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Ovarian pregnancy and endometriosis
OVARIAN
PREGNANCY AND ENDOMETRIOSIS”
A Case Report JOHN HUGH
(From
the Department
P
of Obstetrics
RIMARY ovarian 120 having been endometriosis. With of 2.5 per cent of all
and Gynecology,
R.
DURBURG,
GAVIN
GRIMES,
St. Joseph
:M.D.,** M.D.,
Hospital,
AND
ILL.
CHICAGO,
Chicago)
pregnancy is the rarest of all eetopic pregnancies, only reported to date. Two of these had coexistent ovarian the following report, there are now 3 cases, an incidence ovarian pregnancies.
The criteria used for the diagnosis of primary ovarian pregnancy are those of Spiegelberg.” Further, this case was of the primary extrafollicular type, according to the classification based on site of implantation and development.* M. D., a 32-year-old grevida ii, para i, was seen on April 21, 1956, complaining of sharp, stabbing intermittent paraumbilical pain, weakness, and spncope. The last normal menses commenced on Jan. 1, 1956. A skimpy menses oczcurred in February with no further vaginal bleeding until admission. Four weeks prior to admission, there had been a 2 day episode of severe, intermittent lower abdominal pain that subsided spantaneously. There was a past history of pelvic inflammatory disease noted first in 1954. Examination revealed a pale white woman in acute distress. The blood pressure was 100/65, pulse 108 per minute, temperature 98” F. There was marked tenderness in both lower quadrants with rebound referred to the right lower quadrant. Voluntary guarding was present but no rigidity. Bowel sounds were normoactive. Pelvic examination disclosed a softened cervix, and an anterior soft, mobile corpus, enlarged to approximately the size of a 10 weeks’ gestation. The posterior cul-de-sac was filled with a tense, tender, cystic mass, approximately 6 by 6 by 4 1~11. The adncaxa could not be wt>11 delineated. Laboratory studies revealed a hemoglobin 31 per cent, and a white blood count of 13,700. 9.3 Qm. of hemoglobin and a hematocrit of 29 uterine pregnancy with an impacted hemorrhagic subjected to pelvic examination under anesthesia
of 10.9 Bm. per 100 ml., a hematocrit of A repeat hemogram 12 hours later disc:losr~l per cent. A tentative diagnosis of intraovarian cyst was made and t,he patient was followed by celiotomy.
When the abdomen was opened, the peritoneal cavity was found to be filled with The uterus was small, with a soft 5 by 5 by 6 cm. leiomyoma occupying the area. The left oviduct and ovary were adherent to i;he broad ligament and lateral wall. The right oviduct was apparently normal, The right ovary was not grossly identifiable. The posterior cul-de-sac was filled with a soft, spongy, hemorrhagic mass consisting mostly of placental tissue. It wa.s deemed technically impossible to resect the mass in the cul-de-sac and control bleeding without sacrificing the uterus, and hence a rapid supracervical hysterectomy and bilateral salpingo-oophorectomy were performed. The subsequent postoperative course was uneventful. blood. fundal pelvic
*Presented **Clinical
at a meeting of the Chicago Gynecological S#ociety, May Instructor, Stritch School of Mellicine of Loyola University, 285
17, 1957. Chicago,
111,
286
DURBURG
Fig.
1.
Fig.
2.
Fig.
3.
Figs.
1-3.-I7or
AXI)
legends
C+RTMES
see
opposite page.
Am. J. Obst. & Gyner. February. 19iR
l’oIume 75 Number 2 Pathologic
OVARIAN
PREGNANCY
AND
ENDOMETRIOSIS
287
FMings.-
ovary, measuring 6.3 by 4.5 by 2.2 cm., was irregular. On Section. Gross : The right there was a large unilocular cyst in part filled with clotted blood. The lining of the Adjacent to it cyst was smooth and glistening except for one large area of rupture. there was irregular, hemorrhagic tissue to which the placenta, measuring 7.2 by 7.1 by 3.0 cm., umbilical cord, and fetus (crown-rump measurement of 4.5 cm.) were attached. The remaining ovarian stroma contained a large corpus luteum. The size, shape, ami cut surface of t,he right oviduct were normal. The left adnexa was normal. The ~uprncervically amputated uterus (340 grams) contained several large leiomyomas. Microscopic : The right ovarian cyst was lined by tissue strongly suggestive of The glands contained endometrium, apparently both glands and stroma (Fig. 1). hemolyzed hlood and debris, and the stroma had marked decidual reaction (Fig. 2) and abundant hemosiderin pigment. Numerous other areas in t,he left ovary and oviduct contained similar endometrium-like tissue with a structure virtually identical with that A small portion of the left oviductal mucosa was al.so lining the endometrial cavity. replaced hp endometrium. Lying almost in contact with the endometrial lining of the right ovarian cyst, and in most areas surrounded by ovarian stroma, there was a large mass of placental tissue consisting of viable, well-formed decidua and choriorricL villi with abundant clot1 ed blood (Fig. 3). The pathologic diagnosis included right ovarian pregnancy; endometriosis with decidual reaction of the ovaries and left oviduct; leiompomas of the uterus; and right <>viduct with no pathologic diagnosis.
