Ovarian ectopic pregnancies are a rare occurrence; however the incidence is on the rise. Preoperative diagnosis remains difficult due to nonspecific clinical symptoms and USS findings. Most patients undergo diagnostic laparoscopy with subsequent surgical management. We present the case of a 32-year-old female who presented with vaginal bleeding and an unsited pregnancy, with a BhCG of 24693. Formal USS described unruptured right tubal ectopic with ovarian pregnancy being diagnosed at laparoscopy. A wedge resection was conducted to preserve ovarian function. Postoperative recovery was uneventful and BhCG levels returned to zero (nonpregnant) in an outpatient setting. Although laparoscopy remains the gold standard of diagnosis and treatment, in this case report we discuss benefits of early diagnosis for fertility conserving management, including nonsurgical options.
A 32-year-old female, gravida 6 and parity 3, presented with mild vaginal bleeding and unsited pregnancy. Her obstetric history included one normal vaginal delivery, followed by 2 caesarean sections and previous left salpingectomy for removal of ectopic pregnancy. On presentation she had been amenorrhoeic for 36 days and was estimated to be at 5 weeks and 6 days of gestation by the first day of her last menstrual period. An outpatient USS requested by her general practitioner 4 days prior to admission demonstrated no intra- or extrauterine pregnancy. On examination she was haemodynamically stable with a soft abdomen. There was mild tenderness in the left iliac fossa but no signs of peritonism. A speculum exam revealed a normal cervix with no evidence of bleeding. On a bimanual examination she was tender in the right adnexa but no masses were palpable. Her serum BhCG was 24693 and Hb 139. A bedside USS was suspicious for a right sided ectopic pregnancy and this was confirmed on a formal USS which described an unruptured right tube ectopic 51 × 36 × 32 mm and a small amount of free fluid in the pouch of Douglas (Figure
Ultrasound images showing normal right ovary and right tubal ectopic.
On laparoscopy a right ovarian ectopic was identified (Figure
Intraoperative findings. (a) Ovarian ectopic. (b) Wedge resection.
The patient was monitored overnight and had an uneventful postoperative recovery period. She was discharged the following day with weekly outpatient BhCG tracking through the early pregnancy assessment clinic. Diagnosis was confirmed with histopathology.
The earliest reported case of an ovarian pregnancy was described in the 17th century [
Delayed diagnosis of ovarian ectopic pregnancies can be fatal with massive haemorrhage and carry a risk of oophorectomy with subsequent reduced fertility. As demonstrated in the case discussed, preoperative diagnosis of ovarian ectopic can be challenging as symptoms are nonspecific and ultrasound diagnosis is difficult [
New advances in ultrasound may lead to earlier detection. A case series regarding the ultrasound appearances of ovarian ectopic pregnancy conducted by Comstock et al. [
Currently diagnosis is made using the criteria described by Spiegelberg [
Diagnosis is commonly made at surgery, which suggests that clinicians must be confident in identifying diagnostic features of an ovarian ectopic at laparoscopy, and also to consider management steps at laparoscopy after diagnosis. Although ipsilateral oophorectomy is definitive in its management, this is becoming less common in favour of fertility preserving surgical management. These include partial ovariectomy (wedge resection), ovarian cystectomy, or blunt dissection of the trophoblastic tissue [
After preoperative or intraoperative diagnosis of ovarian ectopic pregnancy, if the patient is clinically stable without significant symptoms, clinicians may offer patients conservative or medical management. This may be suitable in those who may carry operative risks as seen in our case where there were significant pelvic adhesion. In those seeking future fertility, nonsurgical management may preserve ovarian tissue. Medical treatment to halt trophoblast development includes administration of methotrexate, prostaglandins, potassium chloride, and hypertonic glucose [
In patients who are clinically unstable or have significant symptoms or in whom intraoperative diagnosis is not clear, laparoscopy remains the preferred method of treatment. In our case, although the patient did not present with an acute abdomen, was haemodynamically stable, and had a history of two previous caesarean sections, surgical management was the preferable treatment option given the size of her ovarian pregnancy (>30 mm).
Although it is a rare occurrence, the incidence of ovarian pregnancy is on the rise. Preoperative diagnosis remains difficult; however USG may assist in early detection. In these cases or in haemodynamically stable patients, medical management should be strongly considered, in order to avoid operative complications and preserve fertility of the patient.
To ensure anonymity patient information was deidentified. Verbal consent was obtained from the patient.
The authors declare they have no financial, personal, or commercial conflicts of interest while describing this case report.