Late Diagnose Ovarian Pregnancy by Laparoscopic Diagnostic After Curretage and

Laparotomy Outside Hospital

Fauzan1 Dr. dr. Mohd. Andalas, Sp. OG, FMAS2
1
Resident of Obstetrics and Gynecology Faculty of Medicine Syiah Kuala University/Zainoel
Abidin General Hospital Banda Aceh 2Staff Division of Department Of Obstetrics and
Gynecology Faculty of Medicine Syiah Kuala University/Zainoel Abidin General Hospital
Banda Aceh

ABSTRACT
Background: Ovarian pregnancy isanuncommon form ofectopic gestation the diagnosis of
which continues to challenge practicing clinicians. Although ovarian pregnancy is rare, it was
shown to occur 4 times more frequently than previously believed-on the order of 1 per 7000
deliveries and slightly less than 3%of all ectopic pregnancies.

Objective:Transvaginal ultrasonography is a valuable tool in identifying an ovarian pregnancy

from other types of ectopic pregnancies. Management with laparoscopy or laparotomy is
required in all cases, and in almost all cases, ovary can be preserved since implantation is usually
superficial. Awareness of the possibility of ovarian pregnancy and closer histologic examination
of surgical specimens are critical factors for increased recognition.

Cases:Woman 25 y.o G3P1A1 with 9-10 weeks gestation without prior gynecological and
surgical history, but with incomplete abortion history. Physical examination and gynecologic
obstetric status found that abdominal tenderness of the right inguinal region and porsio pain in
motion, but no mass was found in adnexa. Hemoglobin 11.6 g/dl, levels of -hCG 277.89
mIU/mL. Ultrasound examination the uterine is in anteflection, the size appears to be enlarged,
the endometrial line appears decidualized, the gestational sach figure in the right ovary 15.7 mm
in size, no fetal echo or fetal heart rate, left ovaries in normal range, visible free fluid in the
douglas cavity. Impression suspect right ectopic pregnancy of the ovary.

Conclusion: Diagnosis of ovarian pregnancy is very difficult. Primary ovarian pregnancy may
appear without giving classical signs and symptoms even the absence of risk factors in the
patient. A prompt and rapid diagnosis can allow for appropriate conservative surgery actions and
maintain patient fertilization status in the future.

Keywords: Ovarian Pregnancy, Laparoscopic Diagnostic

Nama lengkap : Fauzan

Judul Makalah bebas :Late Diagnose Ovarian Pregnancy by Laparoscopic
Diagnostic after Curretage and Laparotomy Outside Hospital

