Ectopic Pregnancies in Unusual Locations

Thomas A Molinaro, M.D.; Kurt T Barnhart,M.D.,M.S.C.E.

Disclosures

Semin Reprod Med. 2007;25(2):123-130. 

In This Article

Ovarian Ectopic Pregnancy

Ovarian pregnancy is a rare event. Reports vary from one in 2100 pregnancies to one in 60,000, making ovarian pregnancy 1 to 3% of all ectopic pregnancies.[26] Risk factors include previous pelvic inflammatory disease, IUD use, endometriosis, and assisted reproductive technologies.[26,27,28,29,30] Ovarian pregnancies can be classified as extrafollicular and as the less common intrafollicular type.[27,28,29,30] There is some controversy regarding whether ovarian pregnancy is a result of secondary implantation of the embryo or of failure of follicular extrusion.[27,30] Extrafollicular pregnancies can be classified as interstitial, cortical, superficial, and juxtafollicular.

In 1878, Spiegelberg described four criteria for the pathologic diagnosis of ovarian pregnancy: the tube has to be entirely normal, the gestational sac has to be anatomically located in the ovary, the ovary and the gestational sac have to be connected to the uterine ovarian ligament, and placental tissue has to be mixed with ovarian cortex. Today, diagnosis routinely is made by ultrasound appearance of a wide echogenic ring on the ovary, frequently with a yolk sac or fetal parts.[26] Ovarian pregnancies are often confused with corpus luteum cysts.[27,31] Three-dimensional ultrasound imaging has been used to distinguish ovarian pregnancy from corpus luteum cysts.[29] It may be useful to perform intraoperative ultrasound to distinguish an ovarian pregnancy from an ovarian cyst.[28] Particular care should be taken to investigate thick-walled cystic ovarian lesions in the patient with an empty uterus and a quantitative hCG above the discriminatory zone.[27] Doppler ultrasonography seems to offer little additional diagnostic value due to the high vascularity of the ovary.[26] Diagnostic laparoscopy frequently is required to make the diagnosis of ovarian pregnancy, which is only later confirmed by histologic examination of removed tissue.[32] In a study of six cases of ovarian pregnancy, Comstock et al[26] found abdominal pain and light vaginal bleeding to be common presenting symptoms. At the time of surgery, ovarian pregnancies frequently resemble hemorrhagic cysts.

Treatment of ovarian pregnancy usually requires oophorectomy or wedge resection of the ovary.[33] Seinera et al[33] reported a series of eight patients treated with conservative ovarian surgery with no persistent pregnancies. Bontis et al[27] reported a case of intrafollicular fertilization and subsequent growth after controlled ovarian hyperstimulation and intrauterine insemination. This case was treated with partial oophorectomy and future fertility was accomplished. Einenkel et al[28] reported a case of primary ovarian pregnancy after controlled ovarian hyperstimulation and intrauterine insemination, which was treated with laparoscopic cystectomy. Ovarian pregnancy has been reported in patients without functional fallopian tubes.[34]

Medical management with methotrexate has been reported but may not be feasible; laparoscopy often plays a key role in diagnosis. Methotrexate may be an option if there is persistent trophoblastic tissue after laparoscopy.[28] If future fertility is desired, wedge resection may be considered. Oophorectomy should be reserved for cases of advanced gestation.[28] In many case reports, subsequent pregnancy has been uncomplicated.[33]

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