Ovarian pregnancies represent between 1 to 6% of all ectopic pregnancies and remain a challenge for the diagnosis , even with technological advancements in imaging methods. It is estimated that this event occurs in up to 1:70.000 pregnancies and one of the consequences is the rupture at an earlier stage, associated with high rates of circulatory collapse and maternal fetal morbidity and mortality [2,3]. In relation to the ovaries, when diagnosed in early stages, most of them require surgical treatment; it can be conservative (wedge resection) or radical (oophorectomy). The first option can be destinaded to patients with reproductive desire or single ovary, and the second is limited to cases of advanced pregnancies. The definitive diagnosis is made during the intraoperative period and histopathological confirmation . The placenta may be left in situ in situations involving large vessels or vital structures, as spontaneous resorption will occur. Placental maintenance is associated with great morbidity such as paralytic ileus, intestinal obstruction, thromboembolism, hemorrhage or infections, however, low mortality .
E.M.P., 26 years old, black, married, primigravida, admitted to the service at 28 weeks and 1 day of gestation, with mild pain in the lower abdomen and blood pressure 170x120mmHg, without headache, scotoma or visual turbidity. She underwent this first hospitalization for clinical investigation, with a diagnostic hypothesis of Hypertensive Disease of Gestation and nephropathy to be clarified. She was submitted to complementary examinations with ultrasound of urinary tract that diagnosed a single kidney. The conclusion of the obstetric
ultrasound was single fetal in pelvic presentation, longitudinal situation, gestational age of 30 weeks and 4 days, estimated weight of 1528g.
The patient was submitted to a complementary transvaginal US, where it was observed in right adnexal region uterus image, measuring 12cm in the largest diameter with 10mm endometrium and empty cavity. A fetus was identified on the right flank and the hypotheses of topic pregnancy (uterus Didelphys) or ectopic pregnancy (abdominal pregnancy) were suggested.Magnetic resonance imaging of the pelvis revealed Mullerian malformation with the presence of two uterine bodies, single cervix and norm implanted placenta. One of the cavities had a fetus in pelvic presentation, while the other had no alterations. After the examination, it was determined that there was no urgency to resolve the gestation and the patient was discharged after the stabilization of the clinical condition.
The patient was readmitted after 8 days complaining of lower abdominal pain, epigastralgy and blood pressure of 170x120mmHg. She had an obstetric ultrasonography performed indicating a single, live fetus in pelvic presentation, restriction of intrauterine growth below p10, with gestational age of 32 weeks and 3 days, weight of 1860g. The concept evolved with acute fetal distress and bradycardia, and the cesarean section was indicated. During the surgery, extra-uterine gestation was identified, and the gynecological surgery team was informed.Placental and fetal insertion was detected in the right ovary (Figure 1) with intense vascularization coming from the abdominal aorta (Figure 2). An intense adhesion process of the omentum and bowel were also identified, as well as the left ovary without alterations and a non-gravid uterus with normal format and consistency.
After lysis of adhesion, the extraction of a single live concept,
with 1715g of weight, APGAR 8/9, plated in thick meconium
fluid and Capurro of 37 weeks was performed (Figure 3). The
cord was clamped at the placental insertion base and the ovary
was sutured using a synthetic absorbent thread and applying
regenerated oxidized cellulose to prevent pelvic adhesions in the
future (Figure 4). At the end of the procedure, she was referred
to the ICU, prescribed prophylactic antibiotics, analgesia and
prophylaxis for thromboembolism. After 3 days, the patient
was referred to the highrisk ward, which underwent infectious,
hemantimetric and imaging tests to prevent acute hemorrhagic
disease. Placental resorption was monitored for a period of 2
months and after stabilization of the condition, the patient was
referred to the specialty outpatient clinic.
Ovarian gestation is a rare occurrence in obstetrics, becoming
an even rarer event when it progresses with a live, viable
fetus until its birth and with postnatal development without
alterations . The case in question demonstrates an immense
diagnostic challenge, even with the use of nuclear magnetic
resonance, since it is a rare obstetric pathology. The favorable
evolution observed in the report, with survival of the mother and
its concept, constitutes the exception, not the rule. Therefore,
we must continue to follow the recommendations of the latest
evidence, acting with the interruption of gestation treatment
facing an early diagnosis, through clinical or surgical management
[7,4]. When the diagnosis occurs between the second and third
trimester, due to an intense local vascularization, it is possible to
opt for an expectant conduct and control of the fetal vitality until
it reaches the viability. Although we must explain all the risks
and leave the patients comfortable to decide whether they will
choose or not to continue the pregnancy and receive the signed
informed consent.The guidelines of greater impacts guide the
interruption of pregnancy, either by clinical or surgical methods.
Therefore, based on the case presented and some other rare
reports in the literature, we are faced with the need for more
publications that may guide us to maintain an ovarian pregnancy
until viability or follow the current recommendations.