Ovarian pregnancy

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Ovarian pregnancy
Specialty Obstetrics

Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary. Typically the egg cell is not released or picked up at ovulation, but fertilized within the ovary where the pregnancy implants. [1] [2] [3] Such a pregnancy usually does not proceed past the first four weeks of pregnancy. [3] An untreated ovarian pregnancy causes potentially fatal intra-abdominal bleeding and thus may become a medical emergency.

Contents

Cause and pathology

The cause of ovarian pregnancy is unknown, specifically as the usual causative factors – pelvic inflammatory disease and pelvic surgery – implicated in tubal ectopic pregnancy seem to be uninvolved. [4] There appears to be a link to the intrauterine device (IUD), [5] [4] however, it cannot be concluded that this is causative as it could be that IUDs prevent other but not ovarian pregnancies. Some have suggested that patients who undergo IVF therapy are at higher risk for ovarian pregnancy. [6]

An ovarian pregnancy is usually understood to begin when a mature egg cell is not expelled or picked up from its follicle and a sperm enters the follicle and fertilizes the egg, giving rise to an intrafollicular pregnancy. [3] It has also been debated that an egg cell fertilized outside of the ovary could implant on the ovarian surface, perhaps aided by a decidual reaction or endometriosis. [3] Ovarian pregnancies rarely go longer than 4 weeks; nevertheless, there is the possibility that the trophoblast finds further support outside the ovary and thus may affect the tube and other organs. [3] In very rare occasions the pregnancy may find a sufficient foothold outside the ovary to continue as an abdominal pregnancy, and an occasional delivery has been reported. [3] y

Diagnosis

The diagnosis is made in asymptomatic pregnant women by obstetric ultrasonography. On pelvic examination a unilateral adnexal mass may be found. Typical symptoms are abdominal pain and, to a lesser degree, vaginal bleeding during pregnancy. Patients may present with hypovolemia or be in circulatory shock because of internal bleeding. [5]

Ideally, ultrasound will show the location of the gestational sac in the ovary, while the uterine cavity is "empty", and if there is internal bleeding, it can be identified. [7] Because of the proximity of the tube, the sonographic distinction between a tubal and an ovarian pregnancy may be difficult. Serial hCG levels generally show not the normal progressive rise. [8] [7] In a series of 12 patients the mean gestation age was 45 days. [7]

Histologically, the diagnosis has been made by Spiegelberg criteria on the surgical specimen of the removed ovary and tube. However, the tube and ovary are not usually removed as sonography allows for earlier diagnosis and surgeons strive to preserve the ovary. Prior to the introduction of Spiegelberg's criteria in 1878, the existence of ovarian pregnancy was in doubt; his criteria helped to identify the ovarian pregnancy from other ectopics: [2]

An ovarian pregnancy can be mistaken for a tubal pregnancy or a hemorrhagic ovarian cyst or corpus luteum prior to surgery. [8] Sometimes, only the presence of trophoblastic tissue during the histologic examination of material of a bleeding ovarian cyst shows that an ovarian pregnancy was the cause of the bleeding. [3] [8]

Management

Ovarian pregnancies are dangerous and prone to internal bleeding. Thus, when suspected, intervention is called for. Traditionally, an explorative laparotomy was performed, and once the ovarian pregnancy was identified, an oophorectomy or salpingo-oophorectomy was performed, including the removal of the pregnancy. Today, the surgery can often be performed via laparoscopy. [7] The extent of surgery varies according to the amount of tissue destruction that has occurred. Patients with an ovarian pregnancy have a good prognosis for future fertility and therefore conservative surgical management is advocated. [9] Further, in attempts to preserve ovarian tissue, surgery may involve just the removal of the pregnancy with only a part of the ovary. [7] This can be accomplished by an ovarian wedge resection. [5]

Ovarian pregnancies have been successfully treated with methotrexate [10] since it was introduced in the management of ectopic pregnancy in 1988. [11]

An ovarian pregnancy can develop together with a normal intrauterine pregnancy; such a heterotopic pregnancy will call for expert management as not to endanger the intrauterine pregnancy.

