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Case Report

Laparoscopic Management of Ovarian Ectopic Pregnancy

Jose Carugno, MD; Devendra Patel, MD; Ray Mercado, DO

Primary ovarian pregnancy is an uncommon form of ectopic pregnancy. Its incidence ranges from 1/59,740 to 1/1,100 pregnancies, representing less than 3% of all ectopic pregnancies.1-6 Recently—perhaps in response to improved diagnostic capabilities—there appears to be an increase in its incidence. Transvaginal ultrasonography (TVU) and testing for serum human chorionic gonadotropin-β (β-hCG) are extremely useful tools in the prompt diagnosis of ovarian pregnancy. Once the condition is suspected, surgical management is generally indicated. A challenging case of primary ovarian ectopic pregnancy successfully managed by laparoscopic wedge resection prompted the authors to review various aspects of this unique problem.

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CASE REPORT

A 23-year-old woman, gravida 3, para 3-0-0-3, presented at 5 weeks of amenorrhea with complaints of severe suprapubic pain, nausea, and vomiting. The patient¡s β-hCG level was 4,902 mIU/mL. Suprapubic tenderness and positive rebound were noted on physical examination. Vaginal examination revealed a closed cervix, with positive cervical-motion sensitivity and severe right adnexal tenderness. There was no vaginal bleeding. Transvaginal ultrasonography showed a right adnexal mass with no intrauterine gestation (Figure 1).

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FIGURE 1. The image on the left shows pelvic ultrasonography of a normal, empty uterus. The image on the right shows right ovary with ectopic pregnancy. The donut sign and periovarian fluid collection and absence of intrauterine pregnancy raises the possibility of ectopic pregnancy. Courtesy of Jose Carugno, MD; Devendra Patel, MD; Ray Mercado, MD.

Laparoscopy was performed, revealing a normal uterus, fallopian tubes, and left ovary. The gestational sac was clearly identified, implanted on the right ovary (Figure 2). Wedge excision of the gestational sac was accomplished using unipolar and bipolar cautery, without complications (Figure 3). The patient had an uneventful postoperative recovery. The pathology report confirmed the diagnosis of an ovarian ectopic pregnancy (Figure 4).

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FIGURE 2. Right ovarian pregnancy. Courtesy of Jose Carugno, MD; Devendra Patel, MD; Ray Mercado, MD.

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FIGURE 3. Right ovary after removal of the ectopic pregnancy. Courtesy of Jose Carugno, MD; Devendra Patel, MD; Ray Mercado, MD.

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FIGURE 4. Histopathology of the ovarian ectopic pregnancy. POC = products of conception. Courtesy of Jose Carugno, MD; Devendra Patel, MD; Ray Mercado, MD.

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DISCUSSION

Ectopic pregnancy is defined as any pregnancy in which implantation occurs at a location other than the endometrial lining. Its US incidence has increased recently to a high of 19.7/1,000 pregnancies, according to the US Centers for Disease Control and Prevention.7 One of the leading causes of maternal morbidity and mortality in this country, it still accounted for 9% of all maternal deaths from 1990 to 1992.7 Indeed, despite significant advances in diagnosis and treatment, ectopic pregnancy remains the leading cause of maternal death in the first trimester. Most ectopic pregnancies occur in the fallopian tube (95%); Bouyer et al8 reported a series of 1,800 surgically treated cases in which the distribution of sites was ampullary (70%), isthmic (12%), fimbrial (11.1%), interstitial (2.4%), and abdominal (1.3%).

Ovarian pregnancy represents a diagnostic challenge. Usually, the diagnosis results from a surprising finding at surgery. However, with the advances in TVU, widespread availability of laparoscopy, and more sensitive β-hCG testing, more ovarian pregnancies are diagnosed preoperatively.

The most valuable information in the evaluation of a patient with suspected ectopic pregnancy is obtained via pelvic ultrasonography. Assessment should begin with transabdominal scanning to evaluate the portion of the pelvis that cannot be visualized transvaginally. Zinn et al9 have described ectopic pregnancies visualized on transabdominal ultrasonography that were missed on vaginal scanning.

There is scant information on the ultrasonographic appearance of ovarian ectopic pregnancies. Marcus and Brinsden5 published ultrasonographic findings for cystic masses located on or within the ovaries of seven patients with primary ovarian pregnancy who also had lower-than-expected β-hCG levels. In addition, Comstock et al10 reported a case series evaluating the ultrasonographic appearance of proven ovarian ectopic pregnancies wherein a wide, echogenic ring with an internal echolucent area was seen in five out of six patients; a yolk sac or fetal heart motion was also identified on occasion. The visualization of a yolk sac/embryo within the cyst is pathognomonic of ectopic pregnancy, but is a rare finding. Benacerraf et al11 suggest increasing the transducer frequency from 7 MHz to 10 MHz to improve diagnostic accuracy when an echolucent intrauterine collection of fluid is seen in early pregnancy.

