Case Report

Ectopic ovarian pregnancy in a second-trimester patient

Abdominal pain in the first 20 weeks of pregnancy is a frequent complaint in the emergency department (ED). The assessment of a gravid patient with abdominal pain is chal- lenging with advancing gestational age because the uterus can displace intraperitoneal structures. In addition, imaging is restricted to minimize radiation exposure to the fetus. It is important to remain vigilant for Ectopic pregnancy past 7.2 F 2 weeks of gestation. Most ovarian pregnancies present with unstable vital signs and hemoperitoneum. When ultrasound findings are nondiagnostic and Hemodynamic compromise and pain persist despite initial Resuscitative efforts, it is paramount to have early involvement of surgical consultants. A 35-year-old, gravida 3, para 2 woman who was 16 weeks 1 day by first trimester ultrasound presented to our emergency department (ED) after 7 hours of acute-onset, constant right- sided abdominal pain, shortness of breath, and nausea. The patient went to a neighboring ED 11 days prior for similar symptoms and was discharged home with diagnoses of urinary tract and Trichomonas vaginalis infections. She had a history of placenta previa and anxiety, and felt that it may be anxiety because she had familiar complaints of paresthesias

to her fingers and shortness of breath.

Her physical examination was remarkable for right-sided abdominal pain with light palpation and for a gravid uterus that was 1 cm to the right of the midline and 5 cm below the umbilicus. A bedside ultrasound performed by the ED physician demonstrated fetal heart tones in the 140s with visualization of Cardiac activity. Her pelvic examination was most notable for the amount of pain she had when getting into the examining position. She had no bleeding, and her cervical os was closed and nontender.

While in the ED, she received 2 L of isotonic sodium chloride solution. Her systolic blood pressure improved, but her heart rate was persistently 130 to 150. She was still tender, and her Laboratory test results indicated a 1.3-g decline in hemoglobin to 7.2 from 11 days prior. The radiologist submitted a preliminary ultrasound report that demonstrated ba 16 and 2/7 week live gestation with a small subchorionic bleed and ascites around the liver.Q The gallbladder appeared normal and the appendix was not well visualized (Fig. 1A and B). It was at that time that the gynecologist and the general surgeon were both consulted, and the patient was consented for a blood transfusion and a laparoscopy. The patient was taken to surgery, was found to

have a right ovarian pregnancy (Table 1), and subsequently underwent a right oophorectomy and salpingectomy.

Because ectopic pregnancy is responsible for 10% of pregnancy-related deaths and is the leading cause of maternal death in the first trimester, emergency physicians must be vigilant for this diagnosis [1]. However, ovarian pregnancy provides an additional challenge. Not only is it rare-1:7000 of all deliveries and 1% to 3% of all ectopics-but it may present later than tubal ectopics [2,3]. Furthermore, initial misdiagnosis leads to hemodynamic instability being more common in ovarian ectopics [5,6]. Although ovarian preg- nancies usually rupture by the 40th gestational day, there have been reports of these progressing into the Third trimester and even to live births [4]. The risk factors for tubal ectopic pregnancies do not correspond with the incidence of ovarian pregnancies. Ovarian pregnancy seems to be a random event with a debatable association with multiparity and intrauterine device use [2,5,7].

The definitive treatment of peritoneal pain of unknown etiology and unstable vital signs is a laparoscopy. For ovarian pregnancy, it is both diagnostic and therapeutic; and at the time of operation, 90% have been found to be ruptured with hemo- peritoneum secondary to the high ovarian vascularity [2,7].

Kevin J. Corrigan DO

Department of Emergency Medicine

Midwestern University Olympia Fields, IL, USA

Daniel R. Kowalzyk DO Department of Emergency Medicine St Francis Hospital Blue Island Midwestern University

St. Francis Hospital Blue Island, IL, USA

E-mail address: [email protected]

doi:10.1016/j.ajem.2007.03.012

References

1. Ectopic pregnancy-United States, 1990-1992. MMWR Morb Mortal Wkly Rep 1995;44:46.
2. Vasilev S, Sauer M. Diagnosis and modern surgical management of ovarian pregnancy. Surg Gynecol Obstet 1990;170:395 - 8.
3. Gaudoin M, Coulter K, Robins A, et al. Is the incidence of ovarian ectop- ic pregnancy increasing? Eur J Obstet Gynecol Reprod Biol 1996;70:141.

0735-6757/$ - see front matter D 2007

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Fig. 1 A and B, These figures reinforce the challenge with diagnosing an ovarian pregnancy and that emergency physicians should not solely rely on laboratory tests or radiographs to make critical therapeutic decisions. Even an experienced radiologist has difficulty noting the location of the pregnancy, as it is a Rare occurrence. The question marks on the ultrasound illustrate the confusion to identify landmarks. The bfluidQ demonstrated in the Morrison pouch was misinterpreted as ascites rather than blood.

1. Evruke C, Ozgunen T, Demir C. Second trimester ovarian pregnancy. Int J Gynecol Obstet 1996;53:167 - 9.

Table 1 Diagnostic criteria of ovarian pregnancy described by Spiegelberg

1. The fallopian tube on the affected side must be intact.
2. The Gestational sac must occupy the same position as the ovary.
3. The ovary must be connected to the uterus by the utero-ovarian ligament.
4. Ovarian tissue must be located in the gestational sac wall.
5. Sidek S, Lai S, Lim-Tan S. Primary ovarian pregnancy: current diagnosis and management. Singapore Med J 1994;35:71 - 3.
6. Kaplan BC, Dart RG, Moskos M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med 1996;28:10 - 7.
7. Raziel A, Schacter M, Mordechai E, et al. Ovarian pregnancy-a 12-year experience of 19 cases in one institution. Eur J Obstet Gynecol Reprod Biol 2004;114:92 - 6.