Ovarian pregnancy and operative laparoscopy: report of eight cases

Non-tubal ectopic pregnancy treatment experiences of a tertiary care center

AIM

To evaluate the incidence, the risk factors, and the treatment outcomes of Non-tubal ectopic pregnancies (NTEP) treated in a tertiary care center.

MATERIAL AND METHODS

A total of 110 NTEP cases treated between 2014 and 2019 were included in the retrospective study. The study cohort was divided into 6 groups according to the pregnancy localization: 87 cesarean scar pregnancies (CSPs), 7 ovarian pregnancies, 6 interstitial pregnancies, 4 rudimentary horn pregnancies, 4 abdominal pregnancies, and 2 cervical pregnancies. One woman rejected all treatment modalities. Demographic characteristics, treatment modalities, and outcomes of each group were evaluated.

RESULTS

In the study cohort, expectant management was performed in one (0.9%) woman. The methotrexate (MTX) treatment was administered in 29 (26.3%) women. Seventeen (15.4%) women underwent surgery, and 63 (57.2%) women underwent manual vacuum aspiration (MVA). A woman rejected all treatment modalities. Although 70.1% (n = 61) of CSPs were cured with MVA, 24.1% (n = 21) of them were treated with a single-dose MTX regimen in addition to MVA. The higher mean gestational sac size (33,9 ± 12,96 mm vs. 17,34 ± 9,87 mm), the higher mean gestational week (8,43 ± 1,16w vs. 6,66 ± 1,49w), the presence of fetal heartbeat (FHB) (90.5% vs. 26,2%) and the history of pelvic ınflammatory disease (PID) (38.1% vs. 6,6%) were found in the CSPs with MVA treatment failure (p < 0.05).

CONCLUSION

The management of NTEPs should be individualized according to the clinical and ultrasonographic findings. The size of the ectopic pregnancy mass, the gestational week, the presence of FHB, and the PID history were the predictive factors for the failure of MVA in CSP cases.

Rare case of haemoperitoneum secondary to a ruptured ovarian ectopic pregnancy superimposed by a bleeding corpus luteum cyst

An adolescent female presented with an acute abdomen and elevated beta-human chorionic gonadotropin levels and underwent a laparoscopy for a suspected ruptured ectopic pregnancy. Intraoperatively, a ruptured haemorrhagic corpus luteal cyst and tissues suggestive of products of conception were noted in the same ovary. Histology confirmed an ovarian ectopic pregnancy. Haemorrhagic ovarian cysts, and ectopic pregnancies, can cause acute pelvic pain in women of childbearing age. Their similar clinical signs and symptoms pose a diagnostic dilemma for any gynaecologist. Ruptured corpus luteal cysts, as well as ruptured ovarian ectopic pregnancies, should be considered rare but differential diagnoses in women presenting with acute abdominal pain, an adnexal mass and ultrasound features of haemoperitoneum. The mainstay of treatment is a diagnostic laparoscopy, which is a safe and feasible management strategy without compromising patient safety or ovarian function in the long run.

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.

Interventions for non-tubal ectopic pregnancy

BACKGROUND

Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua uteri, the ovary, the cervix, and the abdomen. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP).

OBJECTIVES

To evaluate the clinical effectiveness and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy in terms of fertility outcomes and complications.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) search portal and nine other databases to 12 December 2019. We handsearched reference lists of articles retrieved and contacted experts in the field to obtain additional data.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) published in all languages that examined the effects and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy.

DATA COLLECTION AND ANALYSIS

We used Cochrane standard methodological procedures. Primary outcomes were treatment success and complications.

