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Ovarian pregnancy: Association with IUD, pelvic pathology and recurrent abortion
Europ. J. Obstet. Gynec. reprod. Biol., 12 (1981) ElsevierlNorth-Holland Biomedical Press
333
333-337
OVARIAN PREGNANCY: ASSOCIATION WITH IUD, PELVIC PATHOLOGY AND RECURRENT ABORTION
J. REICHMAN,
J.A. GOLDMAN
and D. FELDBERG
Department of Obstetrics and Gynaecology, Hasharon Hospital, Tel-Aviv University Medical School, Tel Aviv, Israel Accepted
for publication
18 September
Petah-Tikva,
and
1981
REICHMAN, J., GOLDMAN, J.A. and FELDBERG, D. (1981): Ovarian pregnancy: association with IUD, pelvic pathology and recurrent abortion. Europ. J. Obstet. Gynec. reprod. Biol., 12/6, 333-337. Six cases of ovarian pregnancy were reviewed and their relationship with the IUD, fibromyoma of the uterus and previous spontaneous abortion was examined. In fact, 5 patients had an IUD in situ, in 2 women fibroids were found; 4 of the women had spontaneous abortions in their past history. The latter fact has been discussed, and it is suggested that this association may possibly contribute to an early diagnosis of ectopic pregnancy resulting in improved chances for conservative microsurgery. Attention is drawn to the fact that the diagnosis of ovarian pregnancy is often made only on microscopic examination. Thus, it is concluded that the true incidence of ovarian pregnancy may be higher than is apparent. ovarian
pregnancy;
IUD; recurrent
abortion
INTRODUCTION
In 1929, Grlfenberg noted the relationship between ovarian ectopic pregnancy and the intrauterine device (IUD). Until recently the incidence of ovarian pregnancies has been estimated at about l/25 000 to l/40 000 of all pregnancies and 0.7-l% of all ectopic gestations (Hertig, 1951). Since 1970 there has been an increasing number of reports of ovarian pregnancies, many of which were associated with IUDs (Puch et al., 1973; Pratt-Thomas et al., 1974; Hallatt, 1976; Grail et al., 1978; Evans et al., 1979). In a review of 33 ovarian pregnancies diagnosed in women with IUDs, Berger and Blechner (1978) found a ratio of 1 ovarian pregnancy to every 9 ectopic pregnancies in IUD users. Others (Tietze, 1968; Grey and Buffalo, 1978) reported a smaller ratio. In a review of the data from the Cooperative Statistical Program of the Population Council, Lehfeldt et al. (1970) estimated that IUDs reduced intrauterine implantation by 99.5%, tubal implantation by 95% and the incidence of ovarian pregnancy not at ail. Address Israel.
for correspondence:
0029-2243/81/0000-0000/$02.50
Professor
Jack
Goldman,
Hasharon
0 1981 Elsevier/North-Holland
Hospital,
Biomedical
Petah-Tikva,
Press
334 TABLE I DETAILS
OF OVARIAN
PREGNANCIES
Age
Obstetric history
IUD
Pregnancy test (/3subunits)
Presenting symptoms
Clinical findings
37
G5, Pl, Ab4 LMP not known
No
Positive
Pelvic mass
20-Wk size uterus and left adnexal mass
30
G2, P2 LMP 21 days prior to admission
Lippes loop (4 yr)
Positive
Metrorrhagia 2wk-IUD removed 1 wk prior to admission
Right adnexal mass (5 X 6 cm) positive culdocentesis
29
G2, P2 LMP 24 days prior to admission
Lippes loop (41 yr)
Not done
Lower abdominal pain day of admission
Shock, right adnexal fullness and tenderness, positive culdocentesis
36
Cl 2, P2, AblO LMP 60 days prior to admission
Lippes loop (21 yr)
Not done
Lower abdominal pain day of admission ; metrorrhagia 3 wk-IUD removed 2 wk prior to admission
Left adnexal mass (5 X 5 cm), positive culdocentesis
30
G3, P2, Abl LMP 3 5 days prior to admission
Copper T (3 yr)
Positive
Metrorrhagia
Enlarged fibroid uterus, laparoscopy
33
G4, P2, Ab2 LMP 26 days prior to admission
Copper
Negative
Abdominal
2 wk
pain
None, laparoscopy
Tz& yr)
Abbreviations used: G = gravida; P = para; Ab = abortion; LMP = last menstrual period; TAH = total abdominal hysterectomy; LSO = left salpingooophorectomy; RSO = right salpingooophorectomy.