Epidemiology

Ovarian pregnancies are rare: the vast majority of ectopic pregnancies occur in the fallopian tube; only about 0.15-3% of ectopics occur in the ovary. [8] The incidence has been reported to be about 1:3,000 [5] to 1:7,000 deliveries. [8]

History

In 1614 Mercier (also shown as Mercerus) described ovarian pregnancy for the first time, as a condition separate from a tubal pregnancy. [12] Once the study of physiology emerged, [13] Boehmer classified extra-uterine pregnancy into three classes: abdominal, ovarian, and tubal. There were many doubters that such a condition existed, particularly Mayer, who wrote an essay not only denying the existence of ovarian pregnancy, but demonstrating that recorded cases to that time were other conditions. [14] Then Cohnstein proposed four criteria that would need to be present for ovarian pregnancy exist. His requirements were: 1) absence of the ovary on the side in which the alleged pregnancy was located; 2) connection of the uterus and sac via an ovarian ligament; 3) cylindrical tissue must line the layers of the sac with direct connection between the tunica albuginea and sac wall; and 4) evidence of the amniotic cavity connection to the ovarian follicle or corpus luteum. These were replaced by Otto Spiegelberg's criteria [15] in 1878, which have been used into the 20th century with additions and modifications. [16]

Up to 1845, about 80 cases of ovarian pregnancy were proposed. [17] With Mayer's 1845 denial that ovarian pregnancy could exist, physicians began taking more care in their descriptions and analysis of cases. [18] Though numerous cases were evaluated, some failed to provide microscopic evidence and others failed to show the necessary histological changes of pregnancy, or failed on one or more of the criteria. [19] In 1899, Catharine van Tussenbroek finally settled the question of the existence of ovarian pregnancy, [12] by providing the first accurate clinical and histological description of a case. [20] [21] Though doubted, [22] [23] her results were confirmed three years later in a case by Thompson. [23]

Related Research Articles

<span class="mw-page-title-main">Ectopic pregnancy</span> Female reproductive system health issue

Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions the fetus is unable to survive.

<span class="mw-page-title-main">Tubal ligation</span> Surgical clipping,removal or blocking of the fallopian tubes

Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.

<span class="mw-page-title-main">Miscarriage</span> Natural death of an embryo or fetus before its independent survival

Miscarriage, also known in medical terms as a spontaneous abortion and pregnancy loss, is the death of an embryo or fetus before it is able to survive independently. Miscarriage before 6 weeks of gestation is defined by ESHRE as biochemical loss. Once ultrasound or histological evidence shows that a pregnancy has existed, the used term is clinical miscarriage, which can be early before 12 weeks and late between 12-21 weeks. Fetal death after 20 weeks of gestation is also known as a stillbirth. The most common symptom of a miscarriage is vaginal bleeding with or without pain. Sadness, anxiety, and guilt may occur afterwards. Tissue and clot-like material may leave the uterus and pass through and out of the vagina. Recurrent miscarriage may also be considered a form of infertility.

Gestational choriocarcinoma is a form of gestational trophoblastic neoplasia, which is a type of gestational trophoblastic disease (GTD), that can occur during pregnancy. It is a rare disease where the trophoblast, a layer of cells surrounding the blastocyst, undergoes abnormal developments, leading to trophoblastic tumors. The choriocarcinoma can metastasize to other organs, including the lungs, kidney, and liver. The amount and degree of choriocarcinoma spread to other parts of the body can vary greatly from person to person.

<span class="mw-page-title-main">Salpingectomy</span> Surgical removal of Fallopian tube

Salpingectomy refers to the surgical removal of a Fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception.

<span class="mw-page-title-main">Abdominal pregnancy</span> Medical condition

An abdominal pregnancy is a rare type of ectopic pregnancy where the embryo or fetus is growing and developing outside the womb in the abdomen, but not in the Fallopian tube, ovary or broad ligament.

Tubal reversal, also called tubal sterilization reversal, tubal ligation reversal, or microsurgical tubal reanastomosis, is a surgical procedure that can restore fertility to women after a tubal ligation. By rejoining the separated segments of the fallopian tube, tubal reversal can give women the chance to become pregnant again. In some cases, however, the separated segments cannot actually be reattached to each other. In some cases the remaining segment of tube needs to be re-implanted into the uterus. In other cases, when the end of the tube has been removed, a procedure called a neofimbrioplasty must be performed to recreate a functional end of the tube which can then act like the missing fimbria and retrieve the egg that has been released during ovulation.