Comment The case reported is a primary ovarian pregnancy of the so-called extrafollicular type in that the adjacent ovarian tissue contained an apparently intact corpus luteum. The mode of implantation in this case is a matter of conjecture. Possibly the presence of endometrium within the ovary fa,vo#red nidation of the ovum, as Grin-Lajoiej stated. Maturation of the ovum within the oviduct is not considered necessary. The follicular ovum does undergo mitosis as past of the reduction division process.8 Thus a stray virile spermatozoon caould penetrate such an ovum, resulting in fertilization within the ovary. Such an event must have occurred in the case report, of an ovarian pregnancy occurring 11 years after a vaginal hpsterrctorny, complicated postoperatively bj- an asymptomatic fistula of the vaginal vault.” Bobrow and Winkelstein? believe pelvic inflammatory disease may he a basis for all extrauterine gestations. In the present case there was a history of such disease, without pathologic substantiation. The marked decidual reaction described in t,he endometrium in the present ease is noteworthy. Romney and associates9 reported a 19.1 per cent incidence Fig. I.--Unilocular ovarian cyst containing products of conception. Arrow at A reprecyst lined by a sin le layer of cuboidal to columnar epithelium, similar to endometrlal with subjacent en d ometrlal stromalike components containfng a marked de&dual reacAt B there is abundant hemorrhage. Beneath this (C’) is a well-formed chat-ionic villus. reduced ‘/4.) Fig. 2.-Another adjacent cyst wall lined by cuboidal to columnar epithelium with marked subjacent de&dual reaction in the stroma. (x100: reduced )/4.) Fig. 3.-A higher magnification revealing further cellular detail of a charionic vjllu~. (x100: reduced %.)
sents lining. tion. (x10:
288
DURBURG
ANJ)
GRIMES
Am. J. Obst. & Gym. February.
1958
of decidual reaction with ectopic pregnancies, the remaining cases containing nondecidual endometrium t’hat difftbrs in no way from that, seen in normal menstrual cycles. The fetus was well preserved, indicating that rupture had occurred just preceding operation. Its crown-rump measurement was 4.5 cm. representing a gestational age of 10 weeks.lO This first trimester termination is not unusual, because 75 per cent of ovarian pregnancies end then.l
Summary A brief discussion of the classification, incidence, and criteria for ovarian pregnancy has been presented, followed by a description of a single case of the primary extrafollicular type. The possible pathogenetic role of ectopic ovarian endometrium is discussed.
References 1. 2. 3, 4. 5. 6. 7. 8. 9. 10. 11. 12.
Baden, W. F., and Heins, 0. H.: AM. J. OBST. & GYNEC. 64: 353, 1952. Bobrow, M. L,, and Winkelstein, L. B.: Am. J. Burg. 91: 991, 1956. Farell, D. M., and Abrams, J.: Obst. & Gynec. 7: 562, 1956. Garry, J:, and Persona, L.: Obst. & Gynec. 9: 29, 195’7. G&in-LaJoie, L.: AK J. OBST. & GYNEC. 62: 920, 1951. Lyle, F. M., and Christianson, 0. 0.: Northwest. Med. 54: 1425, 1955. Pewters, J. T.: AM. J. OBST. & GYNEC. 71: 855, 1956. Rock, J., and Hertig, A. T.: AM. J. OBST. & GYNEC. 47: 343, 1944. Burg., Gynec. & Obst. 91: 605, 1950. Romney, S. L., Hertig, A. T., and Reid, D. E.: Scammon, R. E., and Calkins, L. A.: Proc. Sot. Exper. Biol. & Med. 20: 353, 1923. Spiegelberg, 0.: Arch. Gyn4ik. 13: 73, 1878. Tisdell, J. H., and Hill, W. T.: Obst. & Gynec. 7: 325, 1956.
