Ruptured Ovarian Pregnancy associated with Ovarian Endometrioma : A case report
Dr. Fatima N. Tasneem, Associate Professor Dr. Kakali Saha, Associate Professor Dr. Shilpi Saha, Consultant Dr. Momena Khatun
Medical College for Women and Hospital , Dhaka ,Bangladesh
Objective:
oTo present a rare case of ovarian pregnancy in association with ovarian endometrioma
oOur objective is to emphasize the diagnostic challenges and the role of laparoscopy in such cases.
Background:
oFrequency : 0.3 – 3 % of all ectopic.1
oIncidence : 1 in 25000 – 40000 pregnancies.2
oTherefore, finding ovarian ectopic pregnancies along with Ovarian endometrioma may seem unlikely but not impossible.
Case report:
oA 22 years old nulliparous woman ,married for 3 months was admitted to our hospital with severe lower abdominal pain and acute gastroenteritis. She had her last menstruation 45 days ago from the day of her admission. Her menstrual cycle was previously regular.
oOn admission ,she was haemodynamically stable. Conservative treatment was given for her chief complaints.
Initial investigation:
oPositive urine pregnancy test
oCBC: Hb 11.1 g/dl, WBC: 14.2x109 L , Neutrophil 85%
oTVS: Bulky uterus with 1.7 cm thick endometrium ; complex SOL in right adnexa (6.5x4.1x4.4 cm); No free fluid.
Due to the above results blood workup for S. β.hCG, S. Progesterone and tumour markers were done.
Labs
oβ.hCG -688 mIU/ml
oS.Progesterone-1.71 ng/ml(low)
oTumour markers : CA-125= 15310U/ml, CA 19.9=606 U/mL, AFP=<5ng/mL
o
This suboptimal rise in β.hCG level and patient’s worsening pain even after using anti-spasmodic drugs , the decision of laparoscopic evaluation was taken.
Surgical findings
oModerate free blood in Pouch of Douglas and in peritoneal cavity.
oBulky uterus with two well visualised and intact fallopian tubes.
oRight Ovary: Actively bleeding ruptured ovarian mass along with two endometriotic cysts containing chocolate material.
oLeft ovary : Normal
Procedure: The mass along with the cyst walls were removed, preserving the healthy ovarian tissues of the right ovary . This was followed by D&C to exclude any pathology in the thickened endometrium .
Histopathology
oCyst wall : chorionic villi lined with trophoblast.
oEndometrial cell: Decidualisation.
Discussion:
oA rare case of ovarian ectopic is discussed here. The exact cause of which is unknown. The implantation anomaly is may be as a consequence of defective follicular disruption or disruption of ovum transport pathway which cause fertilization of ovum in peritoneal cavity or on the surface of the ovary itself.3,4
oEctopic pregnancy in association with endometriosis is suggested to be due to the loss of tubo-ovarian anatomy.
oIn our case, the patient was previously dysmenorrhic which was not assessed. Hence, she was not a diagnosed case of endometriosis. This was an incidental finding while evaluating her acute abdomen. Owing to the size of the cyst we would have gone for a conservative management if not for the worsening symptoms (with suboptimal rise in β.hCG) which was highly suggestive of ectopic.
oSince sonographic finding was inconclusive, diagnosis had to be made intraoperatively and confirm postoperatively by histopathology following Spiegelberg criteria.
Conclusion
oWhen sonological findings are not clear, diagnosis can be confusing in cases as such. Exploratory laparoscopy along with biochemical markers like β.hCG and serum progesterone can be proved useful.
oWe also need to keep in mind that any female patient with acute abdomen needs to be evaluated for ectopic pregnancy.
oEarly detection and prompt management is essential not only for better prognosis but also to minimise complications which can impair future fertility.5
oClinicians must be mindful regarding the differential diagnosis of ovarian endometrioma and ovarian pregnancy and their synchronism.6
References :
1. R Sallam., et al. "Laparoscopic Conservative Management of an Ovarian Ectopic Pregnancy: Case Study". EC Gynaecology 13.2 (2024): 01-04.
2. Thapa M, Rawal S, Jha R, Singh M. Ovarian pregnancy: a rare ectopic pregnancy. JNMA J Nepal Med Assoc. 2010 Jan-Mar;49(177):52-5. PMID: 21180222.-
3. Hallatt JG. Primary ovarian pregnancy: A report of twenty-five cases. Am J Obstet
Gynecol 1982;143:55–60.
4. Birge O, Erkan MM, Ozbey EG, Arslan D. Medical management of an ovarian
ectopic pregnancy: a case report. J Med Case Rep 2015;9:290-293.
5. Bharti S, Sharma M, Malik N, Myes D, Marwaha P. Primary Ovarian Pregnancy: A Case Report With a Review of the Literature. Cureus. 2024 Mar 22;16(3):e56688. doi: 10.7759/cureus.56688. PMID: 38646339; PMCID: PMC11032508.
6. Aoyagi Y, Kai K, Aso S, Nishida M, Kawano Y. Coexistence of Ovarian Endometrioma and Ovarian Pregnancy: A Case Report. Cureus. 2023 Feb 28;15(2):e35608. doi: 10.7759/cureus.35608. PMID: 37007423; PMCID: PMC10063240.