MAIN RESULTS

We included five RCTs with 303 women, all reporting Caesarean scar pregnancy. Two compared uterine arterial embolization (UAE) or uterine arterial chemoembolization (UACE) plus methotrexate (MTX) versus systemic MTX and subsequent dilation and suction curettage; one compared UACE plus MTX versus ultrasonography-guided local MTX injection; and two compared suction curettage under hysteroscopy versus suction curettage under ultrasonography after UAE/UACE. The quality of evidence ranged from moderate to very low. The main limitations were imprecision (small sample sizes and very wide confidence intervals (CI) for most analyses), multiple comparisons with a small number of trials, and insufficient data available to assess heterogeneity. UAE/UACE versus systemic MTX prior to suction curettage Two studies reported this comparison. One compared UAE with systemic MTX and one compared UACE plus MTX versus systemic MTX, in both cases followed by a suction curettage. We are uncertain whether UAE/UACE improved success rates after initial treatment (UAE: risk ratio (RR) 1.00, 95% CI 0.90 to 1.12; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.87, 95% CI 0.54 to 1.38; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced rates of complications (UAE: RR 0.47, 95% CI 0.13 to 1.75; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.62, 95% CI 0.26 to 1.48; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced adverse effects (UAE: RR 1.58, 95% CI 0.41 to 6.11; 1 RCT, 72 women; low-quality evidence; UACE: RR 1.16, 95% CI 0.32 to 4.24; 1 RCT, 28 women; low-quality evidence), and it was not obvious that the types of events had similar values to participants (e.g. fever versus vomiting). Blood loss was lower in UAE/UACE groups than systemic MTX groups (UAE: mean difference (MD) -378.70 mL, 95% CI -401.43 to -355.97; 1 RCT, 72 women; moderate-quality evidence; UACE: MD -879.00 mL, 95% CI -1135.23 to -622.77; 1 RCT, 28 women; moderate-quality evidence). Data were not available on time to normalize β-human chorionic gonadotropin (β-hCG). UACE plus MTX versus ultrasonography-guided local MTX injection We are uncertain whether UACE improved success rates after initial treatment (RR 0.95, 95% CI 0.56 to 1.60; 1 RCT, 45 women; very low-quality evidence). Adverse effects: the study reported the same number of failed treatments in each arm (RR 0.88, 95% CI 0.40 to 1.92; 1 RCT, 45 women). We are uncertain whether UACE shortened the time to normalize β-hCG (MD 1.50 days, 95% CI -3.16 to 6.16; 1 RCT, 45 women; very low-quality evidence). Data were not available for complications. Suction curettage under hysteroscopy versus under ultrasonography after UAE/UACE. Two studies reported this comparison. One compared suction curettage under hysteroscopy versus under ultrasonography after UAE, and one compared these interventions after UACE. We are uncertain whether suction curettage under hysteroscopy improved success rates after initial treatment (UAE: RR 0.91, 95% CI 0.81 to 1.03; 1 RCT, 66 women; very low-quality evidence; UACE: RR 1.02, 95% CI 0.96 to 1.09; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced rates of complications (UAE: RR 4.00, 95% CI 0.47 to 33.91; 1 RCT, 66 women; very low-quality evidence; UACE: RR 0.18, 95% CI 0.01 to 3.72; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced adverse effects (UAE: RR 3.09, 95% CI 0.12 to 78.70; 1 RCT, 66 women; very low-quality evidence; UACE: not estimable; 1 RCT, 92 women; very low-quality evidence). We are uncertain whether suction curettage under hysteroscopy shortened the time to normalize β-hCG (UAE: MD 4.03 days, 95% CI -1.79 to 9.85; 1 RCT, 66 women; very low-quality evidence; UACE: MD 0.84 days, 95% CI -1.90 to 3.58; 1 RCT, 92 women; low-quality evidence). Non-tubal ectopic pregnancy other than CSP No studies reported on non-tubal ectopic pregnancies in locations other than on a caesarean scar.

AUTHORS' CONCLUSIONS

For Caesarean scar pregnancies (CSP) it is uncertain whether there is a difference in success rates, complications, or adverse events between UAE/UACE and administration of systemic MTX before suction curettage (low-quality evidence). Blood loss was lower if suction curettage is conducted after UAE/UACE than after administration of systemic MTX (moderate-quality evidence). It is uncertain whether there is a difference in treatment success rates, complications, adverse effects or time to normalize β-hCG between suction curettage under hysteroscopy and under ultrasonography (very low-quality evidence). There are no studies of non-tubal ectopic pregnancy other than CSP and RCTs for these types of pregnancy are unlikely.

Evidence-based management of non-tubal ectopic pregnancies

Recent advances in ultrasonography and the use of other modalities including magnetic resonance imaging scans have led to the early and more accurate diagnosis of non-tubal ectopic pregnancies (NTE). As a result, the management of these pregnancies has evolved. This article addresses the management options currently available for NTE. While surgical management remains the mainstay of treatment for ovarian, abdominal and cornual ectopics, there is growing evidence that some of these can be managed medically. Many authors have utilised a combination of medical and surgical approaches in the management of cervical and caesarean section (CS) scar ectopic pregnancies with good outcome. The availability of dedicated early pregnancy units has further improved diagnosis and more importantly the follow-up care for these patients. The rarity of cases and the difficulty of ethically organising randomised trials for NTE remain a problem in formulating consistent pathways for optimum management of women with NTE.