Nama Institusi :-
Alamat Institusi :-
Nomer Handphone presenter : 0811683399
Email presenter : fauzanfkusk2002@gmail.com
Introduction
Ectopic pregnancy is an important health problem and accounts for 10% of all maternal
ortolity incidence of ovarian pregnancy in natural conception vary from in 7.000 to one in 40.000
deliveris an accounts for <3% of all ectopic pregnancy. Ovarium pregnancy is classified into
primary and secondery. The former is usually due to ovulatory dysfunction, where fertilization
takes place within the folicle, where as the later is doe to tubal abortion or perforation of the
conceptus with ovarian stromal implantation. Ovarian pregnancy can again be as intrafollicular
and extrafollicular types, intrafollicular is mostly primary but extrafillicular type can be either
primary ar secondery.1
Ovarian pregnancy is a unique form of ectopic pregnancy that must be
documented by the four postulates of Spiegelberg, which establish that the pregnancy is
in the ovary and does not involve the tube. Ovarian pregnancy is the most common
form of abdominal pregnancy, but it must be distinguished from primary peritoneal
implantation, which can involve .any intra peritoneal site with different problems of
diagnosis and management related to the organs involved. The ovary has no peritoneal
covering, and the implantation within the ovary results in a predictable sequence of
events because of the consistent vascular anatomy of the ovary. This vascularity
results in maternal hemorrhage early in the first trimester, which disrupts the preg
nancy and usually ruptures the ovary with sufficient hemoperitoneum to require
emergency operation. This inherent self-destruction occurs so early that ovarian
pregnancy presents surgically as a hemorrhagic ovary and is usually not correctly
diagnosed.5
The distinction of ovarian pregnancy from the much more common ectopic pregnancy
occurring in the fallopian tube usually depends on findings from transvaginal ultrasonography
(TV-US). Reported TV-US features in ovarian pregnancy include a cyst on the ovary with a
wide echogenic outside ring, fluid collection surrounding the ovary, and an absence of
hematosalpinx. However, this condition is still a diagnostic challenge, and laparoscopy is usually
required for the diagnosis. Magnetic resonance imaging (MRI) has served as a problem-solving
modality in ectopic pregnancies by providing excellent tissue contrast for an implantation site,
even when it is unclear on TV-U.3
II.Case report
We report a woman 25 y.o G3P1A1 with 9-10 weeks gestation without prior
gynecological and surgical history, but with incomplete abortion history. Physical examination
and gynecologic obstetric status found that abdominal tenderness of the right inguinal region
and porsio pain in motion, but no mass was found in adnexa. Hemoglobin 11.6 g/dl, levels of -
hCG 277.89 mIU/mL. Ultrasound examination the uterine is in anteflection, the size appears to
be enlarged, the endometrial line appears decidualized, the gestational sach figure in the right
ovary 15.7 mm in size, no fetal echo or fetal heart rate, left ovaries in normal range, visible free
fluid in the douglas cavity. Impression suspect right ectopic pregnancy of the ovary.
III. Discussion
Primary ovarian pregnancy is a rare entity. There has been an increase in the incidence of
ovarian pregnancy due to better diagnostic modalities, wider use of contraceptive IUD,
ovulatory drugs, and assisted reproductive techniques like invitro fertilization, embryo transfer
and empty follicle syndrome. Endometriosis and pelvic inflammatory disease has also been
implicated in the increasing incidence.4
The diagnosis is difficult and a continuous challenge to the gynecologist. Many times it
is misdiagnosed clinically and sonologically as ruptured tubal ectopic pregnancy, corpus luteum
cyst, hemorrhagic cyst and chocolate cyst of ovary. Even it is difficult to differentiate ovarian
pregnancy from haemorrhagic ovarian cyst at the time of surgery. Hallet (1982) in his study
jomp 25 cases of ovarian pregnancies reported that a correct surgical diagnosis was only made in
28% of cases. In the remaining cases the pathologist made the diagnosis.5
The diagnosis is quite difficult before surgery because the clinical presentations are
similar to those of tubal pregnancy wherein both may have amenorrhea, irregular vaginal
bleeding, abdominal pain and adnexal mass. It may be important to note that ovarian pregnancy
can terminate several days before the expected date of menstruation without any history of
amenorrhea. Rimdusit reported ten cases of ovarian pregnancy out of which six had no
amenorrhea and the same thing was observed in this case.6
Some case, we could not obtain any history related to risk factors for ovarian pregnancy
such as pelvic inflammatory disease, contraceptive IUD insertion, and fertility therapies.
Intraoperatively there was no evidence of endometriosis and chronic pelvic infection, so here it can
be hypothesized that the primary ovarian pregnancy took place due to interference in the
release of ovum from the ruptured follicle and subsequently increased the risk of intrafollicular
pregnancy. The diagnosis can sometimes be made before rupture by the use of high resolution
transvaginal ultrasonography followed by diagnostic laparoscopy. Presumptive diagnosis of
ovarian pregnancy can be made based on the positive quantitative HCG without an
intrauterine gestation, with presence of sonographic finding of a wide echogenic ring with an
internal echo lucent area on the ovarian surface. The echogenicity of the ring is usually greater
than that of the ovary itself, compared to a thin tubal ring with tubal pregnancies or corpus luteum
cyst. A yolk sac or embryo was less commonly seen as progression beyond early stages is
exceptional. Other sonograpic finding like complex adnexal masses or solid cystic masses with or
without fluid in cul de sac, fluid surrounding the ovary and ovarian enlargement also result in
high suspicion towards ovarian pregnancy.7
Early diagnosis and treatment is absolutely necessary to ensure a successful outcome.
Seinere et al., concluded that laparoscopy is required for diagnosis and also for effective
definitive surgical management at the same time. In contrast to tubal ectopic pregnancy
medical treatment by methotrexate has not been currently considered as a safe and
successful treatment option. The mainstay of surgical treatment for ovarian pregnancy is
oophorectomy or conservative surgical management like ovarian wedge resection depending
on the extent of tissue destruction. Oophorectomy has been regarded unsuitable as
preservation of ovary should be given precedence. This is because the patients are generally fertile
and the risk of recurrence is zero as no case of recurrent ovarian pregnancy has ever been
documented.8

IV. Conclussions
V. References
1.Jasmina Begum, Pallaves, Sunita Diagnostic Dilemma in Ovarian Pregnancy: A case
series. Jcdr 2015

2. Comstock, K. Huston, and W. Lee, The ultrasonographic appearance of ovarian ectopic

pregnancies, Obstetrics & Gyne- cology,2005
3. R. J. Joseph and L. M. Irvine, Ovarian ectopic pregnancy: etiology, diagnosis, and
challenges in surgical management, Journal of Obstetrics and Gynaecology
4.Das S, Kalyani R, Laksmi V, Harendra Kumar ML,Ovarian Pregnancy, Indian Jurnal
Pathol Microbiol,2008
5.Hallet JG, Primary Ovarian Pregnancy: A report of twenty five cases. Am J Obstetri
Gynecol,1982
6.Rimdusit P, Kastri N.Primary ovarian pregnancy and the intrauterine contraceptive
device. Obstet Gynecol,1976
7.Panda S, Darlong LM, Singh S, Borah T. Case report of primary ovarian pregnancy in
primigravida. J Hum Reprod Sci.2009
8. Sergent F, Mauger-Tinlot F,Gravier A , Versyck E.Ovarian Pregnancies: revaluation of
diagnostis criteria. J gynecol Obstet Biol Reprod,2002