PREGNANCY AND ENDOMETRIOSIS”
A Case Report JOHN HUGH
(From
the Department
P
of Obstetrics
RIMARY ovarian 120 having been endometriosis. With of 2.5 per cent of all
and Gynecology,
R.
DURBURG,
GAVIN
GRIMES,
St. Joseph
:M.D.,** M.D.,
Hospital,
AND
ILL.
CHICAGO,
Chicago)
pregnancy is the rarest of all eetopic pregnancies, only reported to date. Two of these had coexistent ovarian the following report, there are now 3 cases, an incidence ovarian pregnancies.
The criteria used for the diagnosis of primary ovarian pregnancy are those of Spiegelberg.” Further, this case was of the primary extrafollicular type, according to the classification based on site of implantation and development.* M. D., a 32-year-old grevida ii, para i, was seen on April 21, 1956, complaining of sharp, stabbing intermittent paraumbilical pain, weakness, and spncope. The last normal menses commenced on Jan. 1, 1956. A skimpy menses oczcurred in February with no further vaginal bleeding until admission. Four weeks prior to admission, there had been a 2 day episode of severe, intermittent lower abdominal pain that subsided spantaneously. There was a past history of pelvic inflammatory disease noted first in 1954. Examination revealed a pale white woman in acute distress. The blood pressure was 100/65, pulse 108 per minute, temperature 98” F. There was marked tenderness in both lower quadrants with rebound referred to the right lower quadrant. Voluntary guarding was present but no rigidity. Bowel sounds were normoactive. Pelvic examination disclosed a softened cervix, and an anterior soft, mobile corpus, enlarged to approximately the size of a 10 weeks’ gestation. The posterior cul-de-sac was filled with a tense, tender, cystic mass, approximately 6 by 6 by 4 1~11. The adncaxa could not be wt>11 delineated. Laboratory studies revealed a hemoglobin 31 per cent, and a white blood count of 13,700. 9.3 Qm. of hemoglobin and a hematocrit of 29 uterine pregnancy with an impacted hemorrhagic subjected to pelvic examination under anesthesia
of 10.9 Bm. per 100 ml., a hematocrit of A repeat hemogram 12 hours later disc:losr~l per cent. A tentative diagnosis of intraovarian cyst was made and t,he patient was followed by celiotomy.
When the abdomen was opened, the peritoneal cavity was found to be filled with The uterus was small, with a soft 5 by 5 by 6 cm. leiomyoma occupying the area. The left oviduct and ovary were adherent to i;he broad ligament and lateral wall. The right oviduct was apparently normal, The right ovary was not grossly identifiable. The posterior cul-de-sac was filled with a soft, spongy, hemorrhagic mass consisting mostly of placental tissue. It wa.s deemed technically impossible to resect the mass in the cul-de-sac and control bleeding without sacrificing the uterus, and hence a rapid supracervical hysterectomy and bilateral salpingo-oophorectomy were performed. The subsequent postoperative course was uneventful. blood. fundal pelvic
*Presented **Clinical
at a meeting of the Chicago Gynecological S#ociety, May Instructor, Stritch School of Mellicine of Loyola University, 285
17, 1957. Chicago,
111,
286
DURBURG
Fig.
1.
Fig.
2.
Fig.
3.
Figs.
1-3.-I7or
AXI)
legends
C+RTMES
see
opposite page.
Am. J. Obst. & Gyner. February. 19iR
l’oIume 75 Number 2 Pathologic
OVARIAN
PREGNANCY
AND
ENDOMETRIOSIS
287
FMings.-
ovary, measuring 6.3 by 4.5 by 2.2 cm., was irregular. On Section. Gross : The right there was a large unilocular cyst in part filled with clotted blood. The lining of the Adjacent to it cyst was smooth and glistening except for one large area of rupture. there was irregular, hemorrhagic tissue to which the placenta, measuring 7.2 by 7.1 by 3.0 cm., umbilical cord, and fetus (crown-rump measurement of 4.5 cm.) were attached. The remaining ovarian stroma contained a large corpus luteum. The size, shape, ami cut surface of t,he right oviduct were normal. The left adnexa was normal. The ~uprncervically amputated uterus (340 grams) contained several large leiomyomas. Microscopic : The right ovarian cyst was lined by tissue strongly suggestive of The glands contained endometrium, apparently both glands and stroma (Fig. 1). hemolyzed hlood and debris, and the stroma had marked decidual reaction (Fig. 2) and abundant hemosiderin pigment. Numerous other areas in t,he left ovary and oviduct contained similar endometrium-like tissue with a structure virtually identical with that A small portion of the left oviductal mucosa was al.so lining the endometrial cavity. replaced hp endometrium. Lying almost in contact with the endometrial lining of the right ovarian cyst, and in most areas surrounded by ovarian stroma, there was a large mass of placental tissue consisting of viable, well-formed decidua and choriorricL villi with abundant clot1 ed blood (Fig. 3). The pathologic diagnosis included right ovarian pregnancy; endometriosis with decidual reaction of the ovaries and left oviduct; leiompomas of the uterus; and right <>viduct with no pathologic diagnosis.
