Case of Ovarian Pregnancy William C. Bryant, MD, Maj, USA, MC Fort Dix, New Jersey

Ovarian pregnancy is an uncommon event, the cause of which is unknown. The use of the intrauterine device (IUD) has increased the incidence of ovarian pregnancy. This is due to the decreasing contraceptive effect of the IUD on the fallopian tube and the ovary. This case satisfies the four criteria of Spiegelberg. It also demonstrates the advantages of laparoscopy and ultrasonography in patients with obscure pelvic pain. Ovarian pregnancy is a rare type of ectopic pregnancy. The frequency of ovarian pregnancy varies from 1/25,0001 to 1/40,000.2 Such a rare event is not likely to be seen by most gynecologists. The use of IUDs appears to be increasing the incidence of this rare entity. The following case history demonstrates the use of laparoscopy and ultrasonography in the diagnosis of ovanan pregnancy.

Case Report BC, a 22-year-old, gravida 3, para 2, Caucasian female, had her last normal menstrual period in December 1977. She was referred to the Gynecologic Clinic in March with the chief complaint of dyspareunia. She had skipped a period in January, but had a heavy flow in February and reported spotting for several days in March. She was using no form of birth control. The patient complained of pain on intercourse for the two months prior to admission. She denied dizziness, syncope, and shoulder pain. She denied any history of salpingitis or previous pelvic surgery. Vital signs were normal. The abdomen was nontender and not distended. The pelvic examination revealed a 4-5 cm tender right adnexal mass. The uterus was top normal size and the left adnexa and cul-de-sac were negative.

From the Division of Obstetrics/Gynecology, Department of Surgery, Walson Army Hospital, Fort Dix, New Jersey. This material does not constitute endorsement by the Department of the Army or the Department of Defense of the views expressed or the manner of expression. Requests for reprints should be addressed to Dr. William C. Bryant, 720 Nytol Circle, Irondale, AL 35210.

de-sac. A laparotomy was performed and a right salpingo-oophorectomy done.

Pathological Examination The right ovarian mass was 8 x 5 x 4 cm. The outer surface was smooth, congested, and hemorrhagic. The mass

Pregnancy test was positive. The hemoglobin level was at 15.0 gm/100 ml and the hematocrit was 44.8 percent. Ultrasound of the pelvis revealed a mildly enlarged uterus with no apparent gestational ring. The right ovary contained a definite gestational ring (Figures 1-3). Laparoscopy revealed an enlarged cystic right ovary with a bluish color. Probing of the mass revealed a thinwalled cavity with membrane-like material on the inner surface. The right tube was completely free with no evidence of hematoma. The left ovary and the tube were also free and appeared normal. There was no blood in the cul-

Figure 1. Ultrasound, longitudinal

cut at S+12, illustrating empty uterus on left and separate ovarian mass on right

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Figure 2. Ultrasound, transverse cut at S±121/2, illustrating ovarian complex with gestational ring on right. Empty uterus is on left

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979

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was of a spongy consistency, surrounded by a rim of ovarian tissue. Microscopic examination confirmed ovarian pregnancy (Figure 4). W..~

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Discussion

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4. Section o f Figure ovay:it

U.o v.r+ t ring gestatinea

ovarian

The pathologic criteria of ovarian pregnancy were formulated by Spiegelberg in 1878:3 (1) the tube on the affected side should be intact; (2) the fetal sac must occupy the position of the ovary; (3) the ovary and the sac must be connected to the uterus by the uteroovarian ligament; and (4) definite ovarian tissue must be present in the sac wall. This case satisfies these criteria; however, a fetus was not identified. The cause of ovarian pregnancy is not definitely known. Etiologic factors are intraovarian ovulation, previous salpingitis, and surface changes, such as dicidua reaction and endometriosis.4 In recent years, there has been an increased incidence of ovarian pregnancy in IUD users. Lehfeldt2 estimates a frequency of one ovarian pregnancy per nine ectopic pregnancies in IUD users. According to Lehfeldt, this is because the IUD reduces uterine implantation by 99.5 percent and tubal implantation by 95 percent, but has no effect on ovarian implantation. This case demonstrates the usefulness of ultrasonography and laparoscopy in the diagnosis of vague pelvic pain. This patient's main complaint was dyspareunia. The presence of a gestational ring outside the uterus confirmed the diagnosis of ectopic pregnancy. Liberal use of both of these diagnostic tools would assist the physician in making a more certain diagnosis of pelvic pain.

Acknowledgement Figure 5. Sectiasound lofnormaltfallpiana tubeatR+4,illustratingovariancomplexwi

The author is grateful for the assistance of Capt. H. Choksey, Department of Pathology and Mrs. Carol Fluck, Department of Radiology, Walson Army Hospital, Fort Dix, New Jersey.

Literature Cited 1. Lifshitz S, Posner N, Pomerance W: Primary ovarian pregnancy. NY State Med J 74:1632-1633, 1974 2. Lehfeldt H, Tietze C, Gorstein F: Ovarian pregnancy and IUD. Am J Obstet Gynecol 108:1005-1009, 1970 3. Spiegelberg 0: Zur casusistil der ovarial schwangerschaft. Arch Gynaekal 13:73-79, 1878 4. Rengachary D, Fayes J, Jones H: Ovarian pregnancy. Obstet Gynecol 49:765-785, 1977

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 6, 1979

A case of ovarian pregnancy.

Case of Ovarian Pregnancy William C. Bryant, MD, Maj, USA, MC Fort Dix, New Jersey Ovarian pregnancy is an uncommon event, the cause of which is unkn...
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