Primary Ovarian Pregnancy: A Case Report With a Review of the Literature

Ectopic pregnancy (EP) constitutes 1%-2% of all pregnancies and is one of the leading causes of maternal morbidity and mortality. The most common site of ectopic pregnancy is the ampulla. Ectopic ovarian pregnancy (EOP) is one of the rare events, with an incidence of 0.5%-3% of all pregnancies. The incidence is higher in intrauterine device users or assisted reproductive techniques. The precise aetiology and pathogenesis of EOP remain elusive. Clinically, EOP mirrors the presentation of tubal pregnancy or a ruptured luteal cyst, often leading to life-threatening hypovolemic shock. Transvaginal sonography is the primary diagnostic tool. Still pinpointing the exact location early on poses challenges, and it's usually misinterpreted as a tubo-ovarian mass, hemorrhagic cyst, or luteal cyst. Furthermore, while a suboptimal rise in serum beta-human chorionic gonadotropin (β-hCG) levels may indicate pregnancy, it doesn't definitively confirm EOP. Only histopathological examination offers a conclusive diagnosis. This paper discusses an EOP case in a young woman who experienced five months of amenorrhea and exhibited no traditional risk factors, underscoring the significant challenges inherent in preoperative diagnosis.

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.

Nontubal ectopic pregnancies: overview of diagnosis and treatment

Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.

Challenges of Management of Ruptured Second Trimester Ovarian Pregnancy in Low-and Middle-Income Settings: A Case Report

Background

Ovarian ectopic pregnancy is a rare form of non-tubal ectopic pregnancy. It can rupture before the end of the first trimester, causing hemoperitoneum, and present with signs and symptoms similar to other commoner abdominal emergencies or the pregnancy can continue intraperitoneally. Therefore, they are not often diagnosed preoperatively. Ultrasound can assist in diagnosis of ovarian ectopic pregnancy but the findings could be ambiguous or inconclusive. We present a case of ruptured ovarian ectopic pregnancy at the second trimester causing massive hemoperitoneum that was suspected as an intrabdominal malignancy co-existing with intrabdominal pregnancy.

Case presentation

She was a 34 year-old Nigerian unbooked G4P3+0, (3 alive), who presented to the labor ward on 21st January, 2021 with a complaint of a 6-week history of abdominal pain and swelling. Pain was insidious in onset, generalized, non-colicky, non-radiating, constant, no known aggravating or relieving factor, but it was of moderate intensity. She had amenorrhea with a positive serum pregnancy test without prior early ultrasound. At presentation, initial abdominopelvic ultrasound revealed intra-uterine viable pregnancy but repeat ultrasound done showed a left adnexal ectopic gestation and an echo-rich intraperitoneal fluid collection. Laparotomy was done and ovarian pregnancy was accurately diagnosed intra-operatively. Tissue samples from the ovary confirmed normal products of conception, namely chorionic villi, trophoblastic cells and ovarian stroma at histology.

Conclusion

Despite advances in imaging techniques, the diagnosis of ovarian ectopic gestation is still very difficult. When premenopausal women present with amenorrhea, generalized non-colicky abdominal pain and swelling in combination with ambiguous findings of pregnancy on ultrasound in the absence of trauma, differential diagnoses should include ruptured ovarian pregnancy. Obstetricians should maintain a high index of suspicion to forestall delayed diagnosis and the potential maternal morbidity and mortality. However, the need for high-index of suspicion should be for any ectopic, not just ovarian pregnancy.

Retrospective analysis of a case report of a left ovarian ectopic pregnancy after the former tubal

Up to 2% of pregnancies may be extrauterine. Despite reproductive problems, they might increase the risk of serious complications. We present a case report of a 31-year-old woman with two extrauterine pregnancies - tubal and ovarian, which occurred at the same side with little time difference. In addition, we aimed to examine possible reasons underlying this rare pathology. Thus, surgically removed tissue specimens were morphologically assessed and further compared with specimens from healthy control patients. Telocytes were analysed in detail due to their pivotal role in the female reproductive system. Our study had observational character and obvious limitations typical for a clinical case. Yet, such a clinical case of two ectopic pregnancies has not been previously reported in the literature.

