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PrinlaJγ Ovarian Pregnancy with intrauterine deviceOUD) a case report and reviews of the Iiterature
Kyu-ha Shin
，
.1ae-sung Lee，
Sung-yob KimDepartment이Obsletrics&Gynecology，Jeju NalionalUniversity.SCh
∞
1이Medicine，Jeju，Korea(Received May 23. 2013; Re에sed May 30. 2013; Accepted June 7. 2013)
「
←Abstract
← → 「 ← ]
Ovar↑an pregnancy is a rare lorm 01 eclopic pregnancy，with a reported incidence of approximalely 3% 01 all ectopic pregnancies. We rep。끼 a primary ovarian pregnancy in a 29-year-old woman wilh a hiSIOry01 intraulerine device. The patient was admitted 10 Ihe emergency department with signs and symptoms of acute abdomen with hemoperitoneum. Diagnoslic laparoscopy and pelviscopic righl ovarian cysleclomy were perfαmed. On hislopalhological examinalion，products 이conception embedded in the ovarian lissue were seen，which were confirmalory 01 primary ovarian pregnancy. This article is to describe a case 이
。
varian pregnancy and to discuss reviews 01 the Iileralure. (J Med니fe SCi 2013;10(1 );54-57)Key Words ; Primarγ ovarian pregnancy，Ectopic pre밍1ancy. Intrauterine deviceOUD)
Address for c
。
πeSpOndence: Sung-yob Kim，M.D.，PH.D Departme미。
f Obslelrics&Gynecology，Je씨NalionalUniversity Sch。이。
f Medicine‘Aran 13-이lS(Ara-l Dong)，Jeju-si，Jeju 690-767. Republic01"α'eaE얘ail :[email protected]
A 29-year-old. G1 P1 Al woman was admilted tD lhe emergency department with lower abdominal pain for 1 day Her previous mensσu떠eycle was regular with average f10w and no d.ysmenorrhea
On examination，pulse 90/min，BP 120170 mmHg and tenderness in whole abdomen were observed. She had ov밍ian pregnaney is a rare fonn of ectopic pregnaney，
with a reported incidence of approximately 3% of all ectopic pregnanciesl) η1e diagnostic crit:eria were described in 1878 by Spiegelbergll. Confused with a
∞
rpus luteum cyst‘ misdiagnosis can reach around 75%:>. Un1ike the Lubal gestation. ovarian pregnancy is associated wiLh neither pelvic inflanunation disease(PlD) nor infert피ty 까1e on1y risk factor associated with the development of ov와lan pregnaneyis the current use of lUD31.Usually. the first clinical presentation is a shock
、
with hemoperitoneum requiring emergency surgery. In recent years，the incidence rat:e of ovarian pregnancy has increased because of the assisted reproduct.ive techniQues and wider use of lUDIntroduction
Case Report
j
당i
received di1atation and evacuation. and removed the intrauterine device(IUD) eighteen days ago. She had a copper intTauterine deviceOUD)for ahout 32 months
。
n investigation，the urine pre밍1ancy t:est was positive. hemo잉obin was 8.1 g/dL. Iotal le마αγte∞
unt was 10‘7OOM. platelet count was 153αXJM and lhe blood group was 0 positiveOn ulσ'asonography，no gestationa1 S8C was seen inside the uterus but a right adnexal mass 4.4 cm x 3 cm was seen with fluid collection in the posterior c띠de S8C ] .5cm and anterior c띠de sac 3.6cm
A CT image showed a feature of slightly high densi앙
peritoneal fluid collection suggesting hemoperit.oneum. A heterogeneous hi밍1 density mass lesion 6.5 X 3.&m was noted in right adnexa with blood in cul de S8C. There was no ascit:es in the abdominopelvic cavity π1e assessment was that there W8Shemoperitoneum due ω a corpus lut:eum양sl
rupωre，or rupture of ectopic pregnancy (Fig1따e 1). Serum ß
human chorionic gonadotropin (ß-hCG) was 16.770 mru/mL A decision for diagnostic laparoscopy was taken because of the hemoperitoneum
Intra-operative!y ，the uLcrus was a normal 5ιe ，bolh fallopian tubes were normal ，but had massive hemoperitonium (Figure 2). Grossly. right ovary was swollen with a hematoma like mass about 4cm 5αed and rupwred in part with oozing of blood from the surface of the mass (Figure 2‘3). A diagnostic laparoscopy and pelviscopic ri링11
。
V없ian cystectomy were penonned 없1d the contents werePrim밍γ Ovarian Pregnan양with in。낀uterine device(IUD) : 8
∞
S8 repOrt and reviews of the literature。%옳魔
。
、
、
Figure 3. Ri영lt 0VllIY양lOWing]JrimaJYovæ때n끼"gr냉ocy.