Diagnostic dilemma in ovarian pregnancy: a case series

Ovarian pregnancy is a rare form of ectopic pregnancy but it is the most common type of nontubal ectopic pregnancy. Many times it is operated with a misdiagnosis of ruptured tubal ectopic pregnancy or hemorrhagic corpus luteum. The high resolution transvaginal ultrasonography is a valuable tool for diagnosis of ectopic pregnancy but ovarian pregnancy still remains a diagnostic problem and a continuous challenge to the gynecologist. The correct diagnosis is made at the time of surgery and confirmation is by histopathological report. Here we report three cases of primary ovarian ectopic pregnancies, consistent with the Spiegelberg's criteria. Out of this, two cases have corroboration of ovarian ectopic pregnancy with use of intrauterine contraceptive device and one case by chance without any preexisting risk factors, probably due to interference in the release of ovum from the follicle. In all the three cases, emergency laparotomy was done for ruptured tubal ectopic pregnancy and the diagnosis of ruptured primary ovarian pregnancy was made at the time of surgery, this was subsequently confirmed by histopathology report. In the era where wider usage of intrauterine devices, ovulatory drugs and assisted reproductive techniques are rife, there is a possibility of an increase in the incidence of this rare entity, so ovarian ectopic pregnancy should be kept in mind as a possibility. Thereby early diagnosis by high resolution transvaginal ultrasound and laparoscopy can decrease the risk of complications like rupture, secondary implantation, hemorrhagic shock and maternal mortality.

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.

Laparoscopic Surgery for Ovarian Pregnancy using Diathermy Hook with Conservation of Ovary: A Case Report and Literature Review

A 31-year-old woman presented with a 7-week history of irregular vaginal bleeding without abdominal pain. She had been using the intrauterine contraceptive device (IUD) for the last 3 years. A pregnancy test was positive and subsequent serum beta human chorionic gonadotropin (β-HCG) was 4992 mIU/mL. A transvaginal ultrasound scan demonstrated an empty uterus with an associated adnexal mass but no free fluid. A right primary ovarian ectopic pregnancy was diagnosed a laparoscopy. This was managed laparoscopically using monopolar diathermy hook with conservation of the ovary and minimal blood loss. Ovarian pregnancy is rare, especially in women without the classical risk factors for tubal pregnancy, and efforts should be made to exclude ectopic pregnancy in the absence of abdominal pain in a woman of reproductive age presenting with prolonged and irregular vaginal bleeding. Methods to conserve the ovary are also encouraged in cases of ovarian pregnancy.

Primary ovarian pregnancy: case report and review of literature

A young woman in her 20s presented with sudden onset right-sided abdominal pain. On examination she was tender in the right adnexae. Her urine pregnancy test was positive and βHCG value was 1862. Abdominal and pelvic ultrasound revealed evidence of a significant right-sided adnexal mass, a small amount of peritoneal-free fluid and an empty uterus. The decision was made to proceed with laparoscopy in view of mass size and the presence of fluid in the pelvis. Conservative resection of the gestational sac was performed and the patient made an uneventful recovery. Histology was consistent with ovarian ectopic pregnancy.

Ovarian ectopic pregnancy: aetiology, diagnosis, and challenges in surgical management

Primary ovarian ectopic pregnancy (OEP) remains a rare but important type of ectopic pregnancy which is normally diagnosed at surgery. The aetiology is unknown. We have found fertility treatments (18.1%) and intrauterine contraceptive devices (19.3%) remain important associated risk factors. We undertook a world literature review of all cases since 1995. We found that 52% of cases were managed laparoscopically, which is less than the reported UK rate of all ectopics, of 85.9%. Over that time period, eight patients were treated medically with a success rate of 50%. While the original 1878 Spiegelberg's criterion still holds for the diagnosis, the addition of modern ultrasound scanning has made a radiological diagnosis possible. In a few cases, the management of OEP remains similar to that of a tubal ectopic pregnancy with the same challenges. Laparoscopy with ovarian sparing in the stable woman is today the surgical treatment of choice.

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.

Pregnancy outcomes after surgical treatment of ovarian pregnancy

OBJECTIVE

To investigate pregnancy outcomes subsequent to ovarian pregnancy treated by surgery.

METHODS

A retrospective analysis was conducted of ovarian pregnancies that were treated by surgery at a hospital in Korea between January 1996 and December 2009.

RESULTS

Forty-nine women with ovarian pregnancies (1.6% of all ectopic pregnancies) were treated; 28 of these patients who were followed-up for more than a year were included in the study. The most common risk factor for ovarian pregnancy was endometriosis (42.9%). Accurate diagnosis of ovarian pregnancy was made preoperatively in 7 patients (25%). Of the 28 patients, 16 (57.1%) had subsequent pregnancies: 13 (46.4%) were intrauterine pregnancies and 3 (10.7%) were tubal pregnancies. However, no subsequent ovarian pregnancies occurred. In addition, only 1 patient had secondary infertility after surgery for ovarian pregnancy.