Ovarian Pregnancy

Ovarian pregnancy is a rare uncommon presentation of an ectopic pregnancy. Without any known risk factors, ovarian pregnancy seems to appear at random. A 29-year-old female patient with previous two cesarean deliveries visited the gynecology emergency department with the complaint of constant dull aching pain in the lower abdomen, aggravated by postural changes. Per vaginal examination, cervical motion tenderness was present. The patient was admitted, and her transvaginal sonography was done along with a urine pregnancy kit test for the suspicion of ectopic gestation. After the initial treatment and arrangement of two units of packed red blood cells after proper grouping and cross-matching for the patient, laparotomy was done. At the time of surgery, left-sided ruptured ovarian pregnancy was confirmed by the Spiegelberg criteria.

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.

A Case of Heterotopic Ovarian Pregnancy after in vitro Fertilization: Early Diagnosis and Single-port Access Conservative Laparoscopic Treatment

Here, we reported the case of a 32-year-old pregnant woman who presented with sudden abdominal pain at 5 weeks of gestation and diagnosed as ruptured heterotopic ovarian pregnancy. She was conceived after in vitro fertilization. Right ovarian pregnancy was noticed, and we performed right ovarian wedge resection via single-port access laparoscopic surgery. Intrauterine pregnancy had remained intact, and she delivered a term baby. Rapid diagnosis in early gestation and minimally invasive laparoscopy resulted in a satisfactory pregnancy outcome without other complications. Single-port laparoscopic surgery can be feasible and appears to be a good first treatment option in a ruptured heterotopic ovarian pregnancy.

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

A twenty-eight-year-old female patient during the second pregnancy, about 6 hbd (according to the date of the last menstrual period) from the spontaneous cycle, was directed to the local hospital because of suspected ectopic pregnancy with the location of the fallopian tube on the left side. She had no symptoms and vital parameters were in normal range. It was revealed that three years ago ectopic pregnancy of the right uterine tubule ended with right fallopian tube removal.

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.

Medical management of an ovarian ectopic pregnancy: a case report

BACKGROUND

Primary ovarian ectopic pregnancy is a rare type of ectopic pregnancy which has an estimated prevalence ranging from 1:7000 to 1:70,000 accounting for almost 3 % of all ectopic cases. Here we report the case of a 25-year-old woman who presented to our clinic with abdominal pain, 6 weeks' delay of menstruation and 3 days of vaginal bleeding, whose transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary. This case shows that early diagnosis is very important particularly in places like the Sub-Saharan region of Africa.

CASE PRESENTATION

A 25-year-old African woman was referred to our clinic with 6 weeks' delay of menstruation, frequent increasing abdominal pain and 3 days of vaginal bleeding. Her general condition was good and her vital signs were normal. She felt tenderness in an abdominal examination and had a small amount of vaginal bleeding. Transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary. Our final diagnosis was ectopic ovarian pregnancy and we successfully treated her with methotrexate. After 3 weeks of methotrexate administration her beta human chorionic gonadotropin was negative and a sonographic examination was completely normal.

CONCLUSIONS

Ectopic ovarian pregnancy is a very important medical situation. It should be diagnosed in its early stages otherwise it could be life-threatening and surgical treatment may be inevitable. Because of the importance of fertility, medical treatment is an acceptable option and can be feasible with early diagnosis.

A case report and up-to-date literature review

Ovarian pregnancy (OP) after embryo transfer is very rare. Due to the rarity and the asymptomatic nature, there are still difficulties in diagnosis and treatment. The traditional operative treatment for OP has been oophorectomy. However, the desire to maintain reproductive capability and improvements in laparoscopy have more recently led to conservative laparoscopic techniques. This rare complication could be diagnosed early and managed by a conservative laparoscopic approach. Here we present a survey of the literature and a case of successful laparoscopic management of ovarian pregnancy after intracytoplasmic sperm injection and embryo transfer. The current case is the first case in the literature in which ovarian pregnancy occurred after a single embryo transfer. We also summarize the literature about management of ovarian pregnancy after embryo transfer.

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.