Figure 4.
ω
lDW-πJWer、
liew of 칙JeCUneIl양1OW5chorionic찌m
and troph<i비astic tissue in hemontlllgic 밟ckground 머&E，x40)‘
‘
Figure 4. 03) ovu끼an 잉roma 양1!JW∞
J1lUSIuteal ChangES ffi&E‘ x100) on h잉opathological 밍엄mination. products of∞
næptionembedded in the ovarian tissue were seen ，which were
∞
nfumatoIγ of ]JrimaJYovarian미잉gnancy~
Q
Figure 1. Ri영lt ovarian cystic rupture
A cr image 허α어a feature of패빙11lyhi앙1d잉"lSityperiωneaJ
fluid
∞
Illection su!쩔esting hom이>eritoneum. And herero뿜leoUS hi양1 densi\Y mass lesion 6.‘5 x 3.8cm is not<었 în ri앙lt a이lexawith blood in cul de sac. There was no ascites in the abdomino따찌c ævi\Y.
까'"
"'"영
lSInel1twas hemn따itoneum due to a OOJ1lUSlu1eum c;& rupωre，or rupturo of∞
toPκ pre밍ancy examination ，products of conception embedded in the。
varian tissue were seen. which were confirmatory of pnmarγ。
v때an pregnancy (Figure 4)꺼18 patient was discharged from the hospital on the 6th postoperative day withoul any complication. The β hCG level was 20 mIU/mL on the 22M postoperative day
The precise etiology of ov앙1an pre밍lancy is not known Tn conσ'ast to patients with tubal pregnancies ，σ'aditionaJ risk factors ，such as pelvic infl밍nma
∞
ry disease and priorsurgical procedure 야)Qn the pelvis，may not play a role in tho etiology
‘’
π1ere appears to be a link to the intrauterine device(IUD)“
Some have suggested that patients wh。
Figure 2. Intra-따""tlveiy.‘the uterus was a nonnal size‘bothfallopisn tubes were norrnal，but had massive hem야생itonium. Gπ>ssiy，ri명lt 0YaJY was SVJOllenwith a hema띠nalil
‘
e mass about 4cm 양rodm퍼ruptur어mpaπ with 00'ling of blαXI from the surfaoe of the mass..
.
Discussion
55
_.-accomplished by an ovarian wedge resectiodSl
Ovarian pregnancy have been successfu1ly treated vvith methotrexate since it was introduced in the management of ectopic pregnancy in 198817)
Oγ30an pre밍lancy can develop together vvith a normal
intrauterine pregnancy; such a heterotopic pregnancy vvill call for expert management as not to endanger the intrauterine pregnancy
Ov암ian pregnancy is a rare condition but has specific
features. Its diagnosis is diffic니It잉1d relies on criteria based
on the inσa-operative findings and the histopathological examination. Therefore ， 8piegelberg criteria are quite important in making the diagnosis of ovarian pre망1ancy
EveljT clinician treating women of reproductive age shou1d keep this diagnosis in mind
This presented case
、
.vas confirmed to meet criteria suggested by Spieglberg1. 8piegelberg O. Zur Casuistik der Ovarialschwangerschaft Arch Gynaekol 1878:13:73-6
2. Halat JG. Primarγ
。
varian pregnancy. A report of 25 cases. Am J Obstet Gynaecol 1982:143:50-6C3. Raziel A，Schachter M，Mordechai E ，Friedler S，Panski M，Ron-EI R. Ovarian pregnancy a 12-year e:자erience of 19 cases in one' institution. Eur J Obstet Gynecol Reprod Biol 2004:114:92-6
4. Ercal '1'，Cinar 0 ，Mumcu A，Lacin S，Ozer E. Ovarian pregnancy; relationship to an intrauterine device. Aust N Z J Obstet Gynaecol 1997:37(3):362-4.37(3):362 - 4 5. Priya S. Karn머a S. Gunjan S. Tψ
。
interesting cases of。
varian pregnancy after in vitro fertilization-embry。
transfer and its successful laparoscopic management Fertility and sterility 2009:92(1):394.eI7 - 96. Helde MD，Campbell JS ，Himaya A，Nuyens JJ. C。、N"ley FC， Hurteau GD. Detection of unsuspected ovarian pregnancy by wedge resection. Can Med Assoc J 1972:106(3):237-42
7. Subrat Panda，Laleng M Darlong ，Sant.a Singh ，and Tulon Borah. Case report of a primarγ
。
V잉1an pregnancy m aprimigravida. J Hum Reprod Sci 2009:2(2):90 - 2
8. Nwanodi 0，Khulpateea N 매e Preoperative Diagnosis of Primary Ovarian Pregnancy. J Natl Med Assoc 2006:98(5):796 - 8
9. Bradley WG. F'iske CE，F'illy RA 만1e double sac sign 이 early intrauterine pregnancy: use in exclusion of e야이l1C pregnancy. Radiology 1982:143:1223-6
Ky;니 ha 8hîn，Jae-sung 18e，Sung-yob Kim
