insemination; this could possibly be the first such report. Our patient presented with circulatory collapse in the first trimester and laparoscopy disclosed an ovarian pregnancy with hemoperitoneum. Following resection of the ovarian pregnancy, the intrauterine gestation continued undisturbed and the patient delivered at term. Heterotopic pregnancy and unusual ectopic locations should be considered a possibility in pregnant women with pelvic pain, particularly following fertility treatment, including ovarian stimulation and intrauterine insemination.
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16
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García-Ferreyra J, Hilario R, Dueñas J. Ectopic ovarian pregnancy after intracytoplasmic sperm injection with testicular spermatozoa - a case report. JBRA Assist Reprod 2017; 21:135-136. [PMID: 28609281 PMCID: PMC5473707 DOI: 10.5935/1518-0557.20170029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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
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Affiliation(s)
| | | | - Julio Dueñas
- FERTILAB Assisted Reproduction Laboratories, Lima, Peru.,PROCREAR Fertility Center, Lima, Peru
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17
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Samara N, Bentov Y. Case Report of Ectopic Ovarian Pregnancy Following Fresh Embryo Transfer. CLINICAL MEDICINE INSIGHTS: REPRODUCTIVE HEALTH 2016; 10:29-32. [PMID: 27867306 PMCID: PMC5110221 DOI: 10.4137/cmrh.s40593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/21/2016] [Accepted: 09/23/2016] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Nivin Samara
- Department of Obstetrics and Gynecology, TRIO Fertility Clinic, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Yaakov Bentov
- Department of Obstetrics and Gynecology, TRIO Fertility Clinic, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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18
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19
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Andrade AG, Rocha S, Marques CO, Simões M, Martins I, Biscaia I, F Barros C. Ovarian ectopic pregnancy in adolescence. Clin Case Rep 2015; 3:912-5. [PMID: 26576271 PMCID: PMC4641473 DOI: 10.1002/ccr3.336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 01/11/2015] [Accepted: 06/24/2015] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Ana Gonçalves Andrade
- Department of Gynecology, Maternidade Dr. Alfredo da Costa – Centro Hospitalar Lisboa CentralAzinhaga das Galhardas n°17, bloco A 9°D, 1600-097, Lisboa, Portugal
| | - Sara Rocha
- Department of Gynecology, Maternidade Dr. Alfredo da Costa – Centro Hospitalar Lisboa CentralAzinhaga das Galhardas n°17, bloco A 9°D, 1600-097, Lisboa, Portugal
| | - Catarina O Marques
- Department of Gynecology, Maternidade Dr. Alfredo da Costa – Centro Hospitalar Lisboa CentralAzinhaga das Galhardas n°17, bloco A 9°D, 1600-097, Lisboa, Portugal
| | - Mafalda Simões
- Department of Gynecology, Maternidade Dr. Alfredo da Costa – Centro Hospitalar Lisboa CentralAzinhaga das Galhardas n°17, bloco A 9°D, 1600-097, Lisboa, Portugal
| | - Isabel Martins
- Department of Gynecology, Maternidade Dr. Alfredo da Costa – Centro Hospitalar Lisboa CentralAzinhaga das Galhardas n°17, bloco A 9°D, 1600-097, Lisboa, Portugal
| | - Isabel Biscaia
- Department of Anatomopathology, Maternidade Dr. Alfredo da Costa – Centro Hospitalar Lisboa CentralAzinhaga das Galhardas n°17, bloco A 9°D, 1600-097, Lisboa, Portugal
| | - Carlos F Barros
- Department of Gynecology, Maternidade Dr. Alfredo da Costa – Centro Hospitalar Lisboa CentralAzinhaga das Galhardas n°17, bloco A 9°D, 1600-097, Lisboa, Portugal
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20
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A Case of Ovarian Pregnancy Diagnosed by MRI. Case Rep Obstet Gynecol 2015; 2015:143031. [PMID: 26491583 PMCID: PMC4600503 DOI: 10.1155/2015/143031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/13/2015] [Indexed: 12/26/2022] Open
Abstract
Ovarian pregnancy is a rare form of ectopic pregnancy, causing a great diagnostic challenge. We report a case of ovarian pregnancy in a 42-year-old woman, in whom MRI successfully demonstrated the implantation in the ovary. Transvaginal ultrasonography showed an echogenic mass in the right ovary but failed to demonstrate tubal pregnancy. T2-weighted MR images disclosed a gestational sac structure in the right ovary, which exhibited heterogeneous high intensity intermingled with punctate foci of distinct low intensity. MRI may be a useful tool for diagnosing ovarian pregnancy, by demonstrating a gestational sac in the ovary.
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21
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Ghaneie A, Grajo JR, Derr C, Kumm TR. Unusual ectopic pregnancies: sonographic findings and implications for management. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:951-962. [PMID: 26014313 DOI: 10.7863/ultra.34.6.951] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
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.
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Affiliation(s)
- Ashkan Ghaneie
- Departments of Radiology (A.G., T.R.K.) and Emergency Medicine (C.D.), University of South Florida, Tampa, Florida USA; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts USA (J.R.G.)
| | - Joseph R Grajo
- Departments of Radiology (A.G., T.R.K.) and Emergency Medicine (C.D.), University of South Florida, Tampa, Florida USA; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts USA (J.R.G.).
| | - Charlotte Derr
- Departments of Radiology (A.G., T.R.K.) and Emergency Medicine (C.D.), University of South Florida, Tampa, Florida USA; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts USA (J.R.G.)
| | - Todd R Kumm
- Departments of Radiology (A.G., T.R.K.) and Emergency Medicine (C.D.), University of South Florida, Tampa, Florida USA; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts USA (J.R.G.)