Because the incidence of heterotopic pregnancy (combined intrauterine and ectopic pregnancy) is extremely rare,12 any patient with a β-hCG level > 1,000 IU/L without an intrauterine gestational sac visualized on TVU is presumed to have an ectopic pregnancy until proved otherwise. According to Cacciatore et al,13 the sensitivity for diagnosing ectopic pregnancy with a β-hCG level > 1,000 IU/L and ultrasonographic evidence of an adnexal mass can approach 96%, with a specificity of 100%. However, in the presence of ovarian ectopic pregnancy, such findings are difficult to obtain.14

Spiegelberg15 has described four criteria that must be fulfilled for the diagnosis of ovarian pregnancy:

• The fallopian tube on the affected side must be intact.
• The gestational sac must occupy the position of the ovary.
• The affected ovary must be connected to the uterus by the ovarian ligament.
• Ovarian tissue must be demonstrated within the wall of the sac.

Postresection pathologic documentation of ovarian tissue within the gestational sac may be difficult or impossible due to coagulation artifacts and the small tissue volume. Therefore, the detection of chorionic villi without concurrent intact ovarian parenchyma is acceptable for the fourth criterion.2,13,16 The case presented here—which featured a clearly implanted gestational sac over the ovarian surface, a normal-appearing ipsilateral fallopian tube, and ovarian tissue on the pathologic specimen—met all of Spiegelberg¡s criteria for ovarian ectopic pregnancy.

Four different histologic forms of ovarian ectopic pregnancy have been described: intrafollicular, juxtafollicular, juxtacortical, and interstitial.17 Thus, the laparoscopic surgeon must look for a variety of presentations. The macroscopic appearance can simulate an ovarian hematoma, clear ovum, or embryonized ovum at < 12 weeks¡ gestation, or a placenta with fetus at > 12 weeks¡ gestation.17 The corpus luteum is usually located on the same side, but ovarian pregnancy with contralateral corpus luteum has been described.18

Several conditions can simulate ovarian pregnancy, including ruptured hemorrhagic corpus luteum and endometriotic Àchocolate” cyst. It is extremely difficult to diagnose ovarian ectopic pregnancy based on macroscopic evaluation, but indirect signs such as the presence of hemoperitoneum associated with β-hCG > 1,000 IU/L, normal-appearing fallopian tubes, and the absence of intrauterine pregnancy are highly suggestive.

In contrast to tubal pregnancy, patients with ovarian pregnancy do not generally have a history of impaired fertility.14 The classic risk factors for tubal pregnancy—eg, pelvic inflammatory disease, history of pelvic surgery, or ectopic pregnancy—are likewise absent. Endometriosis does appear to be a risk factor for ovarian implantation,17 but most investigators agree that it is a random event.19

Once the need for surgery is established, the authors believe (based on the case presented here) that laparoscopic wedge resection is the option of choice. This is in accord with Seinera et al,14 who advocated preserving as many follicular units as possible; given the young age of most of these patients and their future fertility, there is no justification for a more aggressive procedure. Furthermore, surgical manipulation of ovarian tissue can enhance adhesion formation.20,21

Several investigators advocate the use of methotrexate in selected patients with ovarian pregnancy.22,23 However, the difficulty of diagnosis without laparoscopy is an important limiting factor. The authors agree with Einenkel et al24 and Seinera et al,14 concluding that as laparoscopy is required for diagnosis, it is logical to effect definitive surgical management at that time.

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CONCLUSION

Ovarian ectopic pregnancy is uncommon, and can present challenging diagnostic and management issues. However, sensitive β-hCG assays and TVU now permit early recognition and successful treatment.

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Jose Carugno, MD, is junior resident, Department of Obstetrics and Gynecology, Lincoln Medical Center, Bronx, NY. Devendra Patel, MD, is director of education, Department of Obstetrics and Gynecology, Lincoln Medical Center, Bronx, NY; and assistant clinical professor, Department of Obstetrics and Gynecology, Weill-Cornell Medical College, New York, NY. Ray Mercado, DO, is chairman, Department of Obstetrics and Gynecology, Lincoln Medical Center, Bronx, NY; and assistant professor, Department of Obstetrics and Gynecology, Weill-Cornell Medical College, New York, NY.

References

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