Some advocate leaving the placenta in place as the lesser of two evils. It decreases the chance of immediate life-threatening hemorrhage, but at the expense of long-term sequelae. If let in the abdominal cavity, the placenta commonly becomes infected, with subsequent formation of abscesses, adhesions, intestinal or ureteral obstruction, and wound dehiscence (Bergstrom, 1998; Martin, 1988). In many of these cases, surgical removal becomes inevitable. If the placenta is let, its involution may be monitored using sonography and serum �-hCG levels (France, 1980; Martin, 1990). Color Doppler sonography can be used to assess changes in blood low. In some cases, and usually depending on its size, placental function rapidly declines, and the placenta is resorbed. But placental resorption may take years (Roberts, 2005; Valenzano, 2003).
If the placenta is left in place, postoperative methotrexate use is controversial. It has been recommended to hasten involution but has been reported to cause accelerated placental destruction with accumulation of necrotic tissue and infection with abscess formation (Rahman, 1982). It is diicult to envision a supporting role for the use of an antimetabolite for a senescent organ (Worley, 2008).
Ectopic implantation of the fertilized egg in the ovary is rare and is diagnosed if four clinical criteria are met. hese were outlined by Spiegelberg (1878): (1) the ipsilateral tube is intact and distinct from the ovary; (2) the ectopic pregnancy occupies the ovary; (3) the ectopic pregnancy is connected by the uteroovarian ligament to the uterus; and (4) ovarian tissue can be demonstrated histologically amid the placental tissue. Risk factors are similar to those for tubal pregnancies, but ART or IUD failure seems to be disproportionately associated (Zhu, 2014). Presenting complaints and findings mirror those for tubal ectopic pregnancy. Although the ovary can accommodate the expanding pregnancy more easily than the fallopian tube, rupture at an early stage is the usual consequence (Melcer, 2016).
Transvaginal sonography use has resulted in a more frequent diagnosis of unruptured ovarian pregnancies. Sonographically, an internal anechoic area is surrounded by a wide echogenic ring, which in turn is surrounded by ovarian cortex (Comstock, 2005). In their review of 49 cases, Choi and associates (2011) noted that the diagnosis may not be made until surgery, as many cases are presumed tubal ectopic pregnancy. Moreover, at surgery, an early ovarian pregnancy may be considered to be a hemorrhagic corpus luteum.
Evidence-based management accrues mainly from case reports (Hassan, 2012; Scutiero, 2012). Classically, management for ovarian pregnancies has been surgical. Small lesions can be managed by ovarian wedge resection or cystectomy, whereas larger lesions require oophorectomy (Elwell, 2015; Melcer, 2015). With conservative surgery, 3-hCG levels should be monitored to exclude remnant trophoblast.