Other factors reported to be conducive to ovarian pregnancy include previous abdominal surgery, PID, ineffectual tubal function, decidual reaction of the ovary and endometriosis (Rengachary et al., 1977). In the past 4 yr we have treated 6 patients with ovarian pregnancy; 5 with in situ IUDs and one in conjunction with a 20-wk-size fibroid uterus. One of the patients with an IUD also had a fibroid uterus. All cases met Spiegelberg’s requirements for the diagnosis of ovarian pregnancy (Spiegelberg, 1978). A summary of the 6 cases is presented in Table I.
335 (table I continued) Operative findings
Operative procedure
Morphology
Fibroid uterus, left ovarian hemorrhagic cyst (5 x 5 cm), both tubes and right ovary normal
TAH and LSO
Trophoblastic tissue in clots within cyst of left ovary, remnants of corpus luteum in cyst capsule, leiomyoma of uterus, normal right tube
400 cc Hemoperitoneum, hemorrhagic mass (6 X 6 cm) protruding from right ovary, both tubes and left ovary normal
RSO
Right ovary with blood clots containing trophoblastic tissue and villi, mild chronic salpingitis
2 000 cc Hemoperitoneum, right ruptured hemorrhagic ovarian cyst (5 x 4 cm) with active bleeding, both tubes and right ovary normal
RSO
Right ovary with ruptured corpus luteum containing clots, decidual cells and trophoblastic tissue, normal right tube
200 cc Hemoperitoneum, 4 X 5 cm ruptured hemorrhagic cyst of left ovary with many adherent clots
LSO
Left ovary with corpus luteum containing clots, trophoblastic tissue, normal left tube
Fibroid uterus, right corpus luteum, hemorrhagic cyst, both tubes and left ovary normal
Myomectomy RSO
Right ovary with ruptured corpus luteum, cyst containing trophoblastic tissue
50 cc Hemoperitoneum, no active bleeding, left ovary and both tubes normal, right ovary with blood clots
RSO
Right ovary with ruptured corpus luteum containing trophoblastic tissue
DISCUSSION
During this 4-yr period there was a total of 59 ectopic pregnancies treated in our department, 18 (30.5%) occurring in patients with in situ IUDs. This high incidence of ectopic pregnancy in patients using an IUD may be attributed to the recent increase in the use of this mode of contraception in our population and the inability of the IUD to protect these women from ectopic nidation. Laufer et al. (1978), in a review of ectopic pregnancies in a similar population, found a 21% association of ectopic pregnancies and IUD contraception. Ovarian pregnancies constituted 10.2% of all the ectopic pregnancies and 20% of our ectopic pregnancies in the group of patients using IUDs. This frequency is higher than that reported by Lehfeldt et al. (1970),
336
who proposed that the IUD does not prevent ovarian nidation. The possibility that the IUD may potentiate ovarian nidation must therefore be considered. It has been suggested that the IUD causes changes in the synthesis of prostaglandins so that tubal peristalsis is increased and this could increase the incidence of both tubal and ovarian pregnancies (Dar-wish, 1975). It should be noted that 2 of the patients were initially treated for vaginal bleeding and pelvic pain by removal of their IUDs, and the proper treatment was delayed for 14 days. Similar delays in diagnosis of ovarian pregnancies in IUD users have been noted by other authors (Pratt-Thomas et al., 1974, Hallat, 1976). The ovarian pregnancy in the patient with the fibroid uterus was diagnosed only after histological examination of an incidental hemorrhagic mass found at laparotomy. It is interesting to note the association between spontaneous abortion and ectopic ovarian pregnancy in 4 out of our 6 cases. In fact, there is evidence (Asherman, 1957; Berger and Blechner, 1978) that the major forms of abnormal human gestation, i.e., spontaneous abortion, hydatiform mole, ectopic pregnancy, dystopic placentation and fetal malformations, constitute a spectrum of conditions with a similar background of clinical associations and a significantly higher concurrence rate in the same patients (Darwish, 1975). Honor+ (1979), in a study of 83 