Medical management of an ovarian ectopic pregnancy: a case report

The history of ectopic pregnancy is as old as humanity. The first successful operation
for ectopic pregnancy took place in 1759 in the USA but the usual treatment was still
medical up to the 1800s with a maternal mortality rate reaching up to 60 % 3]. The high mortality rates drew special attention which led to crucial developments
in the diagnosis and treatment of this condition. Salpingectomy, which started to
be performed from the 1800s, is observed to be lifesaving because it decreased the
maternal mortality rates to nearly 5 %.

Ovarian ectopic pregnancy is a rare variant of ectopic pregnancy 4]. It occurs by fertilization of an ovum retained in the peritoneal cavity leading
to implantation on the ovarian surface 5]. Women with ovarian ectopic pregnancies usually present with lower abdominal pain,
menstrual irregularities as in other ectopic conditions and corpus luteum cyst. Although
early diagnosis and early treatment are crucial, preoperative and sometimes intraoperative
diagnoses are difficult. Diagnosis is usually made by pathological assessment and
therefore the Spiegelberg criteria are very important for the diagnosis of ectopic
ovarian pregnancy 6].

Prediagnosis is usually supported by increased beta HCG levels. The current data inform
that most cases occur in the first trimester. Early onset rupture can lead to massive
intraabdominal hemorrhage resulting in hypovolemia which can be life-threatening.
Some rare cases that reach second trimester are also documented 7]. There are also published cases of twin ovarian ectopic pregnancies and coincidence
of uterine and ovarian ectopic pregnancies 7]–10]. We also found some articles on ectopic pregnancies of advanced gestational age diagnosed
preoperatively with USG and magnetic resonance imaging (MRI) 7], 11]. In the study of Hallat, a preoperative diagnosis was achieved in 28 % of 25 primary
ectopic pregnancy cases. All other cases were diagnosed by pathological assessment
postoperatively 12]. Phupong and Ultchaswadi declared that the evaluation of beta HCG together with transvaginal
USG can be helpful for early diagnosis 13].

The cause of implantation anomalies in ovarian ectopic pregnancy is not clear 7], 12], 13]. There are various hypotheses such as:

a. Delay of ovum liberation.

b. Thickening of tunica albuginea.

c. Tubal dysfunction.

d. Intrauterine contraception devices (for example, IUDs).

Pelvic inflammatory disease does not have an effect on ovarian ectopic pregnancy like
it does on tubal pregnancy 9], 14]. IUDs are thought to be a main factor in ovarian ectopic pregnancy cases according
to the majority of studies. It is believed that IUDs trigger mild inflammation that
disturbs the ciliary activity of the endosalpinx and leads to ovum transport delay
and ectopic implantation 15], 16]. In our case, ectopic pregnancy was diagnosed from clinical and laboratory examinations
and evaluations of her condition. Because of her two previous cesarean sections and
the suspicion of secondary salpingitis by endemic chronic pelvic infections we performed
medical treatment with MTX.

Primary ovarian ectopic pregnancy is usually seen among young fertile multipara women
who use an IUD 17]. Berger and Blechner documented that the ratio of ovarian ectopic pregnancy among
women using an IUD to all ectopic cases is 1:9; its prevalence in the general population
is detected as 1:150 to 200 16]. Our case had no history of IUD usage. In the case series of Raziel et al., 18 of 20 cases of ovarian pregnancy were using an IUD 14]. The link between IUDs and ovarian pregnancy in fertile patients is worthy of comment.
In their study, Lehfeldt et al. detected that the IUDs prevent uterine implantation by 99.5 % and tubal implantation
by 95.5 %; however, there is no preventive effect on ovarian implantation 18].

As the definitive diagnosis is made surgically and histopathologically even in patients
with early onset, surgical interventions have both a diagnostic and a therapeutic
value. Because oophorectomy is a radical procedure for ovarian ectopic pregnancy,
consideration should be given to the patient’s age, fertility, her desire to have
further pregnancies, and the size of the mass; wedge resection can also be another
surgical option.

Medical and conservative treatments have also been introduced in recent years to prevent
ovarian tissue loss, pelvic adhesions and to preserve the patient’s fertility. These
include administration of mifepristone for patients diagnosed using a transvaginal
USG, parenteral prostaglandin F2a and MTX treatment for non-ruptured cases detected
with laparoscopy 11], 19]. Pagidas and Frishman performed MTX treatment for ovarian ectopic cases diagnosed
using transvaginal USG and achieved healing. They emphasized that early staged cases
diagnosed by transvaginal USG, can benefit from MTX treatment 20]. Di Luigi et al. also performed and succeeded with multidose MTX treatment which they administered
to a 37-year-old patient with a history of two previous cesarean sections and IUD
usage; she was diagnosed at 6 weeks of ectopic ovarian pregnancy by use of a transvaginal
USG. They emphasized that with careful clinical evaluation and transvaginal examination
early staged ovarian ectopic cases can be treated medically which preserves the normal
anatomy crucial for fertility 21]. A review of the data shows that MTX treatment is chosen after a clear diagnosis
and detection of the localization of ectopic cases by laparoscopy and therefore laparoscopy
is declared to be a supporting diagnostic procedure 22]. In cases in which the gestational sac is lower than 30 mm, without fetal cardiac
activity, and less than 6-weeks old, MTX treatment is supported in particular and
is superior to surgery because it does not disturb fertility 23].

In our case although she had pelvic fluid of hemorrhagic character that could have
been caused by pelvic rupture, a clinical evaluation and consideration of her previous
operations led us to treat her medically. Her beta HCG levels progressively decreased
after single dose MTX and she did not face the risks of further surgery.