Comment The case reported is a primary ovarian pregnancy of the so-called extrafollicular type in that the adjacent ovarian tissue contained an apparently intact corpus luteum. The mode of implantation in this case is a matter of conjecture. Possibly the presence of endometrium within the ovary fa,vo#red nidation of the ovum, as Grin-Lajoiej stated. Maturation of the ovum within the oviduct is not considered necessary. The follicular ovum does undergo mitosis as past of the reduction division process.8 Thus a stray virile spermatozoon caould penetrate such an ovum, resulting in fertilization within the ovary. Such an event must have occurred in the case report, of an ovarian pregnancy occurring 11 years after a vaginal hpsterrctorny, complicated postoperatively bj- an asymptomatic fistula of the vaginal vault.” Bobrow and Winkelstein? believe pelvic inflammatory disease may he a basis for all extrauterine gestations. In the present case there was a history of such disease, without pathologic substantiation. The marked decidual reaction described in t,he endometrium in the present ease is noteworthy. Romney and associates9 reported a 19.1 per cent incidence Fig. I.--Unilocular ovarian cyst containing products of conception. Arrow at A reprecyst lined by a sin le layer of cuboidal to columnar epithelium, similar to endometrlal with subjacent en d ometrlal stromalike components containfng a marked de&dual reacAt B there is abundant hemorrhage. Beneath this (C’) is a well-formed chat-ionic villus. reduced ‘/4.) Fig. 2.-Another adjacent cyst wall lined by cuboidal to columnar epithelium with marked subjacent de&dual reaction in the stroma. (x100: reduced )/4.) Fig. 3.-A higher magnification revealing further cellular detail of a charionic vjllu~. (x100: reduced %.)
sents lining. tion. (x10:
288
DURBURG
ANJ)
GRIMES
Am. J. Obst. & Gym. February.
1958
of decidual reaction with ectopic pregnancies, the remaining cases containing nondecidual endometrium t’hat difftbrs in no way from that, seen in normal menstrual cycles. The fetus was well preserved, indicating that rupture had occurred just preceding operation. Its crown-rump measurement was 4.5 cm. representing a gestational age of 10 weeks.lO This first trimester termination is not unusual, because 75 per cent of ovarian pregnancies end then.l
Summary A brief discussion of the classification, incidence, and criteria for ovarian pregnancy has been presented, followed by a description of a single case of the primary extrafollicular type. The possible pathogenetic role of ectopic ovarian endometrium is discussed.
References 1. 2. 3, 4. 5. 6. 7. 8. 9. 10. 11. 12.
Baden, W. F., and Heins, 0. H.: AM. J. OBST. & GYNEC. 64: 353, 1952. Bobrow, M. L,, and Winkelstein, L. B.: Am. J. Burg. 91: 991, 1956. Farell, D. M., and Abrams, J.: Obst. & Gynec. 7: 562, 1956. Garry, J:, and Persona, L.: Obst. & Gynec. 9: 29, 195’7. G&in-LaJoie, L.: AK J. OBST. & GYNEC. 62: 920, 1951. Lyle, F. M., and Christianson, 0. 0.: Northwest. Med. 54: 1425, 1955. Pewters, J. T.: AM. J. OBST. & GYNEC. 71: 855, 1956. Rock, J., and Hertig, A. T.: AM. J. OBST. & GYNEC. 47: 343, 1944. Burg., Gynec. & Obst. 91: 605, 1950. Romney, S. L., Hertig, A. T., and Reid, D. E.: Scammon, R. E., and Calkins, L. A.: Proc. Sot. Exper. Biol. & Med. 20: 353, 1923. Spiegelberg, 0.: Arch. Gyn4ik. 13: 73, 1878. Tisdell, J. H., and Hill, W. T.: Obst. & Gynec. 7: 325, 1956.