patients with pathologically documented tubal ectopic pregnancy, demonstrated a statistically significant association between prior spontaneous abortion and ectopic pregnancy. He suggested that delayed (post-midcycle) ovulation, causing preovulatory over-ripeness of the ovum, may be the common underlying etiologic factor. Our series of 6 cases of ovarian ectopic pregnancy seems to confirm the association. It is also well to note the fact that mild chronic salpingitis was reported on histopathological examination only in one case. No conclusion can be drawn from such a small group of patients; nevertheless, if indeed a significantly higher early pregnancy wastage is confirmed in larger series of cases, this association may contribute to the earlier diagnosis of ectopic pregnancy, with improved chances for conservative management, i.e., a possibility of microsurgery, resulting in increasing the patients’ chances of subsequent reproductive success. The recent increase in documented cases of ovarian pregnancy may be due to the recognition of the importance of performing wedge resection and histological examination of all ovarian hemorrhagic cysts. In fact, Helde et al. (1972) in a review of five cases of ovarian pregnancy, found that in three cases the preliminary diagnosis at laparotomy was hemorrhagic cyst or corpus luteum and only after histological study was the correct diagnosis made. If the clinician is to diagnose and properly treat ovarian pregnancy at an early stage, he must be aware of its apparent association with IUDs, pelvic pathology and spontaneous abortion. Further reports of cases will help to clarify the true incidence of ovarian pregnancy and its correlation with these factors.
337 REFERENCES Asherman, J.G. (1957): De I’etiologie des grossesses extrauterines. Gynec. Obstet., 56, 462. Berger, B. and Blechner, J.N. (1978): Ovarian pregnancy associated with Copper-7 intrauterine device. Obstet. Gynec., 52, 597. Darwish, D.H. (1975): Ovarian ectopic pregnancy with IUCD. Brit. Med. J., 4,143. Evans, M.I., Angerman, N.S., Morauec, W.D. and Hajj, S. (1979): The intrauterine device and ovarian pregnancy. Fertil. Steril., 32, 31. Grall, J.Y., Jacques, Y. and Kerisit, J. (1978): Ovarian pregnancy. A review of the literature with reference to 4 personal cases. Fra-Rev. Fr. Gynec. Obstet., 72, 139. Gray, C.L. and Buffalo, E.H. (1978): Ovarian pregnancy associated with intrauterine contraception devices. Amer. J. Obstet. Gynec., 132, 134. Hallatt, J.G. (1976): Ectopic pregnancy with the intrauterine device: a study of seventy cases. Amer. J. Obstet. Gynec., 125, 754. Helde, M.D., Campbell, J.S. and Himaya, A. (1972): Detection of unsuspected ovarian pregnancy by wedge resection. Canad. med. Ass. J., 106, 237. Hertig, A.T. (1951): Discussion of Gerin Lajoie’s paper. Amer. J. Obstet. Gynec., 62, 926. Honor+, L.H. (1979): A significant association between spontaneous abortion and tubal ectopic pregnancy. Fertil. Steril., 32,401. Iffy, L. (1962): Contribution to the aetiology of hydatiform mole. Amer. Chir. Gynec., 51,428. Laufer, W., Zilberman, R. and Anteby, S.V. (1978): Ectopic pregnancy and intrauterine device. Harefuah, 94, 71. Lehfeldt, H., Tietze, C. and Gorstein, F. (1970): Ovarian pregnancy and the intrauterine contraceptive device. Amer. J. Obstet. Gynec., 108, 1105. McElin, T.W. and Iffy, L. (1976): Ectopic gestation: a consideration of new and controversial issues relating to pathogenesis and management. Obstet. Gynec. Ann., 5, 241. Pratt-Thomas, H.R., White, L. and Messer, H.H. (1974): Primary ovarian pregnancy, presentation of 10 cases including one full-term pregnancy. Sth. med. J. (Bgham, Ala.), 67,920. Pugh, W.E., Vogt, R.F. and Gibson, R.A. (1973): Primary ovarian pregnancy and the intrauterine device. Obstet. Gynec., 42, 218. Rengachary, D., Fayez, J.A. and Jonas, H.S. (1977): Ovarian pregnancy. Obstet. Gynec., 49,576. Spiegelberg, 0. (1978): Zur Casuistik den Ovarial-schwangenschaft. Arch. Gynaek., 13, 73. Tietze, C. (1968): Letter to the Editor. Amer. J. Obstet. Gynec., 101, 275.
