Primary ovarian pregnancy mimicking malignancy
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/MJDRDYPU.MJDRDYPU_308_16
The incidence of primary ovarian pregnancy is very rare. The clinical diagnosis of ovarian pregnancy remains challenging. There is no definite clinical, ultrasonographic, or laboratory signs to distinguish it from that of a tubal pregnancy. Awareness of the condition and high degree of clinical suspicion and characteristic histopathology is necessary help in arriving at the correct diagnosis. We report one such case in a young female who presented with a complaint of pain abdomen. She had a high serum β-human chorionic gonadotropin levels. She underwent unilateral salpingo-oophorectomy following clinical suspicion of malignancy. Histopathological examination proved it to be a case of ovarian pregnancy. She recovered well in the postoperative period. This is another additional case of ovarian pregnancy to the existing literature highlighting the histopathological findings. Keywords: Malignancy, ovary, pregnancy, primary ovarian pregnancy
Ovarian pregnancy is a rare form of ectopic gestation with a distinct pathology. Its presenting symptoms are similar to other forms of extrauterine or ectopic pregnancy and ovarian tumors. Ovarian pregnancies can be classified as primary and secondary. Primary ovarian pregnancy results when the ovum is fertilized while still remaining within the follicle. Secondary ovarian pregnancy occurs when fertilization takes place in the fallopian tube and the resultant conceptus is later regurgitated to be implanted in the ovarian stroma. Primary ovarian pregnancy is a rare entity. First such case was reported by St. Maurice in the year 1689.[1],[2],[3] The incidence of ovarian pregnancies is 1 in 25,000–40,000 pregnancies.[4],[5] In Indian literature, the incidence of ovarian pregnancy varies from 0.001% to 0.013% of normal pregnancies and from 0.17% to 1% of ectopic pregnancies.[2] There has been an increase in the incidence of reported ovarian pregnancies in recent times owing to better diagnostic modalities such as transvaginal ultrasonography and serum β-human chorionic gonadotropin (β-HCG) estimation. The increased incidence also can be attributed to wider use of intrauterine contraceptive device (IUCD), ovulatory drugs, assisted reproductive techniques such as in vitro fertilization (IVF) and embryo transfer.[3],[4] Ovarian pregnancy can cause diagnostic difficulty clinically as well as intraoperatively. Histopathology helps in arriving at the correct diagnosis.[6] Hereby, we report a case of ovarian pregnancy in a young female, who underwent salpingo-oophorectomy with the clinical suspicion of malignancy. Histopathologically, the case was diagnosed as ovarian pregnancy.
A 22-year-old female presented with the history of pain abdomen of 2 months duration. She gave a previous history of two medical terminations of pregnancy, once 6 months back and another before 2 months. The magnetic resonance imaging showed an evidence of a well-defined altered signal intensity lesion measuring 12 cm × 9.6 cm in the right side of uterus. The lesion was heterogeneously hyperintense on T2w, hypointense with hyperintense foci on T1w. Mass effect was noted on uterus displacing it laterally and also on bladder. Her serum β-HCG level was 200,000 IU/L. Peroperative findings included right ovarian mass of 12 cm × 15 cm with hemorrhagic material. Left ovary grossly looked normal. Right salpingo-oophorectomy was done. Histopathological examination of the right ovarian mass revealed normal looking ovarian tissue with the presence of chorionic villi and proliferation of cytotrophoblasts and syncytiotrophoblasts. The chorionic villi were also seen in continuation with ovarian stroma [Figure 1] and [Figure 2]. There was presence of large areas of hemorrhage. It was histopathologically diagnosed as ovarian pregnancy.
The patient was well in the postoperative period. After 2 years of follow-up, she is doing well.
Primary ovarian ectopic pregnancy is a rare type of ectopic pregnancy which is normally diagnosed at the time of surgery.[7] Ovarian pregnancy can be intrafollicular or extrafollicular. Intrafollicular is invariably primary ovarian pregnancy. Extrafollicular may be either primary or secondary where the ovarian tissue is usually absent in the gestational sac.[1],[4] The exact incidence of ovarian pregnancy is not known because of the large number of asymptomatic patients in whom the conceptus dies and involutes spontaneously. Younger age, high parity, and endometriosis are likely risk factors. The IUCD usage causes relative increase in the incidence of ovarian pregnancy. There have been reports of ovarian pregnancy following IVF, embryo transfer, use of ovulatory drugs, pelvic inflammatory disease, and endometriosis.[4] Criteria for ovarian pregnancy were suggested by Spiegelberg include intact fallopian tube, clearly separated from the ovary, location of fetal sac within the ovary connected to the uterus by the uteroovarian ligament, and the presence of definite ovarian tissue in the sac wall.[4],[8] Ovarian pregnancy can be a cause of diagnostic difficulty both clinically and intraoperatively. It may be subclinical or may present with acute abdomen. Diagnosis of ovarian pregnancy requires high index of clinical suspicion as it lacks specific clinical, laboratory, or ultrasonographic signs to differentiate it from ectopic tubal pregnancy. A combination of rise in serum β-HCG, ultrasonography and laparoscopy findings are desirable for diagnosis.[6] Ovarian pregnancies should be entertained as one of the important differential diagnoses in females of reproductive age group presenting with acute abdomen which helps in early diagnosis, better treatment, and good prognosis.[3] Macroscopically ovarian pregnancy can mimic an ovarian hematoma, clear ovum, and embryonized ovum <3 months size. Histology helps in confirming the diagnosis of ovarian pregnancy with the presence of chorionic villi within and in continuity with ovarian stroma or a corpus luteum.[6] Although the ovary usually can accommodate an expanding pregnancy more readily than the fallopian tube, rupture at an early stage is the usual consequence.[9] Majority (91.0%) of ovarian pregnancies get terminated in the first trimester, 5.3% in second trimester, and 3.7% in third trimester.[1],[3] Recurrence in ovarian pregnancies is rare unlike tubal pregnancy.[10] In our case, the patient is a 22-year-old primipara who presented with pain abdomen and history of termination of pregnancy. Treatment of ovarian pregnancy consists of a single-dose methotrexate protocol or conservative surgery. Partial overiectomy by either laparotomy or laparoscopy is preferred.[7] In women in stable condition, the surgical treatment of choice nowadays is laparoscopy with ovarian sparing.[7]
Ovarian pregnancy remains a rare condition. Awareness of this condition is helpful in reducing the morbidity and mortality associated with this condition. In a female of reproductive age group presenting with acute abdomen, ovarian ectopic pregnancy should be considered as one of the important differential diagnoses. The treatment is mainly surgical. With advancement in ultrasonographic modality, nowadays, there is increased chance of preoperative diagnosis and conservative surgery. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2]
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