Otto Spiegelberg was a German gynecologist. He was born in Peine and died in Breslau.

<span class="mw-page-title-main">Heterotopic pregnancy</span> Medical condition

A heterotopic pregnancy is a complication of pregnancy in which both extrauterine (ectopic) pregnancy and intrauterine pregnancy occur simultaneously. It may also be referred to as a combined ectopic pregnancy, multiple‑sited pregnancy, or coincident pregnancy.

<span class="mw-page-title-main">Ovarian torsion</span> Medical condition

Ovarian torsion (OT) or adnexal torsion is an abnormal condition where an ovary twists on its attachment to other structures, such that blood flow is decreased. Symptoms typically include pelvic pain on one side. While classically the pain is sudden in onset, this is not always the case. Other symptoms may include nausea. Complications may include infection, bleeding, or infertility.

<span class="mw-page-title-main">Chorionic hematoma</span> Medical condition

Chorionic hematoma is the pooling of blood (hematoma) between the chorion, a membrane surrounding the embryo, and the uterine wall. It occurs in about 3.1% of all pregnancies, it is the most common sonographic abnormality and the most common cause of first trimester bleeding.

The following outline is provided as an overview of and topical guide to obstetrics:

The Spiegelberg criteria are four criteria used to identify ovarian ectopic pregnancies named after Otto Spiegelberg.

<span class="mw-page-title-main">Interstitial pregnancy</span> Medical condition

An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.

<span class="mw-page-title-main">Cervical pregnancy</span> Medical condition

A cervical pregnancy is an ectopic pregnancy that has implanted in the uterine endocervix. Such a pregnancy typically aborts within the first trimester, however, if it is implanted closer to the uterine cavity – a so-called cervico-isthmic pregnancy – it may continue longer. Placental removal in a cervical pregnancy may result in major hemorrhage.

Theca lutein cyst is a type of bilateral functional ovarian cyst filled with clear, straw-colored fluid. These cysts result from exaggerated physiological stimulation due to elevated levels of beta-human chorionic gonadotropin (beta-hCG) or hypersensitivity to beta-hCG. On ultrasound and MRI, theca lutein cysts appear in multiples on ovaries that are enlarged.

Early pregnancy bleeding refers to vaginal bleeding before 14 weeks of gestational age. If the bleeding is significant, hemorrhagic shock may occur. Concern for shock is increased in those who have loss of consciousness, chest pain, shortness of breath, or shoulder pain.

Endometriosis and its complications are a major cause of female infertility. Endometriosis is a dysfunction characterized by the migration of endometrial tissue to areas outside of the endometrium of the uterus. The most common places to find stray tissue are on ovaries and fallopian tubes, followed by other organs in the lower abdominal cavity such as the bladder and intestines. Typically, the endometrial tissue adheres to the exteriors of the organs, and then creates attachments of scar tissue called adhesions that can join adjacent organs together. The endometrial tissue and the adhesions can block a fallopian tube and prevent the meeting of ovum and sperm cells, or otherwise interfere with fertilization, implantation and, rarely, the carrying of the fetus to term.

<span class="mw-page-title-main">Catharine van Tussenbroek</span> Dutch physician and writer, editor

Catharine van Tussenbroek was a Dutch physician and feminist. She was the second woman to qualify as a physician in the Netherlands and the first physician to confirm evidence of the ovarian type of ectopic pregnancy. A foundation that administers research grants was set up in her name to continue her legacy of empowering women.

<span class="mw-page-title-main">Prophylactic salpingectomy</span> Surgical technique

Prophylactic salpingectomy is a preventative surgical technique performed on patients who are at higher risk of having ovarian cancer, such as individuals who may have pathogenic variants of the BRCA1 or BRCA2 gene. Originally salpingectomy was used in cases of ectopic pregnancies. As a preventative surgery however, it involves the removal of the fallopian tubes. By not removing the ovaries this procedure is advantageous to individuals who are still of child bearing age. It also reduces risks such as cardiovascular disease and osteoporosis which are associated with removal of the ovaries.