333
333-337
OVARIAN PREGNANCY: ASSOCIATION WITH IUD, PELVIC PATHOLOGY AND RECURRENT ABORTION
J. REICHMAN,
J.A. GOLDMAN
and D. FELDBERG
Department of Obstetrics and Gynaecology, Hasharon Hospital, Tel-Aviv University Medical School, Tel Aviv, Israel Accepted
for publication
18 September
Petah-Tikva,
and
1981
REICHMAN, J., GOLDMAN, J.A. and FELDBERG, D. (1981): Ovarian pregnancy: association with IUD, pelvic pathology and recurrent abortion. Europ. J. Obstet. Gynec. reprod. Biol., 12/6, 333-337. Six cases of ovarian pregnancy were reviewed and their relationship with the IUD, fibromyoma of the uterus and previous spontaneous abortion was examined. In fact, 5 patients had an IUD in situ, in 2 women fibroids were found; 4 of the women had spontaneous abortions in their past history. The latter fact has been discussed, and it is suggested that this association may possibly contribute to an early diagnosis of ectopic pregnancy resulting in improved chances for conservative microsurgery. Attention is drawn to the fact that the diagnosis of ovarian pregnancy is often made only on microscopic examination. Thus, it is concluded that the true incidence of ovarian pregnancy may be higher than is apparent. ovarian
pregnancy;
IUD; recurrent
abortion
INTRODUCTION
In 1929, Grlfenberg noted the relationship between ovarian ectopic pregnancy and the intrauterine device (IUD). Until recently the incidence of ovarian pregnancies has been estimated at about l/25 000 to l/40 000 of all pregnancies and 0.7-l% of all ectopic gestations (Hertig, 1951). Since 1970 there has been an increasing number of reports of ovarian pregnancies, many of which were associated with IUDs (Puch et al., 1973; Pratt-Thomas et al., 1974; Hallatt, 1976; Grail et al., 1978; Evans et al., 1979). In a review of 33 ovarian pregnancies diagnosed in women with IUDs, Berger and Blechner (1978) found a ratio of 1 ovarian pregnancy to every 9 ectopic pregnancies in IUD users. Others (Tietze, 1968; Grey and Buffalo, 1978) reported a smaller ratio. In a review of the data from the Cooperative Statistical Program of the Population Council, Lehfeldt et al. (1970) estimated that IUDs reduced intrauterine implantation by 99.5%, tubal implantation by 95% and the incidence of ovarian pregnancy not at ail. Address Israel.
for correspondence:
0029-2243/81/0000-0000/$02.50
Professor
Jack
Goldman,
Hasharon
0 1981 Elsevier/North-Holland
Hospital,
Biomedical
Petah-Tikva,
Press
334 TABLE I DETAILS
OF OVARIAN
PREGNANCIES
Age
Obstetric history
IUD
Pregnancy test (/3subunits)
Presenting symptoms
Clinical findings
37
G5, Pl, Ab4 LMP not known
No
Positive
Pelvic mass
20-Wk size uterus and left adnexal mass
30
G2, P2 LMP 21 days prior to admission
Lippes loop (4 yr)
Positive
Metrorrhagia 2wk-IUD removed 1 wk prior to admission
Right adnexal mass (5 X 6 cm) positive culdocentesis
29
G2, P2 LMP 24 days prior to admission
Lippes loop (41 yr)
Not done
Lower abdominal pain day of admission
Shock, right adnexal fullness and tenderness, positive culdocentesis
36
Cl 2, P2, AblO LMP 60 days prior to admission
Lippes loop (21 yr)
Not done
Lower abdominal pain day of admission ; metrorrhagia 3 wk-IUD removed 2 wk prior to admission
Left adnexal mass (5 X 5 cm), positive culdocentesis
30
G3, P2, Abl LMP 3 5 days prior to admission
Copper T (3 yr)
Positive
Metrorrhagia
Enlarged fibroid uterus, laparoscopy
33
G4, P2, Ab2 LMP 26 days prior to admission
Copper
Negative
Abdominal
2 wk
pain
None, laparoscopy
Tz& yr)
Abbreviations used: G = gravida; P = para; Ab = abortion; LMP = last menstrual period; TAH = total abdominal hysterectomy; LSO = left salpingooophorectomy; RSO = right salpingooophorectomy.