CONCLUSIONS

After an ovarian pregnancy treated by surgery, the outcome of a subsequent pregnancy is reasonable; there is a high rate of successful subsequent pregnancy and a low rate of subsequent ectopic pregnancy or of infertility.

Operative laparoscopy as the mainstay method in management of hemodynamically unstable patients with ectopic pregnancy

STUDY OBJECTIVE

To determine the safety and sustainability of operative laparoscopy in hemodynamically unstable women with ectopic pregnancy according to the effect of operator experience on success rates, whether the volume of hemoperitoneum affects the operative method used, and requirements for admission to the intensive care unit (ICU) and administration of blood transfusion.

DESIGN

Prospective cohort study (Canadian Task Force classification II-A).

SETTING

University hospital.

PATIENTS

Between January 2003 and February 2010, 505 women with ectopic pregnancy (55 tubal, 4 ovarian, 7 cornual, and 1 in the cesarean scar) were seen, including 124 women with hemoperitoneum greater than 500 mL, of whom 67 were hemodynamically unstable.

INTERVENTIONS

Operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

The greater the volume of hemoperitoneum, the greater the likelihood of hemodynamic instability. The odds of hemodynamic instability were greater in nontubal ectopic pregnancies. The overall operative laparoscopy rate in hemodynamically unstable patients was 85%, compared with 95% in hemodynamically stable women. The volume of hemoperitoneum did not affect the operative method used. Experienced operators had a 100% success rate at operative laparoscopy in hemodynamically unstable women, compared with a 72% success rate with confident operators. A small number of women required admission to the ICU. Although the laparoscopy group required more blood transfusions, they had a shorter length of hospital stay compared with the laparotomy group.

CONCLUSION

Operative laparoscopy is safe and sustainable in most women with hemodynamic instability. Women who undergo operative laparoscopy do no worse than those who undergo laparotomy, and even those who require ICU admission still benefit from the advantages of operative laparoscopy.

Ovarian Ectopic Pregnancy Following Assisted Reproductive Techniques: A Rare Entity

Ovarian ectopic pregnancy should be kept in mind as a rare possibility following assisted reproductive techniques. Although early use of quantitative serum â-hCG and pelvic ultrasonography has increased our diagnostic capability for ectopic pregnancy, ovarian pregnancy still represents a diagnostic problem. Laparoscopy is the gold standard for diagnosis and treatment for ovarian ectopic pregnancy.

Diagnosis and laparoscopic management of 12 consecutive cases of ovarian pregnancy and review of literature

We sought to determine the outcome of the laparoscopic management of ovarian ectopic pregnancy (OEP) in a United Kingdom district general hospital and reviewed the literature. We conducted a 5-year prospective cohort study of the management of OEP cases between January 2003 and January 2008. Twelve patients had OEP confirmed with histology among a cohort of 421 ectopic pregnancies. The mean gestational age was 45 days. All 12 patients had abdominal pain and 4 (33%) had vaginal bleeding. One (8%) patient became hypovolemic before laparoscopy. Four (33%) women had risk factors for ectopic pregnancy, 2 of whom were current intra-uterine contraceptive users. Preoperative diagnosis of ectopic pregnancy was made in 11 (92%) of 12 patients by transvaginal ultrasonography and OEP in 9 (75%) patients. All cases were managed by laparoscopic surgery with no conversion to laparotomy. The ovarian pregnancy was resected and the ovary conserved in 11 (92%) patients with only 1 requiring an oophorectomy. The mean operating time was 49 minutes. None of the patients needed further treatment. No complications occurred after laparoscopic surgery and the mean hospital stay was 2 days. Considering the rarity of ovarian pregnancy, this is one of the largest series of patients with OEP treated exclusively by laparoscopic surgery and highlights our recent experience of performing conservative laparoscopic surgery for most of our patients.

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

OBJECTIVES

To report the prevalence, presentation, diagnostic modalities, and treatment of ovarian pregnancy in one institution.

STUDY DESIGN

Retrospective case control study of 19 cases of ovarian pregnancy treated between 1990 and 2001 at Assaf Harofeh Medical Center, Zerifin, Israel.

MAIN OUTCOME MEASURES

Prevalence, presentation, diagnostic modalities, surgical treatment, and relation to intrauterine device (IUD) use.