Ovarian pregnancy associated with a fresh blastocyst transfer following in vitro fertilization

Ovarian pregnancy is a rare subtype of ectopic pregnancy, and its mechanisms have not been clarified. We report a case of ovarian pregnancy that supports a blastocyst migration mechanism. An infertile woman became pregnant after a single blastocyst transfer following in vitro fertilization during a fresh non-donor cycle. Transvaginal ultrasound revealed a gestational sac-like structure containing an active fetus that was located adjacent to the corpus luteum of the right ovary. Laparoscopy identified a red, swollen implantation site in the ovary, which was completely removed by wedge resection without damaging the remaining parenchyma. This case demonstrated that a fresh blastocyst transferred into the endometrial cavity migrated through the fallopian tube, implanted on an ovarian surface, and formed an ovarian pregnancy.

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.

Unusual ectopic pregnancies: a retrospective analysis of 65 cases

AIM

The aim of this study was to retrospectively investigate unusual ectopic pregnancies (EP) and compare them with fallopian ones.

MATERIAL AND METHODS

A total of 1000 cases of ectopic pregnancies were analyzed, including 65 unusual cases. We discussed distribution, incidence, risk factors, examinations, treatments and prognoses.

RESULTS

Ovarian pregnancy was associated with placement of intrauterine device and pelvic inflammatory diseases. Extratubal EP have a high rate of misdiagnosis and presented more serious manifestations. Some unusual EP could be diagnosed by ultrasonography. Ovarian pregnancy was usually manifested as positive culdocentesis. Most of the unusual EP underwent surgery, except some early cervical and corneal pregnancies.

CONCLUSION

Although extratubal pregnancies are difficult to diagnose, some histories and auxiliary examinations could make diagnosis easier for clinical physicians. Surgery is still the most effective approach for treatment of unusual EP, while conservative treatment of mifepristone combined with methotrexate or curettage could be used for early diagnosis and treatment of cervical 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.

A 34-week ovarian pregnancy: case report and review of the literature

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.

Ovarian pregnancy associated with pelvic adhesions

Ovarian pregnancy is a rare entity. Making a definitive preoperative or even intraoperative diagnosis of ovarian pregnancy is difficult and the diagnosis is usually established by the pathologist. Rupture in the first trimester is the usual rule in ovarian ectopy. Thus, it continues to challenge practicing clinicians. The literature shows an association between intrauterine device usage and ovarian gestation. We present a case of ovarian pregnancy in a secundipara complaining of abdominal pain that also has pelvic adhesions. This case meets the four criteria of Spiegelberg and is interesting because of its rarity and association with adhesions, which makes diagnosis more difficult.

Case report of a primary ovarian pregnancy in a primigravida

Primary ovarian pregnancy occurs quite rarely and that too usually in young highly fertile multiparous women using intra uterine device. We present a case where a young primigravida presented with abdominal pain and was diagnosed as ectopic pregnancy and was confirmed intra-operatively and histopathologically as primary ovarian pregnancy, managed with partial ovariectomy.

Laparoscopic management of ovarian pregnancy

BACKGROUND

Ovarian pregnancy (OP) comprises 0.15% of all pregnancies and 1% to 3% of ectopic gestations.

CASE REPORT

Two cases of OP detected and treated during laparoscopy for suspected ectopic pregnancy are described. We used clinical examination, serum beta-hCG levels, and transvaginal ultrasonography (TVS) preoperatively to confirm the suspected diagnosis of extrauterine pregnancy. In the first patient, oophorectomy was performed, whereas the second patient was treated by an ovarian wedge resection to restore and preserve ovarian integrity. Postoperative recovery periods were normal in both patients, with no further therapeutic intervention in the follow-up course.

CONCLUSION

Primary OP may occasionally occur in patients with a suspected ectopic pregnancy. Signs and symptoms suggestive of extrauterine pregnancy, TVS, and serum beta-hCG dynamics can be a useful adjunct to allow the preoperative diagnosis of OP prior to the use of the diagnostic gold standard, diagnostic laparoscopy. Preservation of ovarian tissue should be the therapeutic goal to maintain ovarian reserve and preserve fertility in young women with OP.

Unruptured ovarian pregnancy following in-vitro fertilization: Missed diagnosis followed by successful laparoscopic management

Ovarian pregnancy after in-vitro fertilization is rare and can be easily missed unless there is a high index of suspicion. Here we present such a case which was missed initially but was later successfully managed laparoscopically.