Other factors reported to be conducive to ovarian pregnancy include previous abdominal surgery, PID, ineffectual tubal function, decidual reaction of the ovary and endometriosis (Rengachary et al., 1977). In the past 4 yr we have treated 6 patients with ovarian pregnancy; 5 with in situ IUDs and one in conjunction with a 20-wk-size fibroid uterus. One of the patients with an IUD also had a fibroid uterus. All cases met Spiegelberg’s requirements for the diagnosis of ovarian pregnancy (Spiegelberg, 1978). A summary of the 6 cases is presented in Table I.
335 (table I continued) Operative findings
Operative procedure
Morphology
Fibroid uterus, left ovarian hemorrhagic cyst (5 x 5 cm), both tubes and right ovary normal
TAH and LSO
Trophoblastic tissue in clots within cyst of left ovary, remnants of corpus luteum in cyst capsule, leiomyoma of uterus, normal right tube
400 cc Hemoperitoneum, hemorrhagic mass (6 X 6 cm) protruding from right ovary, both tubes and left ovary normal
RSO
Right ovary with blood clots containing trophoblastic tissue and villi, mild chronic salpingitis
2 000 cc Hemoperitoneum, right ruptured hemorrhagic ovarian cyst (5 x 4 cm) with active bleeding, both tubes and right ovary normal
RSO
Right ovary with ruptured corpus luteum containing clots, decidual cells and trophoblastic tissue, normal right tube
200 cc Hemoperitoneum, 4 X 5 cm ruptured hemorrhagic cyst of left ovary with many adherent clots
LSO
Left ovary with corpus luteum containing clots, trophoblastic tissue, normal left tube
Fibroid uterus, right corpus luteum, hemorrhagic cyst, both tubes and left ovary normal
Myomectomy RSO
Right ovary with ruptured corpus luteum, cyst containing trophoblastic tissue
50 cc Hemoperitoneum, no active bleeding, left ovary and both tubes normal, right ovary with blood clots
RSO
Right ovary with ruptured corpus luteum containing trophoblastic tissue
DISCUSSION
During this 4-yr period there was a total of 59 ectopic pregnancies treated in our department, 18 (30.5%) occurring in patients with in situ IUDs. This high incidence of ectopic pregnancy in patients using an IUD may be attributed to the recent increase in the use of this mode of contraception in our population and the inability of the IUD to protect these women from ectopic nidation. Laufer et al. (1978), in a review of ectopic pregnancies in a similar population, found a 21% association of ectopic pregnancies and IUD contraception. Ovarian pregnancies constituted 10.2% of all the ectopic pregnancies and 20% of our ectopic pregnancies in the group of patients using IUDs. This frequency is higher than that reported by Lehfeldt et al. (1970),
336
who proposed that the IUD does not prevent ovarian nidation. The possibility that the IUD may potentiate ovarian nidation must therefore be considered. It has been suggested that the IUD causes changes in the synthesis of prostaglandins so that tubal peristalsis is increased and this could increase the incidence of both tubal and ovarian pregnancies (Dar-wish, 1975). It should be noted that 2 of the patients were initially treated for vaginal bleeding and pelvic pain by removal of their IUDs, and the proper treatment was delayed for 14 days. Similar delays in diagnosis of ovarian pregnancies in IUD users have been noted by other authors (Pratt-Thomas et al., 1974, Hallat, 1976). The ovarian pregnancy in the patient with the fibroid uterus was diagnosed only after histological examination of an incidental hemorrhagic mass found at laparotomy. It is interesting to note the association between spontaneous abortion and ectopic ovarian pregnancy in 4 out of our 6 cases. In fact, there is evidence (Asherman, 1957; Berger and Blechner, 1978) that the major forms of abnormal human gestation, i.e., spontaneous abortion, hydatiform mole, ectopic pregnancy, dystopic placentation and fetal malformations, constitute a spectrum of conditions with a similar background of clinical associations and a significantly higher concurrence rate in the same patients (Darwish, 1975). Honor+ (1979), in a study of 83 patients with pathologically documented tubal ectopic pregnancy, demonstrated a statistically significant association between prior spontaneous abortion and ectopic pregnancy. He suggested that delayed (post-midcycle) ovulation, causing preovulatory over-ripeness of the ovum, may be the common underlying etiologic factor. Our series of 6 cases of ovarian ectopic pregnancy seems to confirm the association. It is also well to note the fact that mild chronic salpingitis was reported on histopathological examination only in one case. No conclusion can be drawn from such a small group of patients; nevertheless, if indeed a significantly higher early pregnancy wastage is confirmed in larger series of cases, this association may contribute to the earlier diagnosis of ectopic pregnancy, with improved chances for conservative management, i.e., a possibility of microsurgery, resulting in increasing the patients’ chances of subsequent reproductive success. The recent increase in documented cases of ovarian pregnancy may be due to the recognition of the importance of performing wedge resection and histological examination of all ovarian hemorrhagic cysts. In fact, Helde et al. (1972) in a review of five cases of ovarian pregnancy, found that in three cases the preliminary diagnosis at laparotomy was hemorrhagic cyst or corpus luteum and only after histological study was the correct diagnosis made. If the clinician is to diagnose and properly treat ovarian pregnancy at an early stage, he must be aware of its apparent association with IUDs, pelvic pathology and spontaneous abortion. Further reports of cases will help to clarify the true incidence of ovarian pregnancy and its correlation with these factors.