RESULTS

Nineteen ovarian pregnancies, diagnosed between 1990 and 2001, comprised (19/694) 2.7% of all ectopic pregnancies, 1:3000 of all live births leading to a mean ovarian pregnancy per year of 1.6. Presenting symptoms were similar to those of tubal pregnancies including circulatory collapse which was present in 4/19 (21%) of patients. Culdocentesis for diagnostic purposes, has become an unnecessary procedure. Wedge resection by laparotomy was the treatment of choice in the past, and from 1994, it was performed exclusively by laparoscopy. When an ovarian pregnancy was diagnosed, intrauterine device was present in 68% of the patients and in 76% of the fertile women.

CONCLUSIONS

The absolute number of ovarian pregnancies between 1900 and 2001 increased but the prevalence rate per delivery was stable. Despite modern diagnostic modalities patients still present in circulatory collapse-conservative approach may underestimate the potential risk of bleeding. Culdocentesis has no clinical diagnostic benefits. Laparoscopy is invaluable, as diagnosis and treatment can be carried out as a single treatment. Laparoscopic wedge resection is the treatment of choice. The relation between IUD use and ovarian pregnancies is still strong.

A Comparison of the Incidence, Presentation, and Management of Ovarian Pregnancies between Two Periods of Time

STUDY OBJECTIVE

To compare the prevalence, presentation diagnostic modalities, and management of 37 ovarian pregnancies in one institution during two time periods.

DESIGN

A retrospective study (Canadian Task Force classification II-2).

SETTING

Department of Gynecology in a university-affiliated hospital.

PATIENTS

Twenty patients with ovarian pregnancy between 1971-1989 compared with 17 patients with ovarian pregnancy between 1990-2000.

MEASUREMENTS AND MAIN RESULTS

Seventeen ovarian pregnancies, diagnosed between 1990-2000, comprised 2.6% (17/634) of all ectopic pregnancies, 1:3500 of all live births leading to a mean ovarian pregnancy rate per year of 1.5, as opposed to 3.1% (20/647) of all ectopic pregnancies, 1:3600 of all live births, and a mean ovarian pregnancy rate per year of 1.1 in the previous period. Circulatory collapse was present in 4/17 (23%) patients in the 1990-2000 time period and in 6/20 (30%) in the previous period. Culdocentesis for diagnostic purposes was practically abandoned in the recent decade. Wedge resection by laparotomy was the treatment of choice in the past, and after 1997, it was performed exclusively by laparoscopy. When an ovarian pregnancy was diagnosed, an intrauterine device (IUD) was present in 65% of all patients and in 73% of women who had previously conceived in the 1999-2000 time period, compared with higher rates in the previous period (90% and 100%, respectively).

CONCLUSION

The absolute number of ovarian pregnancies in the last 11 years increased when compared with the previous 19 years; however, the prevalence rate per delivery was stable. Patients still experienced circulatory collapse despite modern diagnostic modalities. Culdocentesis for diagnostic purposes has become an unnecessary procedure. Laparoscopic wedge resection was the treatment of choice. The relationship between IUD use and ovarian pregnancies was still strong.

Ultrasound of the acute female pelvis

Ultrasound is the most valuable imaging modality in evaluating the premenopausal female presenting with acute pelvic pain. The appropriate interpretation of the ultrasound study requires correlation with the patient's clinical history and laboratory values. This is especially true of the serum beta-hCG, where ultrasound relies on this test to make the diagnosis of ectopic pregnancy. When the serum test for pregnancy is negative and the patient has an adnexal mass this could be secondary to a complicated ovarian cyst (hemorrhage, rupture), ovarian torsion or pelvic inflammatory disease. The ultrasound image can usually make the diagnosis in conjunction with the clinical papameters, however, this is most difficult in patients with ovarian torsion.

Laparoscopic therapy of an intact primary ovarian pregnancy with ovarian hyperstimulation syndrome: case report

A case of an intact primary ovarian pregnancy with ultrasonographic demonstration of heart motion following ovarian stimulation is presented. After preoperative ultrasonographic confirmation of an extrauterine pregnancy, proof of the ovarian localization was achieved by intra-operative ultrasonographic visualization during a diagnostic laparoscopy on post-menstrual day 48. A moderate ovarian hyperstimulation syndrome with a concomitant increase in size, vulnerability and vascularity of the ovaries presented an additional challenge for the surgical approach. However, thanks to the early diagnosis of the ectopic pregnancy localization, a laparoscopic organ-preserving removal of the intact ovarian pregnancy was successfully performed. In this way, the fertility of the patient, who had previously undergone contralateral ovariectomy, was preserved. To our knowledge, this represents the first such treatment to be reported in the medical literature. Improvements in diagnosis and therapy of ovarian pregnancy are reviewed.