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Primary ovarian pregnancy with living mother and child
PRIMARY
OVARIAN I.
J.
PREGNANCY WITH AND CHILD
STRUMPF,
PxO., (From
B.S., the Du~nl
MB., County
LIVING
JSCKSOWILLE,
MOTHER FIA.
Hospital)
T
HIS is to report for record, a case of primary ovarian pregnanq where a full-term living child was recovered by laparotomy. It is obvious from a study of the meager literature that this type of implantation of an ovum is rare, and a fctns developing to full term and living is so much rarer that a report of such an occurrence is justifiable. Most of these ovarian pregnancies terminate in the first trimester by ovarian abortion and are found at laparotomy. A Sew have reached full term, unsuspected by the patient and attendant until labor has supervened. Here again t,he usual termination is death of the fetus following an unproductive period of labor. Spiegelberg in 1879 laid down the following criteria for a diagnosis of primary ovarian pregnancy : 1. The tube on the affected side must be intact. 2. The fetal sac must occupg the position of the ovary. 3. It must be connected to the uterus by the ligament of the ovary. 4. Definite
ovarian
tissue
must
be found
in the walls
of the sac.
It is obvious that in a full-term child Ihe placenta would bc of such size and the anatomic distortion so great that one or more of these criteria could not hc fulfilled. However, sufficient anatomic and histologic evidence is presented to make certain the diagnosis here. The comment of Van %nckel (quoted l)y Schorach)’ concerning the high percentage of abnormalities noted in the babies at term carried as abdominal pregnancies is worthy of not,c. His figures run as high as 50 per cent. The child delivered as tlcscribed below exhibited no evidence of abnormality. The patient, an adult colored multipara (No. 141572)) aged 25 years, whose first child was delivered a6 home uneventfully ten years ago, presented herself at the Duval County Hospital Clinic for prenatal care. There was no history of miscarriage or abortion. She had had chronic pelvic inflammatory disease. Her last menstrual period occurred on Feb. 28, 1941, the quickening on June 15, 1941; Kahn test was negative. The first trimester was uneventful except for one incident which occurred on a visit to the clinic when she became nauseated and had ex-
~TRUMPF:
PRIMARY
OVARIAN
PREGN~NCT
351
treme pain in the right lower quadrant following a pelvic examination. She rested in the clinic for several hours and following this she was at home about a month with fever, nausea, and vomiting associated with lower abdominal pain. This subscquent,ly cleared up and the balance of her prenatal course was fairly normal. On present admission to hospital, Sept. 30, 1941, she claimed to have been in labor at home for about twelve hours with moderately severe regular ‘ ‘labor pains. ’ ’ On physical examination, the blood pressure was 130/80, Kahn was negative, and except for the abdominal examination, the findings were cssentiallv negative. The abdomen was irregular in contour and the fetal parts were very readily distinguishable. The head was in the right flank, the fetal axis in the transverse position. X-ray confirmed this finding. There was considerable tenderness in the upper abdomen but no rigidity. There was cystic swelling in the epigastrium. Fetal heart tones were heard in the umbilical region, loudest on the left, rate 140. No cont,ractions of uterus were palpated. On vaginal examination with aseptic precautions, the cervix was found to be soft and boggy but undilated, the external OS admitting the tip of one finger. Impression at this time was a full-term pregnancy with transverse presentation. C,ourse.-According to* her own story labor had begun the day before admission, Sept. 30, 1941. She complained of pains coming fairly regularly every five minutes and now were hard enough to warrant her coming t,o the hospital for relief. She was in subjective “hard” labor until Oct. 1, 1941. During this day no evidence of progress in labor was noted, but the patient’s pulse began to rise and she complained, in addition to her periodic labor pains, of a Nevere and persistent epigastric pain. She was also becoming markedly distended. I was called in at this time to see her. The labor pains over a period of twenty minutes came periodically at approximately five-minute intervals, During these periods of (‘labor” no uterine contractions were made out, the fetal outlines mere very readily palpable and the diagnosis of a transverse presentation was confirmed. There was continuous and severe epigastric pain. The patient was obviously suffering and her pulse had risen to between 140 and 160. Vaginal examination at this time showed a long, thick, and closed cervix. There was no bleeding following examination and no sign of fibroid or other mechanical interference with descent and engagement of a fetal pole. The pelvis was ample for delivery. The condition of this patient was bad and rapidly becoming worse, and laparotomy was ordered for a probable abdominal pregnancy. At operation under cyclopropane anesthesia, the abdomen was found distended and filled with thin-walled, purplish fetal membranes containing placenta and fetus at term. Uterus was soft, regular in contour, and smooth in outline, anterior in position, 3 to 4 times normal size. It was tremendously engorged with dilated vessels in right infundibulopelvic ligament. Placental encroachment and implantation in region of right broad ligament without any raw surfaces or attachments to uterus or gut. Left tube and ovary grossly normal. Greater part of omentum necrotic, amputated, caused apparently by impingement against pubic arch. Right ovary not recognized. Right round ligaThe removed specimen revealed membranes and comment, normal. plete, normal size placenta with smooth serosal..like covering throughout.