References

Citations

  1. ↑ Lin, E. P.; Bhatt, S; Dogra, V. S. (2008). "Diagnostic clues to ectopic pregnancy". Radiographics. 28 (6): 1661–71. doi: 10.1148/rg.286085506 . PMID   18936028.
  2. 1 2 Speert, H. (1958). Otto Spiegelberg and His criteria of Ovarian Pregnancy, in Obstetric and Gynecologic Milestones. New York: MacMillan. p. 255ff.
  3. 1 2 3 4 5 6 7 8 Helde, M. D.; Campbell, J. S.; Himaya, A.; Nuyens, J. J.; Cowley, F. C.; Hurteau, G. D. (1972). "Detection of unsuspected ovarian pregnancy by wedge resection". The Canadian Medical Association Journal. 106 (3): 237–242. PMC   1940374 . PMID   5057958.
  4. 1 2 Ercal, T.; Cinar, O.; Mumcu, A.; Lacin, S.; Ozer, E. (1997). "Ovarian pregnancy: Relationship to an intrauterine device". Australian and New Zealand Journal of Obstetrics and Gynaecology. 37 (3): 362–364. doi:10.1111/j.1479-828x.1997.tb02434.x. PMID   9325530. S2CID   34369714.
  5. 1 2 3 4 Raziel, A.; Schachter, M.; Mordechai, E.; Friedler, S.; Panski, M.; Ron-El, R. (2004). "Ovarian pregnancy-a 12-year experience of 19 cases in one institution". European Journal of Obstetrics & Gynecology and Reproductive Biology. 114 (1): 92–96. doi:10.1016/j.ejogrb.2003.09.038. PMID   15099878.
  6. ↑ Priya, S.; Kamala, S.; Gunjan, S. (2009). "Two interesting cases of ovarian pregnancy after in vitro fertilization-embryo transfer and its successful laparoscopic management". Fertil. Steril. 92 (1): 394.e17–9. doi: 10.1016/j.fertnstert.2009.03.043 . PMID   19403128.
  7. 1 2 3 4 5 Odejinmi, F.; Rizzuto, M. I.; Macrae, R.; Olowu, O.; Hussain, M. (2009). "Diagnosis and laparoscopic management of 12 consecutive cases of ovarian pregnancy and review of literature". Journal of Minimally Invasive Gynecology. 16 (3): 354–359. doi:10.1016/j.jmig.2009.01.002. PMID   19423068.
  8. 1 2 3 4 5 Nwanodi, O.; Khulpateea, N. (2006). "The preoperative diagnosis of primary ovarian pregnancy". Journal of the National Medical Association. 98 (5): 796–798. PMC   2569290 . PMID   16749658.
  9. ↑ Manjula, N. V.; Sundar, G.; Shetty, S.; Sujani, B. K.; Mamatha. "A rare case of a ruptured ovarian pregnancy". Proceedings in Obstetrics and Gynecology.
  10. ↑ Habbu, J.; Read, M. D. (2006). "Ovarian pregnancy successfully treated with methotrexate". Journal of Obstetrics and Gynaecology. 26 (6): 587–588. doi:10.1080/01443610600831357. PMID   17000523. S2CID   23443252.
  11. ↑ Kudo, M.; Tanaka, T.; Fujimoto, S. (1988). "A successful treatment of left ovarian pregnancy with methotrexate". Nippon Sanka Fujinka Gakkai Zasshi. 40 (6): 811–813. PMID   2969025.
  12. 1 2 Thorek 1926, p. 106.
  13. ↑ Jacobson 1908, pp. 241–242.
  14. ↑ Jacobson 1908, pp. 242–243.
  15. ↑ Jacobson 1908, p. 243.
  16. ↑ Thorek 1926, p. 108.
  17. ↑ Jacobson 1908, p. 247.
  18. ↑ Jacobson 1908, p. 250.
  19. ↑ Jacobson 1908, pp. 258–262.
  20. ↑ Rizk 2010, p. 267.
  21. ↑ McDonald 1914, pp. 92–93.
  22. ↑ British Medical Journal 1900, p. 1442.
  23. 1 2 Ray 1921, p. 437.

Sources

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