undergo in vitro ferti1ization(IVF) are at higher risk for
。
vanan pr‘egnancy')Ovarian pregnancy is usually understood to begin when a mature egg cell is not expel1ed Or picked up from its follicle A sperm enters the follicle and fertilizes the egg. It gives rise to an intrafollicular pregnancy61. It has a180 been debated that an egg cell ferti1ized outside of the ovarγ could implant on the ovarian surface，perhaps aided by a deαdual reaction or endometriosis히 Ovarian pregnancy rarely goes
longer than 4 weeks: never엄1eleSB，there is the possibi1ity that the trophoblast fmds further suppoπ outside the avary and thus may affect 야18 tube and other organsG). In V8rγ rare occasions，the pregnancy may fmd a sufficient foothold outside 며18 OV8.1γto continue as an abdominal pregnancy，
and an occasional delive:ry has been reported6)
The signs and symptoms of ovarian pregnancy are similar to those of disturbed tubal pregnancy，conditions most commonly confused vvith ruptured hemorrhagic corpus luteum and chocolate cyst or tubal ectopic pregnancy7l Presenting symptoms typically include the triad of pelvic mass，abdominal p밍n，and abnormal vaginal bleeding. But ，
the classic triad of pelvic pain，abnoπnal bleeding and a palpable pelvic mass is more frequently associated 、‘rith a tubal ectopic gestation than an ovarian gestation'히
Out of the modem methods，ultrasonography ，laparoscopy and estimation of Serum β human chorioruc gonadotrophic (ß-hCG) levels have been used in conjunction vvith repeated clinical evaluation in the diagnosis and management of extrauterine pregnancies9.10，11.12l
'1'0 be diagnosed as ovarian pregnancy，four diagnostic criteria suggested by Spiegelberg ，3l must be met. It is as
follows
(1) η1e tube on the affected side must be intaet (2) The fetal sac must occupy the position of the ovarγ (3)짜e ovarγ and sac must be connected to the uterus by
the utero-ovarian ligament (Iigamentum proprium
。
V밍，，)(4) Defmite ovarian tissue must be present in the sac wall
Traditionally，an explorative laparotomy was perlonned ， including the removal of the pregnancy. Today，the surgerγ can often be performed via laparoscoPT3). The extent of surgeη varies according to the arnonnt of tissue destnαction that has occurred. Patients vvith ovarian pregnancy have a good prognosis for future fertility. Therefore conseπ-ative smgical' management is advocated14). '1'0 preserγe ov3o없1
tissue，the procedure removing gest.ational sac vvith relative sparing of normal tissue is performed13l. This can be
References
56-r
Primary Ovari밍1Pregnancy with inσauterine deviceOUD): a case report and reVÎewsof the ïiterature
10. Chinn DH， Callen PW. Ultrasound of the acutely ill
。
bstetrics and gynecology patient. Radiol Clin North Am 1983;21(3);585-9411.1awson 'IL. Ectopic Pregnancy: criteria and accuracy of u1trasonic diagnosis. Amer J Roentgenol 1978;131:153-6 12. Schoenbaum S，Rosendrof L，Kappelman N，Rowan T
Gray-scale .ultrasound in tubal pregnancy. Radiology 1978;127;757-61
13.0dejiruni F，Rizzuto :rv:rr，Macrae R，Olowu 0 ，Hussain M Diagnosis and laparoscopic management of 12 consecutive cases of ovarian pregnancy and review of literature. J 뻐nim Invasive Gynecol 2009;16(3);354-9 14. Manjula NV，Sundar G，Shett;y S，Sl.\iani BK，Mamatha. A
.'、
57
rare case of a ruptured ov뻐없 pregnancy. Proc Obstet
Gynecol 2010 ;1(2);Article 4[5p，)
15. Raziel A，Schachter M，Mordechai E ，Frie버er S，Panski
M，Ron-El R. Ovarian pregnáncy-a 12-year experience
。
f 19 cases in one institution. Eur J Obstet Gynecol Reprod Biol 2004;114(1);92-616.Habbu J，Read MD. Ovarian pregnancy successful1y treated with methotrexate. J- Obstet Gynaecol 2006;26(6);587 - 8
17. Kudo M，Tanaka T，Fujimoto S. A successful σeatment of 1eft ovarian pregnancy with methotrexate. Nippon Sanka Fuiinka Gakkai Zasshi 1988;40(6);811-3
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