{"paper_id":"21d55c41-166a-4523-a7d7-04b5d65cbd54","body_text":"Ovarian ectopic pregnancy (OEP) is a well-known but rare type of ectopic pregnancy, accounting for approximately 0.5 %–3 % of all ectopic pregnancies [ 1 ]. A systematic review of reports on OEP published on February 2023 found 667 articles of OEP since 1945 [ 2 ]. It is a potentially fatal type of ectopic pregnancy due to its occurrence in highly vascularized ovarian tissue and its association with a higher chance of rupture of the gestational sac, which leads to intraperitoneal bleeding and hemorrhagic shock [ 1 , 3 ]. It is difficult to diagnose OEP preoperatively, as it can mimic tubal pregnancy or complicated ovarian cysts, both clinically and in radiological studies [ 1 , 4 , 5 ]. Here, we present a rare case of ovarian ectopic pregnancy in a 28-year-old multiparous woman. This work has been reported in line with the SCARE guideline [ 6 ].\n\nA 28-year-old gravida 5 para 4 (all alive and spontaneous vaginal deliveries) woman who had been amenorrheic for 4 weeks presented to the gynecologic emergency department with a complaint of abdominal pain lasting 4 days. The pain initially was on the right side and then progressively involved the whole abdomen. Otherwise, she had no history of vaginal bleeding, contraceptive use, or trauma to the abdomen.\nOn physical examination, she was tachycardic (pulse rate = 120, blood pressure = 120/68, and respiratory rate = 20). She exhibited conjunctival pallor. On abdominal examination, there was diffuse abdominal tenderness with no mass or organomegaly. There was cervical motion tenderness, and the cervix was closed on per vaginum examination. Her complete blood count profile showed moderate anemia (hemoglobin = 8.9 g/dl, hematocrit = 19.6 %). The urine β-HCG was positive. Abdominal-pelvic ultrasound revealed free fluid collection in the cul-de-sac, paracolic gutter, and Morrison's pouch. The uterus was empty, and there was a 2 × 3 cm complex right adnexal mass.\nGiven these finding; she was taken to the operating room for an emergency exploratory laparotomy. The abdomen was entered through a midline infraumbilical incision, revealing a ruptured right ovarian ectopic pregnancy and hemolyzed hemoperitoneum, with normal-appearing contralateral adnexa. Therefore, a right salpingo-oophorectomy was performed, and 500 ml of hemoperitoneum was aspirated.\nThe resected specimen was sent to the pathology department. Macroscopic examination demonstrated a 4.5 × 3 × 2 cm gray-white to gray-brown ovary, with a 2 × 2 cm hemorrhagic focus on cut sections ( Fig. 1 ). Histopathologic sections revealed chorionic villi and trophoblastic cells along with hemorrhage and fibrin within the ovary, adjacent to a mature corpus luteum, confirming intraovarian pregnancy ( Fig. 2 ). Fig. 1 Gross image of an ovary and a hemorrhagic focus (red arrow) of an OEP. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) Fig. 1 Fig. 2 Demonstrates histopathologic images of OEP. (A) Chronic villi (green arrow) embedded in hemorrhage (red arrow) and surrounded by corpus luteum (black arrow). (B) Corpus luteum (black arrow) with hemorrhagic area (red arrow) and syncytiotrophoblast (green arrow). (C) Ovarian stroma (black arrow) and hemorrhagic focus (red arrow). (D) Chorionic villi (green arrows). embedded in hemorrhage (4×, hematoxylin and eosin). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) Fig. 2\nGross image of an ovary and a hemorrhagic focus (red arrow) of an OEP. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)\nDemonstrates histopathologic images of OEP. (A) Chronic villi (green arrow) embedded in hemorrhage (red arrow) and surrounded by corpus luteum (black arrow). (B) Corpus luteum (black arrow) with hemorrhagic area (red arrow) and syncytiotrophoblast (green arrow). (C) Ovarian stroma (black arrow) and hemorrhagic focus (red arrow). (D) Chorionic villi (green arrows). embedded in hemorrhage (4×, hematoxylin and eosin). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)\nThe patient had a smooth postoperative period and was discharged on the fifth day with iron supplements and injectable contraceptives.\n\nThe incidence of ovarian pregnancy is estimated to be 1 in 7000 to 40,000 live births [ 2 ]. Ectopic pregnancy is among the causes of first-trimester maternal death, accounting for around 10 % of pregnancy-related deaths [ 7 ].\nThe cause of ovarian ectopic pregnancy (OEP) is not clearly established, but several factors are associated with it. The proposed risk factors for OEP include the use of intrauterine devices (IUDs), assisted reproductive technologies (ART), endometriosis, pelvic inflammatory diseases, and previous pelvic or abdominal surgeries [ 2 , 3 ]. Previous pelvic or abdominal surgeries and IUDs are among the most frequently encountered risk factors, with around 81 % of OEP associated with IUDs [ 1 , 2 , 18 ]. IUDs can damage the fallopian tubal epithelium and interrupt the normal migration of the ovum [ 8 , 9 ]. Pelvic adhesions caused by pelvic inflammatory disease (PID), previous surgeries, or endometriosis can prevent the release of the ovum, which leads to fertilization in the ovary [ 3 ]. Various theories have been proposed regarding the mechanism of ovarian implantation in women undergoing ART, such as: uterine contractions resulting from difficult embryo transfer can lead to the retrograde movement of embryos through the fallopian tubes and into the ovary; ovarian trauma after oocyte retrieval can facilitate embryo implantation at the injured site; and a large number of spermatozoa that reach the ovary following intrauterine insemination can fertilize the ovum [ 3 ]. The patients can also present without any risk factors [ 10 ], like in this case.