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Received 2016 August 23; Revised 2016 December 10; Accepted 2017 January 04.
Abstract
Introduction: Ectopic pregnancy is a serious health problem that leads to maternal mortality and morbidity. The current article
was based on the record of a female patient with primary ovarian ectopic pregnancy.
Case Presentation: The patient was a 28-year-old female with regular previous menstrual cycle and without using any contracep-
tion method. She presented with right lower abdominal pain and amenorrhea. Transvaginal sonography findings revealed a gesta-
tional sac in the right ovary. Finally, primary ovarian ectopic pregnancy was diagnosed by laparotomy and confirmed by histopathol-
ogy.
Conclusions: To prevent misdiagnosis, an awareness of this issue should be developed by gynecologists, surgeons, and radiologists.
Copyright 2017, Qazvin University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial
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original work is properly cited.
Samiee-Rad F et al.
found and paraclinical data did not support any inflamma- then, via tubal abortion or perforation, products of con-
tory disease including tubo-ovarian mass. ception are implanted on the ovarian surface (8).
Routine laboratory investigations revealed leukocyto- According to the review of the literature, occurrence of
sis with neutrophilia without any anemia (hemoglobin: 14 primary ovarian ectopic pregnancy is confirmed as a very
g/dL). Pregnancy test showed positive result. HCG level exceptional event; but nowadays, due to application of in-
was 15650 mIU/mL. Transvaginal ultrasonography assess- trauterine contraceptive devices, and ovarian hyper stim-
ment showed the presence of a right adnexal complex ulation in infertile patients, its incidence is slightly rising.
mass with fetal pole and hearth rate (Figure 1), free fluid in However, few reported cases had no underlying causes,
the pouch of Douglas, and increased vascular blood flow similar to the current case, and happened by chance (9, 10).
activity. The main risk factors of the development of primary
Estimated gestational age was 8 weeks. The uterus ovarian ectopic pregnancy are as follows: Obstructed ovu-
showed a normal outline with slightly thickened endome- lation, malfunction of fallopian tube from previous salp-
trial line and no intrauterine sac. ingitis, endometriosis, application of intrauterine contra-
At this stage, results were in favor of ectopic pregnancy. ceptive devices, chronic pelvic inflammatory disease, Tu-
Therefore, right salpingo-oophorectomy was performed. berculosis (especially in the developing countries), and as-
On laparotomy, the right fallopian tube appeared normal, sisted reproductive technology (in vitro fertilization and
but the right ovary was enlarged with hemorrhagic area. in vivo transfer of the embryo to the uterus (IVF-ET) and
The left adnexa looked normal. She passed uneventful intrauterine insemination) (8, 11, 12). There were no evi-
postoperative period. dence of such predisposing conditions and factors in the
On macroscopic examination, the enlarged ovary mea- past medical history of the current case.
sured 4.5 3.5 2.5 cm associated with a small creamy pla- It commonly occurs in young females, similar to the
centa 1.3 cm in diameter. On serial cutting, blood clots and current case. The clinical presentations of primary ovar-
a corpus luteum were identified. There was no evidence of ian ectopic pregnancy vary from asymptomatic forms to
embryo, apparently. Associated fallopian tube, measuring life threatening ones. The current patient referred to clinic
5.2 cm in length and 0.7 cm in diameter, appeared normal. with acute abdomen presentation. When the first form
On histopathologic examination, review of the slides dis- happens, early diagnosis may be missed until later in preg-
played large areas of hemorrhage and scattered chorionic nancy (12). Therefore, there is the risk of rupture, sec-
villi associated with corpus luteum embedded in the ovar- ondary ectopic implantation, and complications during
ian stroma (Figures 2 and 3). Therefore, diagnosis of pri- surgery (6, 7). Therefore, its early detection permits the
mary ovarian ectopic pregnancy was confirmed. wedge ovarian resection in the selected cases with pre-
The patient was followed-up according to standard for- served uninvolved ovary. The other treatment option is
mat. Her hemoglobin level on discharge time was 10.7 methotrexate (conservative treatment), but may not be ap-
g/dL and she underwent medical treatment for compensa- propriated (13, 14). In the current case, based on the sur-
tion. She had a successful and full-term pregnancy after 23 geons decision, extension of lesion, and tissue destruc-
months. tion, right salpingo-oophorectomy was selected as the
choice therapy. However, ovarian ectopic pregnancy has
good prognosis; therefore, early diagnosis and immediate
3. Discussion therapy can permit for conservative surgery and retain the
future fertility of the patient (8).
The incidence of primary ovarian ectopic pregnancy The most clinico-radiologic differential diagnosis of
varies from 1 in 7000 to 1 in 40 000 deliveries (6). the primary ovarian ectopic pregnancy includes cor-
The primary ovarian ectopic pregnancy was firstly de- pus luteal cyst, hemorrhagic corpus luteum, tubal ec-
scribed by Saint Maurice in France in 1682 (7). topic pregnancy, hemorrhagic ovarian cyst, ruptured en-
Ovarian ectopic pregnancy is a life threatening medi- dometrioma, ovarian tumor, ovarian torsion, and in-
cal concept and its early detection is perhaps the most diffi- trauterine pregnancy. In the current case, menstrual cy-
cult, compared to all the other forms of extra uterine preg- cle was regular and no previous adnexal fullness or pain
nancies and almost always, the primary diagnosis is made was observed. Also, imaging and laboratory results ruled
on the operating bed (8). out any evidence of benign or malignant cystic, or solid
The ovarian pregnancy forms under 2 circumstances: ovarian tumors. However, similar to many other situa-
First, when fertilization occurs in the peritoneal cavity and, tions in medicine, definite diagnosis was confirmed by a
then, fertilized ovum is implanted into the ovary; and sec- histopathologic review (1, 13, 14).
ond, when fertilization occurs in the fallopian tube and, One important cause of missed early diagnosis is mis-
Figure 1. On transvaginal sonography of the right adnexa, a gestational sac (blue arrow) was visualized
Figure 2. Photomicrograph Shows Trophoblastic villi and Hypercellular Ovarian Figure 3. Large Areas of Hemorrhage and Scattered Chorionic villi (Yellow Arrow) As-
Stroma (Blue Arrow) with Massive Areas of Hemorrhage (Hematoxylin and Eosin sociated with Corpus Luteum (Blue Arrow) Embedded in the Ovarian Stroma (Hema-
Stain; 40) toxylin and Eosin Stain; 200)
interpretation of ultrasonographic findings. The pres- mimic ultrasonographic features of an intrauterine ges-
ence of ovarian gestational sac and its surrounding tissue tation. To prevent this error, systematic ultrasonography
Footnote