dttachetl lo one edge (11’this mass WilS tlla stutllp 011 the sUS~K!Ilsol’\~ l&-~ merit, oI’ lhe oval?-. The s;t(l was incised a,ntl tile spill snc~tioned \YII IIv 1tics 1)a.b-y was being delivcrcd. Cord was clamp~~i and cnt. Thr c*hiitl JV:IY l’ull term and cried sl~o~~I-iln(!ol~sl~ 111~11th~livcr\-. The cntirc& t.cGclual mass of placenta and mcinbrancs w;ls lyiitg free in the abdominal paYit>without adhesion to intestine, or other abdominal viscera, and was IYmoved by salpingo-oophorcetomy. The vessels in the right infundiLulopelvic ligament were huge and t,hc stump required considerable ligaturing to get adequate hemostasis. The abdomen was closed rontincl;- and 1he patient was returned to the ward.
Her postoperative course was entirely- sntisfact,ory and 1)ol.h Inot her and child were discharged in good condition on t.he fourteenth da>-. Pathologic examination as reported l,- Dt*. 1~. I’. D;rcufort.h, ] )athOIogist of Duval Counl,y Hospit,al, was as :Eollows : Gross : This specimrn (Ko. 14l.S’iB) consisted of a placenta with attached membranes and cord. The specimen presented several peculiarities: (1) The size was about 12 cm. in diameter and 4 cam. in thickness. (2) The umbilical cord was at.tached at the edge in a ver? unusual manner. (3) The amniotic membrane was thick and leathery, and it contained bet,ween its two layers remnants of placental tissue. (4) The large venous channels on the snrface of t,he amnion were extremely prominent. (5) At one pole dirccatly opposite the attachment of the umbilical cord there was a ragged mass containing many adhesions and fat. This was intimately adherent to the substance of the placeMa. Sectioning through the latter at, this point, revealed a whitish firm area between the two surfaces of the placenta, but containing portions of placental tissue within it. These whitish areas occurred at many places within the substance of the placenta. These sections apparent1.v bear out the existence of Microscopic: ectopic gestation within the ovary. At least two structures, other than those that were intrinsically placental, were present. And these were so intimately a part of the pregnwnqand its products that they could not be confused as artcfnct.s. In fact, the point of rupture scr~n~ed to have been included in the sectioning of the gross specimen and a definite, unmistakable rim of ovarian cortex appeared, thoroughly confluent as a growing and developing tissue, stretched over the charac,teristic placental structures : chorionic
STRUMPF
:
PRIMARY
OVARIAN
353
PREGNANCY
villi, hemorrhage, and bits of trophoblastic elements were broken off from the main mass. The whitish areas noted grossly were identified as infarcts, resulting from thrombosis of the branches of the umbilical vein.
Fig.
Z.-High
power
view
of
Fig.
1.
Other sections were being made, but I believe there was here incontrovertible proof of the existence of an ovarian pregnancy. Dtignosis.-Ovarian pregnancy. Acknowledgment is made to Dr. A. D. Stollenwoerck, Service, Duval County Hospital, for the privilege of using
Chief of the this case from
Obstetrica. his service.
Reference 1. Schorach,
W.:
Arch.
f. GynSk.