337 REFERENCES Asherman, J.G. (1957): De I’etiologie des grossesses extrauterines. Gynec. Obstet., 56, 462. Berger, B. and Blechner, J.N. (1978): Ovarian pregnancy associated with Copper-7 intrauterine device. Obstet. Gynec., 52, 597. Darwish, D.H. (1975): Ovarian ectopic pregnancy with IUCD. Brit. Med. J., 4,143. Evans, M.I., Angerman, N.S., Morauec, W.D. and Hajj, S. (1979): The intrauterine device and ovarian pregnancy. Fertil. Steril., 32, 31. Grall, J.Y., Jacques, Y. and Kerisit, J. (1978): Ovarian pregnancy. A review of the literature with reference to 4 personal cases. Fra-Rev. Fr. Gynec. Obstet., 72, 139. Gray, C.L. and Buffalo, E.H. (1978): Ovarian pregnancy associated with intrauterine contraception devices. Amer. J. Obstet. Gynec., 132, 134. Hallatt, J.G. (1976): Ectopic pregnancy with the intrauterine device: a study of seventy cases. Amer. J. Obstet. Gynec., 125, 754. Helde, M.D., Campbell, J.S. and Himaya, A. (1972): Detection of unsuspected ovarian pregnancy by wedge resection. Canad. med. Ass. J., 106, 237. Hertig, A.T. (1951): Discussion of Gerin Lajoie’s paper. Amer. J. Obstet. Gynec., 62, 926. Honor+, L.H. (1979): A significant association between spontaneous abortion and tubal ectopic pregnancy. Fertil. Steril., 32,401. Iffy, L. (1962): Contribution to the aetiology of hydatiform mole. Amer. Chir. Gynec., 51,428. Laufer, W., Zilberman, R. and Anteby, S.V. (1978): Ectopic pregnancy and intrauterine device. Harefuah, 94, 71. Lehfeldt, H., Tietze, C. and Gorstein, F. (1970): Ovarian pregnancy and the intrauterine contraceptive device. Amer. J. Obstet. Gynec., 108, 1105. McElin, T.W. and Iffy, L. (1976): Ectopic gestation: a consideration of new and controversial issues relating to pathogenesis and management. Obstet. Gynec. Ann., 5, 241. Pratt-Thomas, H.R., White, L. and Messer, H.H. (1974): Primary ovarian pregnancy, presentation of 10 cases including one full-term pregnancy. Sth. med. J. (Bgham, Ala.), 67,920. Pugh, W.E., Vogt, R.F. and Gibson, R.A. (1973): Primary ovarian pregnancy and the intrauterine device. Obstet. Gynec., 42, 218. Rengachary, D., Fayez, J.A. and Jonas, H.S. (1977): Ovarian pregnancy. Obstet. Gynec., 49,576. Spiegelberg, 0. (1978): Zur Casuistik den Ovarial-schwangenschaft. Arch. Gynaek., 13, 73. Tietze, C. (1968): Letter to the Editor. Amer. J. Obstet. Gynec., 101, 275.