Advanced Ruptured Ovarian Ectopic Pregnancy at 19 Weeks' Gestation Presenting With Massive Hemoperitoneum: A Case Report.

A 30‐year‐old gravida 4 para 3 woman presented to our emergency department with progressively worsening abdominal pain and vaginal spotting. Her last normal menstrual period was unknown, although she reported a 5‐month history of amenorrhea. The abdominal pain had initially started 1 week earlier, for which she sought care at a local health facility and received intravenous fluids without clinical improvement. Four days later, her symptoms worsened, with increasing abdominal pain over 2 days accompanied by vaginal spotting, prompting referral to our institution. She had no history of previous ectopic pregnancy, pelvic surgery, pelvic inflammatory disease, sexually transmitted infection, infertility, endometriosis, or cigarette smoking. On arrival, the patient appeared acutely ill and markedly pale. She was in hypovolemic shock, with a weak pulse of 120 beats/min and an initially unrecordable blood pressure. Following resuscitation with 2 L of Ringer's lactate, her blood pressure improved to 70/50 mmHg. Abdominal examination demonstrated diffuse tenderness with features of peritoneal irritation. On pelvic examination, cervical motion tenderness was elicited, and blood was noted on the examining glove.

Berhe Tekle Tsehaye: conceptualization, data curation, project administration, visualization, writing – original draft, writing – review and editing. Birhanu Kassie Reta: supervision, data curation, writing – review and editing. Aregawi Areaya Woldegiwergis: data curation, investigation. Gebrehiwet Legese Gebremedhn: supervision, data curation, writing – review and editing. Ataklti Gebremedhin Woldemichael: supervision, data curation. Andom Geremew Tesfay: writing – review and editing.

The study was notified to the institution ethics committee, but this is a case report and it does not need a specific ethical approval.

The authors have nothing to report.

A urine pregnancy test was positive. Initial laboratory investigations revealed severe anemia with a hemoglobin level of 6.7 g/dL, and her blood group was O positive. Pelvic ultrasonography demonstrated a large amount of free intraperitoneal fluid, an empty uterine cavity, and an enlarged uterus. A fetus corresponding to approximately 19 weeks of gestation based on femoral length was visualized freely floating within the abdominal cavity. Based on the clinical presentation and ultrasonographic findings, a diagnosis of ruptured advanced ectopic pregnancy with massive hemoperitoneum was made. After informed written consent was taken, emergency exploratory laparotomy was undertaken. Intraoperatively, approximately 2500 mL of hemoperitoneum was evacuated. A ruptured left ovarian pregnancy was identified with active bleeding from the rupture site. A 19‐week fetus was found freely floating within the peritoneal cavity, connected to the placenta by an intact umbilical cord (Figure  1 ). The uterus appeared normal, corresponding to approximately a 12‐week gestational size, while the contralateral fallopian tube and ovary were grossly unremarkable. A left salpingo‐oophorectomy was performed to achieve definitive hemorrhage control (Figure  2 ). Intraoperative clinical images demonstrating the relation of the fetus to the ovary and fallopian tube. (A) The fetus with the ovary (star) and placenta. (B) Fetus with the fallopian tube (arrow). The uterus after left salpingo‐oophorectomy (arrow).

The patient recovered well following surgery. After successful extubation, she was transferred to the recovery unit and received three units of packed red blood cells. Her postoperative course was uneventful, and she was discharged on postoperative day four in stable condition. Upon follow‐up, she remained asymptomatic with satisfactory wound healing and a hemoglobin level of 11.0 g/dL.