\nClinically, the patients presented with abdominal pain and amenorrhea, followed by vaginal bleedin [ 11 ]. When complicated by rupture, the main presentation will be hemorrhagic shock. Most of the cases are found in the first trimester [ 12 ]. However, there are reports of cases that lasted until full term [ 13 ].\nThe diagnosis of OEP is usually made postoperatively and confirmed by histopathological examination. Its similar clinical presentation and sonographic features to tubal pregnancy and complicated ovarian cysts make preoperative diagnosis difficult. The diagnosis remains challenging even during surgery [ 14 , 15 ]. Therefore; Spiegelberg's criteria are used for intraoperative diagnosis. The criteria include the presence of a normal ipsilateral tube that is separate from the ovary, the pregnancy occupying a normal position on the ovary, the ovary being attached to the uterus by the ovarian ligament, and pathologic confirmation of placental tissue attached to the ovarian stroma [ 9 , 15 ]. Ultrasound is the preferred imaging modality for the diagnosis of OEP. The classic sonographic features are a cyst with a wide echogenic outer ring and an empty uterus [ 8 , 15 , 18 ]. In this patient, the abdominopelvic ultrasound shows an empty uterus and a right adnexal complex mass, but it does not definitively indicate the exact location of the ectopic pregnancy. Therefore, the diagnosis of OEP was made intraoperatively and confirmed by histopathologic examination.\nSurgery is the main modality of treatment for OEP, either laparotomy or laparoscopic surgery [ 1 ]. Laparoscopic surgery is becoming the preferred treatment over laparotomy since it has fewer complications and a shorter hospital stay [ 1 , 5 , 16 ]. Medical treatment with methotrexate (MTX) is controversial. There are reports of successful management of OEP with MTX [ 17 ]. However, Xin Zhou et al. report a trial of MTX treatment in three patients, which failed in all cases, and they were later managed surgically [ 1 ]. Our patient has been managed surgically by laparotomy since laparoscopic surgery is not available in our facility.\n\nIn conclusion, OEP is a rare potentially fatal condition. It is a diagnostic challenge since it is rare and mimics tubal ectopic pregnancy and complicated ovarian cysts. It should always be considered in patients presenting with amenorrhea, vaginal bleeding, and abdominal pain, particularly in those using an IUDs. Surgery is the mainstay of management, and histopathologic examination is crucial for confirming the diagnosis.\n\nART assisted reproductive technologies IUDs intrauterine devices OEP Ovarian ectopic pregnancy PID pelvic inflammatory disease MTX methotrexate β- HCG β- human chorionic gonadotropin\nassisted reproductive technologies\nintrauterine devices\nOvarian ectopic pregnancy\npelvic inflammatory disease\nmethotrexate\nβ- human chorionic gonadotropin\n\nWritten informed consent was obtained from the patient for publication of this case report and accompanying images.\n\nThe study was notified to the university ethics committee; but this is case report and it does not need a specific ethical approval.\n\nSeblewengel Maru Wubalem\nShemsu Abraham Hussien\n\nThis work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors .\n\n1. Seblewengel Maru Wubalem: Conceptualization; Data curation; Resources; Visualization; riting – original draft; Writing – review and editing 2. Birhanu Kassie Reta: Data curation; Visualization; Writing – review and editing 3. Mihiret Adane Woldemichael: Data curation; Visualization; Writing – review and editing 4. Sara Alemnew Wedaj: Data curation; Visualization; Writing – review and editing 5. Shemsu Abraham Hussien: Data curation; Supervision; Visualization; Writing – original draft; Writing – review and editing\nSeblewengel Maru Wubalem: Conceptualization; Data curation; Resources; Visualization; riting – original draft; Writing – review and editing\nBirhanu Kassie Reta: Data curation; Visualization; Writing – review and editing\nMihiret Adane Woldemichael: Data curation; Visualization; Writing – review and editing\nSara Alemnew Wedaj: Data curation; Visualization; Writing – review and editing\nShemsu Abraham Hussien: Data curation; Supervision; Visualization; Writing – original draft; Writing – review and editing\n\nThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.","source_license":"CC-BY-4.0","license_restricted":false}