Ovarian Ectopic Pregnancy: Laparoscopic Conservative Management

A 31-year-old woman gravida 2 para 1 presented in the emergency room complaining about spotting, right lower quadrant abdominal pain. A β-hcg was performed and resulted in 1525 IU/ml, in addition an ultrasound examination reported an adnexal mass (28 x 35 x 31 mms) with solid and cystic areas adjacent to the right ovary and no intrauterine pregnancy nor pelvic fluid was visualized. 48 hours later, the subject attended to control with no change on her pelvic pain and hemodynamically stable. β-hcg was measured again and resulted in 1450 IU/ml, with no variations in the ultrasound findings (Figure 1). A laparoscopy surgery was proposed to provide treatment and confirm the suspicion of a non-ruptured ovarian ectopic pregnancy vs., a hemorrhagic corpus luteum with a tubal ectopic pregnancy. During the procedure, a mass (3 x 2 x 3 cm) was found firmly attached to the right ovary, both Fallopian tubes appeared normal, and no other positive alterations were encountered (Figure 2). An ovarian wedge resection with blunt dissection and hemostasis with bipolar forceps was performed without any complications. Histopathological report confirmed the diagnosis of ovarian ectopic pregnancy (Figure 3). The patient was discharged the following day, and attended a control on the consecutive week, were she showed no additional complaints and the laparoscopic incisions evolved properly.

Figure 1: A 2.2 x 1.0 x 1.5 mass on right ovary.

Figure 2: Normal fallopian tubes, enlarged right ovarian and minimal fluid in cul de sac figure 3.

Figure 3: Right ovarian ectopic pregnancy.

Ectopic pregnancy is a potentially life-threatening entity defined as the implantation of a fertilized ovum outside the endometrial cavity, which occurs in approximately 1.5 to 2% of pregnancies [1]. Ovarian pregnancy is a form of ectopic pregnancy with a reported incidence of 1:7000 to 1:40000 pregnancies [2].

There are a known risk factors such as use of Artificial Reproductive Technologies (ART), intrauterine devices and tubal dysfunction but these couldn’t be present in some cases. The cause of this implantation anomaly remains uncertain, nonetheless some hypothesis have been proposed. For instance, Marcus et al suggest embryo migration [3], and Shan N, et al. [4], proposed an ovarian inflammation, thicken albuginea causing detention of the ovum into the broken follicles and fertilized just in the ovary. The diagnosis is difficult and a challenge for the clinician, as no non-invasive tests can confirm or screen it. The surgical criteria that have been described are: 1. Fallopian tubes intact and separate from the ovary, 2. The pregnancy must occupy the position of the ovary, 3. The ovary must be attached to the uterus and 4. There must be ovaria tissue attached o the pregnancy specimen confirmed histologically [5]. Medical management with methotrexate has been used as an alternative to surgery requiring rescue surgery in about 50% of patients [6]. Minimal access surgery is now becoming the preferred option because of the advantages of laparoscopic surgery for tubal ectopic pregnancies over open surgery but there are no specific data for ovarian ectopic pregnancies.

This case outcome supports the success of conservative management regarding the treatment of ovarian ectopic pregnancy.

The authors declare no conflict of interests in regards to personal financial interests that could have appeared to influence the work reported in this paper.

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