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Acta Obstétrica e Ginecológica Portuguesa

Print version ISSN 1646-5830

Acta Obstet Ginecol Port vol.14 no.1 Coimbra Mar. 2020

 

ISSUE IMAGE/IMAGEM DO TRIMESTRE

Ovarian ectopic pregnancy treated with maximum conservative surgery of the ovary in a patient with a copper intrauterine device

Gravidez ectópica ovárica tratada com cirurgia conservadora do ovário numa paciente com um dispositivo intrauterino de cobre

Maria Carlota Cavazza1, Gunes Karakus2, Elisabete Santos3

Centro Hospitalar de Leiria

1 Interna de formação especializada de Ginecologia e Obstetrícia, Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Leiria

2 Assistente hospitalar em Ginecologia e Obstetrícia, Serviço de Ginecologia e Obstetrícia do Hospital de Vila Franca de Xira

3 Assistente hospitalar em Ginecologia e Obstetrícia, Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Leiria.

Endereço para correspondência | Dirección para correspondencia | Correspondence


 

ABSTRACT

The authors present a case of an ovarian ectopic pregnancy in a patient with an intrauterine copper device. Ovarian pregnancies are rare and account for three percent of ectopic pregnancies and the presence of an intrauterine device appears to influence its risk. The sonographic diagnosis of an ovarian pregnancy is difficult and, therefore, its diagnosis is only typically made during surgery and must be confirmed through histopathological analysis. As shown through our case, maximum conservative surgery of normal ovarian tissue can be attempted successfully.

Keywords: Ovarian ectopic pregnancy; Intrauterine device


 

The patient was a 30-year-old female, gravida 2, para 2, that presented to our emergency department complaining of a progressively worsening lower abdominal pain starting five days previously. She had an intrauterine copper device (IUD) for two years and reported last menses 17 days prior to her visit. Nevertheless, she admitted that, in the previous month, her menses had a delay and were less abundant than usual. Upon physical examination, she was hemodynamically stable and had uterine and adnexal tenderness specially on the left side. Laboratory results showed a hemoglobin level of 8.5g/dL and a human chorionic gonadotrophin (hCG) level of 11925mUI/ /mL. Ultrasound examination found a correctly positioned IUD and, on the left side of the pelvis, a normal ovary. Adjacent to it, an adnexal mass with an hyperechoic contour and an anechoic center containing a yolk sac and an embryo with a heart beat, free fluid and abundant blood clots were observed.

Based on these findings and the lack of practice in laparoscopy of the surgical team, we decided to perform an exploratory laparotomy that unveiled a moderate hemoperitoneum, normal aspect of the uterus, right ovary and both fallopian tubes. The left ovary had a peripheral formation compatible with the presence of an ovarian ectopic pregnancy (Figure 1). Ovarian wedge resection with removal of the abnormal mass and a thin layer of normal ovarian tissue was performed and histopathological analysis confirmed the diagnosis. The hCG levels progressively decreased to negativity following surgery.

 

 

Ovarian pregnancies are rare and account for three percent of ectopic pregnancies1. A reflux of the fertilized egg through the fallopian tube and into the ovary, more specifically into the follicle opening, rich in fibrin and blood vessels, appears to be in its origin. The sonographic diagnosis of an ovarian pregnancy is difficult as it can be mistaken for a corpus luteum, an hemorrhagic cyst or a tubal pregnancy. They usually appear on or within the ovary as a cyst with a wide echogenic outside ring and, less commonly, an embryo can be found as in our case2. Due to its rarity, the diagnosis of an ovarian pregnancy is only typically made during surgery and must be confirmed through histopathological analysis. As demonstrated through our case, maximal conservative surgery of the ovary attempting to remove only the trophoblastic tissue and a minimum of normal ovarian tissue can be successfully performed. This is of the most importance specially if the patient desires a future pregnancy.

Albeit a low absolute risk, the presence of an IUD increases the probability of an ectopic location when a pregnancy occurs3. Intrauterine devices induce chronic inflammatory changes of the endometrium and fallopian tubes that have spermicidal effects and inhibit fertilization and implantation but they do not have a preventive effect on ovarian implantation4. The true impact of copper IUD on the prevalence of ovarian pregnancies remains controversial. Joseph et al, in their review of 250 cases of ovarian pregnancies, found that 19.3% were associated with the use of a copper IUD and that risk factors normally associated with ectopic pregnancy, such has a previous history of pelvic inflammatory disease, were not present5.

The authors chose to present this case as, due to its rarity, many medical professionals have probably never seen an ovarian ectopic pregnancy. Its diagnosis should always be considered and, normally, is only established during surgery.

 

REFERÊNCIAS

1. Bouyer J, Coste J, Fernandez H, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 2002; 17:3224-3230.         [ Links ]

2. Comstock C, Huston K, Lee W. The ultrasonographic appearance of ovarian ectopic pregnancies. Obstet Gynecol 2005; 105(1):42.         [ Links ]

3. Mol BW, Ankum WM, Bossuyt PM, et al. Contraception and the risk of ectopic pregnancy: a metaanalysis. Contraception 1995; 52(6):337-341        [ Links ]

4. Patai K, Szilagyi G, Noszal B, et al. Local tissue effects of copper-containing intrauterine devices. Fertil Steril 2003; 80(5):1281-1283        [ Links ]

5. Joseph RJ, Irvine LM. Ovarian ectopic pregnancy: Aetiology, diagnosis, and challenges in surgical management. J Obstet Gynaecol 2012; 32(5):472-474.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

Maria Carlota Cavazza

Centro Hospitalar de Leiria

Portugal

E-Mail: mcarlota.cavazza@gmail.com

 

Recebido em: 03/11/2019

Aceite para publicação: 09/02/2020

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