Primary ovarian pregnancy is one of the rarest forms of ectopic pregnancy. Over recent decades, the reported incidence of ovarian ectopic pregnancies has risen from approximately 0.7% to 1% of all ectopic cases in the 1950s to as high as 3.5% in more recent studies. The precise reason for embryo implantation in the ovary remains unclear. However, several theories have been suggested: delayed release of the ovum, thickening of the tunica albuginea, fallopian tube dysfunction, and the use of intrauterine devices. Researchers have proposed two hypotheses to explain a rare phenomenon. One hypothesis proposes that fertilization happens first, followed by the fertilized egg moving from the fallopian tube to the ovary for implantation. The alternative theory suggests that fertilization occurs within the ovarian follicle before the egg is released, resulting in implantation on the ovary [ 4 ]. About 74% of women with an ovarian pregnancy are initially unaware of the condition. The actual incidence is probably underreported, as many early pregnancies may fail and be reabsorbed naturally. Additionally, some cases suspected to be tubal pregnancies are managed conservatively using methotrexate without confirmation through laparoscopy [ 5 ]. The causes of ovarian pregnancy remain poorly understood, though certain risk factors have been suggested, particularly those involving impaired tubal motility [ 6 ]. Key risk factors include the use of intrauterine contraceptive devices, prior pelvic or adnexal surgeries, pelvic inflammatory disease, and endometriosis [ 1 , 6 ]. Among these, previous pelvic or abdominal surgical procedures and the presence of an IUD are most commonly reported, with IUDs linked to approximately 81% of ovarian ectopic pregnancies [ 1 ]. Ectopic pregnancy most frequently presents with missed periods, vaginal bleeding, and abdominal pain [ 2 , 3 , 6 ]. Early confirmation of the location of pregnancy is important because ectopic pregnancy can progress to tubal or ovarian rupture and life‐threatening intra‐abdominal hemorrhage. Women of reproductive age presenting with abdominal or pelvic pain, particularly when associated with vaginal bleeding or a positive pregnancy test, should be evaluated for ectopic pregnancy. The diagnostic approach includes clinical and hemodynamic assessment, quantitative serum β‐hCG measurement, and transvaginal ultrasonography. When an intrauterine pregnancy cannot be confirmed, serial β‐hCG measurements and repeat ultrasonography may be required to establish the diagnosis and exclude a pregnancy of unknown location. Research indicates that TVUS offers greater accuracy and sensitivity than TAUS in identifying early ectopic pregnancies [ 7 , 8 ]. Primary ovarian pregnancy is among the least common forms of extrauterine gestation. Ovarian ectopic pregnancy is typically diagnosed after surgery and confirmed through histopathological analysis. Even during surgical exploration, accurate identification can be difficult, which is why Spiegelberg's criteria are applied for intraoperative diagnosis. These criteria involve: a normal ipsilateral fallopian tube distinct from the ovary, the pregnancy located in the typical anatomical position on the ovary, the ovary connected to the uterus via the ovarian ligament, and histological evidence of placental tissue within the ovarian stroma [ 1 , 9 , 10 ]. Management should be individualized according to the patient's clinical status, β‐hCG concentration, ultrasound findings, size of the ectopic pregnancy, presence or absence of embryonic cardiac activity, and ability to comply with follow‐up. Selected clinically stable patients may be managed expectantly, while systemic methotrexate is an appropriate option for selected unruptured ectopic pregnancies. Surgical treatment is indicated in patients with hemodynamic instability, suspected rupture, significant pain, or other features making medical or expectant management inappropriate [ 7 , 8 ]. Surgery remains the primary treatment approach. Laparoscopy is now considered the preferred and standard method [ 1 , 10 , 11 , 12 , 13 , 14 , 15 ]. However, in this case, due to the patient's hemodynamic instability, we opted for laparotomy, followed by salpingo‐oophorectomy, along with removal of the gestational sac and adjacent ovarian tissue. Following treatment, appropriate follow‐up is essential to ensure complete resolution. After methotrexate treatment, serum β‐hCG should be monitored on days 4 and 7 and subsequently weekly until it reaches a non‐pregnant level. Patients managed expectantly also require serial β‐hCG monitoring, while additional surveillance is required after conservative tubal surgery [ 12 , 13 , 14 , 15 ]. A previous ectopic pregnancy is an important risk factor for recurrence, with the subsequent risk estimated at approximately 7%–10%. Although recurrence cannot always be prevented, identification and management of modifiable risk factors, together with early confirmation of pregnancy location in subsequent pregnancies, may facilitate earlier diagnosis and reduce the risk of complications. Women with a previous ectopic pregnancy should therefore be advised to seek early antenatal care and undergo an early ultrasound examination, commonly around 6–8 weeks of gestation, to confirm an intrauterine pregnancy [ 12 ].

Written informed consent was obtained from the patient for the publication of this case report and the accompanying images.

Ovarian ectopic pregnancy (OEP) is a recognized yet uncommon condition, representing about 0.5% to 3% of all ectopic pregnancies [ 1 , 2 ]. Its occurrence ranges from 1 in 2100 to 1 in 60,000 pregnancies [ 3 ]. Clinically, it often resembles tubal ectopic pregnancy, typically presenting with symptoms such as missed periods, abdominal pain, and vaginal bleeding. However, if the pregnancy ruptures, it may cause peritoneal irritation and hemodynamic compromise [ 2 , 3 ]. Since both ovarian and tubal pregnancies frequently appear as adnexal [ 2 ] masses, distinguishing between the two can be difficult. Pelvic ultrasound with three‐dimensional imaging and measurement of serum beta‐human chorionic gonadotropin (β‐hCG) are commonly used diagnostic tools. While ultrasound can sometimes identify the location of an unruptured ovarian mass, detecting a ruptured one remains challenging [ 2 ]. Most cases of ovarian pregnancy are diagnosed during the first trimester, but preoperative diagnosis becomes increasingly difficult as gestation advances, often leading to misdiagnosis [ 3 ]. This report describes a rare instance of ovarian ectopic pregnancy in a 30‐year‐old woman with a history of multiple prior deliveries.

The authors declare no conflicts of interest.