162:
371,
1936.
_
.I.
;
OVARIAN I.
J.
PREGNANCY WITH AND CHILD
STRUMPF,
PxO., (From
B.S., the Du~nl
MB., County
LIVING
JSCKSOWILLE,
MOTHER FIA.
Hospital)
T
HIS is to report for record, a case of primary ovarian pregnanq where a full-term living child was recovered by laparotomy. It is obvious from a study of the meager literature that this type of implantation of an ovum is rare, and a fctns developing to full term and living is so much rarer that a report of such an occurrence is justifiable. Most of these ovarian pregnancies terminate in the first trimester by ovarian abortion and are found at laparotomy. A Sew have reached full term, unsuspected by the patient and attendant until labor has supervened. Here again t,he usual termination is death of the fetus following an unproductive period of labor. Spiegelberg in 1879 laid down the following criteria for a diagnosis of primary ovarian pregnancy : 1. The tube on the affected side must be intact. 2. The fetal sac must occupg the position of the ovary. 3. It must be connected to the uterus by the ligament of the ovary. 4. Definite
ovarian
tissue
must
be found
in the walls
of the sac.
It is obvious that in a full-term child Ihe placenta would bc of such size and the anatomic distortion so great that one or more of these criteria could not hc fulfilled. However, sufficient anatomic and histologic evidence is presented to make certain the diagnosis here. The comment of Van %nckel (quoted l)y Schorach)’ concerning the high percentage of abnormalities noted in the babies at term carried as abdominal pregnancies is worthy of not,c. His figures run as high as 50 per cent. The child delivered as tlcscribed below exhibited no evidence of abnormality. The patient, an adult colored multipara (No. 141572)) aged 25 years, whose first child was delivered a6 home uneventfully ten years ago, presented herself at the Duval County Hospital Clinic for prenatal care. There was no history of miscarriage or abortion. She had had chronic pelvic inflammatory disease. Her last menstrual period occurred on Feb. 28, 1941, the quickening on June 15, 1941; Kahn test was negative. The first trimester was uneventful except for one incident which occurred on a visit to the clinic when she became nauseated and had ex-
~TRUMPF:
PRIMARY
OVARIAN
PREGN~NCT
351
treme pain in the right lower quadrant following a pelvic examination. She rested in the clinic for several hours and following this she was at home about a month with fever, nausea, and vomiting associated with lower abdominal pain. This subscquent,ly cleared up and the balance of her prenatal course was fairly normal. On present admission to hospital, Sept. 30, 1941, she claimed to have been in labor at home for about twelve hours with moderately severe regular ‘ ‘labor pains. ’ ’ On physical examination, the blood pressure was 130/80, Kahn was negative, and except for the abdominal examination, the findings were cssentiallv negative. The abdomen was irregular in contour and the fetal parts were very readily distinguishable. The head was in the right flank, the fetal axis in the transverse position. X-ray confirmed this finding. There was considerable tenderness in the upper abdomen but no rigidity. There was cystic swelling in the epigastrium. Fetal heart tones were heard in the umbilical region, loudest on the left, rate 140. No cont,ractions of uterus were palpated. On vaginal examination with aseptic precautions, the cervix was found to be soft and boggy but undilated, the external OS admitting the tip of one finger. Impression at this time was a full-term pregnancy with transverse presentation. C,ourse.-According to* her own story labor had begun the day before admission, Sept. 30, 1941. She complained of pains coming fairly regularly every five minutes and now were hard enough to warrant her coming t,o the hospital for relief. She was in subjective “hard” labor until Oct. 1, 1941. During this day no evidence of progress in labor was noted, but the patient’s pulse began to rise and she complained, in addition to her periodic labor pains, of a Nevere and persistent epigastric pain. She was also becoming markedly distended. I was called in at this time to see her. The labor pains over a period of twenty minutes came periodically at approximately five-minute intervals, During these periods of (‘labor” no uterine contractions were made out, the fetal outlines mere very readily palpable and the diagnosis of a transverse presentation was confirmed. There was continuous and severe epigastric pain. The patient was obviously suffering and her pulse had risen to between 140 and 160. Vaginal examination at this time showed a long, thick, and closed cervix. There was no bleeding following examination and no sign of fibroid or other mechanical interference with descent and engagement of a fetal pole. The pelvis was ample for delivery. The condition of this patient was bad and rapidly becoming worse, and laparotomy was ordered for a probable abdominal pregnancy. At operation under cyclopropane anesthesia, the abdomen was found distended and filled with thin-walled, purplish fetal membranes containing placenta and fetus at term. Uterus was soft, regular in contour, and smooth in outline, anterior in position, 3 to 4 times normal size. It was tremendously engorged with dilated vessels in right infundibulopelvic ligament. Placental encroachment and implantation in region of right broad ligament without any raw surfaces or attachments to uterus or gut. Left tube and ovary grossly normal. Greater part of omentum necrotic, amputated, caused apparently by impingement against pubic arch. Right ovary not recognized. Right round ligaThe removed specimen revealed membranes and comment, normal. plete, normal size placenta with smooth serosal..like covering throughout.