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22
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M Sueldo C, Budinetz T, Maslow BS, Nulsen J, Engmann L, Benadiva C. Concurrent ovarian and ipsilateral tubal ectopic pregnancies after a double embryo transfer: a case report. J Assist Reprod Genet 2014; 31:1643-6. [PMID: 25256554 DOI: 10.1007/s10815-014-0338-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 09/04/2014] [Indexed: 11/27/2022] Open
Affiliation(s)
- Carolina M Sueldo
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, 06030, USA,
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23
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Meşeci E, Güzel Y, Zemheri E, Eser SK, Özkanlı Ş, Kumru P. A 34-week ovarian pregnancy: case report and review of the literature. J Turk Ger Gynecol Assoc 2013; 14:246-9. [PMID: 24592116 PMCID: PMC3935532 DOI: 10.5152/jtgga.2013.31391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 01/23/2013] [Indexed: 12/29/2022] Open
Abstract
Advanced ovarian pregnancy is a quite rare condition. Due to the high maternal and neonatal mortality rates, early and accurate diagnosis is vital. Lack of sufficient data led us to search the literature and compile available data on the topic. A 33-year-old woman presented with acute abdomen at 34 weeks of gestation. She underwent laparotomy, which revealed a live foetus surrounded by an intact amnion membrane located in the left adnexal area. The patient delivered a live female infant. Heavy bleeding from the placenta necessitated salpingo oophorectomy. Histological examination of the removed tissue confirmed the ovarian pregnancy. Because of the substantial risk of adverse outcomes, this condition should be borne in mind, especially in cases presenting with acute abdomen during pregnancy.
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Affiliation(s)
- Elif Meşeci
- Department of Obstetrics and Gynecology, Acıbadem Kozyatağı Hospital, İstanbul, Turkey
| | - Yılmaz Güzel
- Department of Obstetrics and Gynecology, Okmeydanı Education and Research Hospital, İstanbul, Turkey
| | - Ebru Zemheri
- Department of Pathology, Göztepe Education and Training Hospital, Medeniyet University, İstanbul, Turkey
| | - Semra Kayataş Eser
- Department of Obstetrics and Gynecology, Zeynep Kamil Education and Training Hospital, İstanbul, Turkey
| | - Şeyma Özkanlı
- Department of Pathology, Göztepe Education and Training Hospital, Medeniyet University, İstanbul, Turkey
| | - Pınar Kumru
- Department of Obstetrics and Gynecology, Zeynep Kamil Education and Training Hospital, İstanbul, Turkey
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24
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Gupta N, Gupta A, Onyema G, Pantofel Y, Ying SC, Garon JE, Lampley C, Blankstein J. Accurate preoperative diagnosis of ovarian pregnancy with transvaginal scan. Case Rep Obstet Gynecol 2012; 2012:934571. [PMID: 23091755 PMCID: PMC3472540 DOI: 10.1155/2012/934571] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 09/15/2012] [Indexed: 11/26/2022] Open
Abstract
Ovarian pregnancy is a rare variant of ectopic pregnancy, and an accurate preoperative diagnosis is very challenging. Dr. Saint Monnissey described the first reported case of ovarian pregnancy in 17th century. Transvaginal ultrasonography is a valuable tool in identifying an ovarian pregnancy from other types of ectopic pregnancies. Management with laparoscopy or laparotomy is required in all cases, and in almost all cases, ovary can be preserved since implantation is usually superficial (Koo et al.; 2011). A single case of an ovarian pregnancy, consistent with Spiegelberg's criteria is presented here. This case history demonstrates the use of ultrasonography (USG) and surgery in the diagnosis and treatment, respectively, of the ovarian pregnancy. As we step into an era where in vitro fertilization rate is on its hike, one should be aware that incidence of ovarian pregnancy is also increasing, necessitating a high index of suspicion.
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Affiliation(s)
- Natasha Gupta
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA
| | - Anu Gupta
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA
| | - Godwin Onyema
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA
| | - Yelena Pantofel
- Department of Ultrasound, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA
| | - Shan-Ching Ying
- Department of Pathology, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA
| | - Jack E. Garon
- Department of Pathology, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA
| | - Charles Lampley
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA
| | - Josef Blankstein
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, 1500 S California Avenue, Chicago, IL 60608, USA
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25
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Kashima K, Yahata T, Yamaguchi M, Fujita K, Tanaka K. Ovarian pregnancy resulting from cryopreserved blastocyst transfer. J Obstet Gynaecol Res 2012; 39:375-7. [PMID: 22844999 DOI: 10.1111/j.1447-0756.2012.01963.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Katsunori Kashima
- Department of Obstetrics and Gynecology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
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Ovarian pregnancy in a patient with a levonorgestrel intrauterine system in situ. Int J Gynaecol Obstet 2012; 117:82-3. [PMID: 22239756 DOI: 10.1016/j.ijgo.2011.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 11/23/2011] [Accepted: 12/12/2011] [Indexed: 11/22/2022]
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