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Abstract
Twenty one year old woman presented in emergency with 2 months amenorrhoea with bleeding per vaginum and history of multiple episodes of unconsciousness since 2 months. Ultrasound showed evidence of 4.4 * 3.8 * 3.2 cm heterogenous hypervascular mass in right adnexa and presence of free fluid.
Emergency exploratory laprotomy with right ovarian cystectomy with construction of right ovary done.
Ectopic pregnancy implanted in the ovary is rare. Findings are likely to mimic those of tubal pregnancy or a bleeding corpus luteum.
Introduction
Ectopic pregnancy implanted in the ovary is rare. In 1978, Spigelberg formulated criteria for diagnosis of ovarian pregnancy.1 The tube on the affected side must be intact.2 The foetal sac must occupy the position of the ovary.3 The ovary must be connected to the uterus by the ovarian ligament.4 Definite ovarian tissue must be found in the sac wall.1
Case Report
Twenty one year old P2L2 presented with 2 months amenorrhoea with history of bleeding pervaginum since 1 day, history of multiple episodes of unconsciousness since 2 months. She had no bowel or bladder complaints. No significant past medical or surgical history. Her past menstrual cycles were regular. General examination and systemic examination did not reveal any abnormality except mild pallor and tachycardia.
On abdominal examination, there was no tenderness guarding or rigidity. On vaginal examination, uterus was anteverted, normal size 3 x 3 cm tender mass was felt in the right adnexa, left adnexa was clear, cervical movements were tender.
On ultrasonography uterus was 8 x 5 x 4 cm. Evidence of 4.4 x 3.8 x 3.2 cm heterogenous hypervascular mass was noted in right adnexa. Free fluid in the pelvis was present, left ovary was normal. Her Hb was 9.8%. WBC count was 9,200/mm.3 UPT was positive, Colpopuncture showed old blood (hemoperitoneum). Since patient presented in emergency with hemoperitoneum and facilities for laproscopic surgery were not available in the emergency hours, laproscopy was not done for the patient.
Decision of exploratory laprotomy was taken. Exploratory laprotomy with right ovarian cystectomy with reconstruction of the right ovary was done. Intraoperative findings were, uterus was normal size. Left ovary was normal, both fallopian tubes normal, right ovary showed 3 x 4 cm organized haematoma ? ectopic pregnancy. This was situated in the anatomical site of the ovary, was connected to the uterus by the uteroovarian ligament. There was 100 ml of old collected blood in peritoneal cavity. Intraoperative diagnosis of ? corpus luteal haematoma ? ovarian pregnancy was made.
Postoperatively patient received IV antibiotics and was discharged on day 5 of surgery.
Histopath report showed abundant blood and fibrin amongst which chorionic villi are seen with peripheral ring of ovarian tissue.
Discussion
Bobrow and Winkelstein reviewed 154 cases that satisfied these criteria.2 Hallatt described 25 cases of primary ovarian pregnancy3 and Grimse and co-workers reported 24 more.
Traditional risk factors for tubal pregnancy are similar for ovarian ectopic pregnancy. Current use of an intrauterine contraceptive device seems to be inordinately associated with ovarian pregnancy.4
Findings are likely to mimic those of a tubal pregnancy or a bleeding corpus luteum cysts or a bleeding corpus luteum.5 The classical management for ovarian pregnancies has been surgical. Early bleeding for small lesions has been managed by ovarian wedge resection or cystectomy.
References
- Spiegelberg O. Casuistry in ovarian pregnancy. Arch Gynaekol 1978; 13 : 73.
- Bobrow ML, Winkelstein LB. Intrafollicular ovarian pregnancy. Am J Surg 1956; 91 : 991.
- Hallatt JG. Primary ovarian pregnancy: A report of 25 cases. Am J Obstet Gynecol 1982; 143 : 55.
- Golan A, Raziel A, Neumanm, Schneidir D, Bukovskyl, Caspi E. Fertility before and after surgery for primary ovarian pregnancy. Fertile Steril 1991; 55 : 200.
- Schwartz LB, Caocangiu ML, Decherncy AH. Primary ovarian pregnancy. A case report. J Reprod Med 1993; 38 : 155.
RALTEGRAVIR : A NEW ANTIRETROVIRAL CLASS FOR SALVAGE THERAPY
Grinsztejn and colleagues report exciting results at 24 weeks with raltegravir-containing regimens in 178 patients with advanced HIV-1 infection. Enrolment was limited to patients with virological failure and documented multidrug resistance.
CD4 recovery was also seen with raltegravir, with higher increases from baseline in the 400 mg and 600 mg groups.
Clearly, we are in a new era of antiretroviral therapy. More treatment options are available, and AIDS-related morbidity and mortality would be expected to drop. Unfortunately, for more than 85% of patients living with HIV/AIDS, access to basic care, including first-line antiretrovirals, is still unachievable..
Pedro Cahn, Omar Sued, The Lancet, 2007; 369 : 1235-36.
*Associate Professor, **Resident, Department of Ophthalmology, T.N.M.C and B.Y.L. Nair Hospital, Mumbai - 400 008.
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