dttachetl lo one edge (11’this mass WilS tlla stutllp 011 the sUS~K!Ilsol’\~ l&-~ merit, oI’ lhe oval?-. The s;t(l was incised a,ntl tile spill snc~tioned \YII IIv 1tics 1)a.b-y was being delivcrcd. Cord was clamp~~i and cnt. Thr c*hiitl JV:IY l’ull term and cried sl~o~~I-iln(!ol~sl~ 111~11th~livcr\-. The cntirc& t.cGclual mass of placenta and mcinbrancs w;ls lyiitg free in the abdominal paYit>without adhesion to intestine, or other abdominal viscera, and was IYmoved by salpingo-oophorcetomy. The vessels in the right infundiLulopelvic ligament were huge and t,hc stump required considerable ligaturing to get adequate hemostasis. The abdomen was closed rontincl;- and 1he patient was returned to the ward.
Her postoperative course was entirely- sntisfact,ory and 1)ol.h Inot her and child were discharged in good condition on t.he fourteenth da>-. Pathologic examination as reported l,- Dt*. 1~. I’. D;rcufort.h, ] )athOIogist of Duval Counl,y Hospit,al, was as :Eollows : Gross : This specimrn (Ko. 14l.S’iB) consisted of a placenta with attached membranes and cord. The specimen presented several peculiarities: (1) The size was about 12 cm. in diameter and 4 cam. in thickness. (2) The umbilical cord was at.tached at the edge in a ver? unusual manner. (3) The amniotic membrane was thick and leathery, and it contained bet,ween its two layers remnants of placental tissue. (4) The large venous channels on the snrface of t,he amnion were extremely prominent. (5) At one pole dirccatly opposite the attachment of the umbilical cord there was a ragged mass containing many adhesions and fat. This was intimately adherent to the substance of the placeMa. Sectioning through the latter at, this point, revealed a whitish firm area between the two surfaces of the placenta, but containing portions of placental tissue within it. These whitish areas occurred at many places within the substance of the placenta. These sections apparent1.v bear out the existence of Microscopic: ectopic gestation within the ovary. At least two structures, other than those that were intrinsically placental, were present. And these were so intimately a part of the pregnwnqand its products that they could not be confused as artcfnct.s. In fact, the point of rupture scr~n~ed to have been included in the sectioning of the gross specimen and a definite, unmistakable rim of ovarian cortex appeared, thoroughly confluent as a growing and developing tissue, stretched over the charac,teristic placental structures : chorionic
STRUMPF
:
PRIMARY
OVARIAN
353
PREGNANCY
villi, hemorrhage, and bits of trophoblastic elements were broken off from the main mass. The whitish areas noted grossly were identified as infarcts, resulting from thrombosis of the branches of the umbilical vein.
Fig.
Z.-High
power
view
of
Fig.
1.
Other sections were being made, but I believe there was here incontrovertible proof of the existence of an ovarian pregnancy. Dtignosis.-Ovarian pregnancy. Acknowledgment is made to Dr. A. D. Stollenwoerck, Service, Duval County Hospital, for the privilege of using
Chief of the this case from
Obstetrica. his service.
Reference 1. Schorach,
W.:
Arch.
f. GynSk.
162:
371,
1936.
_
.I.
;