A Rare Case of Ectopic Ovarian Pregnancy

A 28-year-old lady with a previous Lower Segment Caesarean Section (LSCS) came in  he OPD of Max Super Speciality Hospital, Shalimar Bagh, with pain in her abdomen for three days. She had complaints of scanty periods and took medication for pain in the  abdomen but got no relief. 

On examination, there was mild tenderness in the lower abdomen, and her vitals were  normal. She was admitted and investigated further. Her Beta HCG was 106. An urgent scan was then done that revealed a normal-sized uterus with an endometrial thickness of 6.4 mm. There was heterogenous SOL inseparable from the left ovary & tube of 3.4 x 3.5 x 3.8 cm with a sac-like ring corresponding to 5.4 weeks and minimal vascularity in the ring. Minimal free fluid was seen in the pouch of Douglas and signs of left tubal pregnancy with surrounding tubovarian organised haematoma. 

The patient's pain was not relieved, and the decision for Laparoscopic Surgery for ectopic pregnancy was taken. During laparoscopy, there was the presence of ruptured left ovarian ectopic with organised clots surrounding it, and the left tube was normal. The bowel was adherent to a complex haematoma that was separated. Approximately 500 cc of fluid and clots were present in the pelvis that was suctioned.

Ovarian wedge resection was done and the specimen was retrieved through mini-laparoscopy. The haemostatic stitch was applied, and a drain was placed. The patient was comfortable in the post-operative period. After a week, beta HCG dropped below 5. The histopathological examination revealed Ectopic Gestation with chronic Villi embedded with haemorrhage and inflammatory debris in ovarian parenchyma. Risk factors are similar to those for tubal pregnancy, but the use of an IUD seems to be disproportionately associated. It ends with a rupture before the end of the first trimester. Classical management is surgical.

Ovarian pregnancy is a rare form of non-tubal ectopic pregnancy. Hertig estimated that ovarian pregnancy occurs in 1 in 25,000 to 40,000 pregnancies[1]. Characterised by poor clinical symptomatology and difficult ultrasound diagnosis. (Incidences after natural conception ranges from 1 in 2000 to 1 in 60,000 deliveries) and accounts for 3% of all ectopic pregnancies[1]. The diagnosis is intricate and based on surgical and histopathological observation. Ovarian pregnancy can be misdiagnosed with ruptured corpus interim cysts in 75% of cases[1].