Laparoscopic management of unruptured left ovarian ectopic pregnancy: a rare case report.

The patient was 30 years old, gravida 5 para 2 with abortion 1, presented with severe lower abdominal and rectal pain for 3–4 days, followed by intermittent spotting vaginal bleeding over 2 months, with dyspareunia, fatigue, nausea, and vomiting. There was no history of irregular menstrual bleeding, contraceptive device, or any systemic illness. She was fully conscious, alert and oriented, GCS15/15, and vitally stable. Abdominal examination shows a soft abdomen with lower abdominal tenderness in the left iliac fossa, speculum examination revealed a healthy cervix and vagina with bloody discharge. Laboratory tests indicated normal hemoglobin levels, suggesting no anemia, and the beta human chorionic gonadotropin (β-hCG) titer was 2678 mIU/mL, indicating early pregnancy. Transabdominal ultrasound findings were largely unremarkable, except for a renal stone and a small cyst. Pelvic ultrasound identified an empty uterus and a left ovary mass measuring 45 mm × 44 mm in size, and an echogenic area with a gestational sac corresponding to 7 weeks and 2 days of gestation; notably, there was no fetal heart activity, raising concerns for a possible non-viable EP or other adnexal pathology. Based on the ultrasound findings and clinical suspicion, a diagnosis of OEP was made, and laparoscopy was performed under general anesthesia. Intraoperatively, a large cystic mass measuring 40–50 mm was observed on the left ovary, fused with the ovarian cortex (Fig. 1 (A) and (B)). A grossly intact left fallopian tube was found and successfully removed using Ligasure scissors with good hemostasis. The mass was removed using a retrieval endobag, without spillage. The procedure included irrigation of the pelvic cavity and placement of drainage, followed by closure of the surgical site in layers. Postoperatively, the patient received antibiotics and analgesics to manage the risk of infection and pain. The patient was discharged on the second postoperative day. The histopathology report reveals sections of hemorrhagic areas contain normal-sized and shaped chorionic villi with few foci of decidual cells with attached ovarian tissue (Fig. 2 (A)) that contains ovarian follicles with corpus luteum and confirms left ovarian gestation (Fig. 2 (B)). Figure 1. Initial laparoscopic view of left ovarian pregnancy: (A) before dissection and (B) after dissection. It is clear that the gestation still occupies the space of the normal ovary. Figure 2. Histopathological view of the left ovarian tissue showing (A) chorionic villi and (B) corpus luteum ovary. Initial laparoscopic view of left ovarian pregnancy: (A) before dissection and (B) after dissection. It is clear that the gestation still occupies the space of the normal ovary. Histopathological view of the left ovarian tissue showing (A) chorionic villi and (B) corpus luteum ovary. Follow-up ultrasound after surgery showed an enlarged left ovary with multiple follicles with normal vascularity, indicating a return to a more typical ovarian structure, and serum hCG levels gradually returned to normal. Two weeks post-surgery, the patient reported significant improvement, with no pain or vaginal bleeding, suggesting successful intervention and recovery.

Ovarian pregnancy is a potential life-threatening complication of pregnancy. When the fertilized ovum implants at any site other than the endometrial lining of the uterus, it is called ectopic pregnancy (EP). The most common implantation site is the fallopian tube (95–98%) [ 1 ] . The incidence of ovarian ectopic pregnancy (OEP) is estimated to be 0.5–3% of all ectopic gestations [ 2 ] ; however, accurate incidence numbers are difficult to estimate because it is a rare entity that is often misdiagnosed as other adnexal masses (e.g., corpus luteum cysts and hemorrhagic ovarian cysts) [ 3 , 4 ] . OEP’s actual etiology of OEP is not entirely known at this time, although it is thought that potential mechanisms include secondary implantation of an aborted tubal pregnancy on the ovarian surface, fertilization of a retained ovum within the ovary, or migration of the zygote into the ovarian stroma [ 5 ] . Risk factors include pelvic inflammatory disease, endometriosis, assisted reproductive techniques, intrauterine device use, and prior tubal surgery [ 6 ] . However, OEPs can also occur in women without identifiable risk factors [ 7 ] . Clinically, OEP is characterized by nonspecific symptoms such as lower abdominal pain, vaginal bleeding, and pregnancy symptoms that are indistinguishable from other types of EP or benign gynecological disorders [ 7 , 8 ] . The typical presentation of amenorrhea, abdominal pain, and vaginal bleeding is often evident; however, the overlap with other gynecological conditions can result in a wrong diagnosis or non-recognition of the need for intervention. Additionally, these lesions are also at high risk for rupture by virtue of the abundant vascularity of the ovarian tissue, and the majority of cases are reported acutely before the end of the first trimester, frequently with internal hemorrhage and hypovolemic shock if not diagnosed early [ 8 ] . OEP is rare but has major clinical significance owing to its tendency to rupture early, rapid progression to intra-abdominal hemorrhage, and diagnostic challenges [ 8 ] . Here, we report a case of OEP diagnosed at an early gestational age and successfully treated with laparoscopic surgery. This report has been written under the SCARE criteria guidelines for case reports [ 9 ] . HIGHLIGHTS Ovarian ectopic pregnancy (OEP) is a rare condition, representing 0.5–3% of all ectopic pregnancies. The patient presented with lower abdominal pain, vaginal bleeding, and positive β-hCG, with ultrasound revealing a left ovarian mass containing a gestational sac. Laparoscopy confirmed the diagnosis, the ectopic tissue was easily removed, and the ovary was preserved Histopathological examination of the excised tissue confirms left ovarian gestation. The case highlights the diagnostic challenge of OEP, which can be confused with other gynecologic conditions, emphasizing the importance of timely detection and management to preserve fertility and avoid complications. Ovarian ectopic pregnancy (OEP) is a rare condition, representing 0.5–3% of all ectopic pregnancies. The patient presented with lower abdominal pain, vaginal bleeding, and positive β-hCG, with ultrasound revealing a left ovarian mass containing a gestational sac. Laparoscopy confirmed the diagnosis, the ectopic tissue was easily removed, and the ovary was preserved Histopathological examination of the excised tissue confirms left ovarian gestation. The case highlights the diagnostic challenge of OEP, which can be confused with other gynecologic conditions, emphasizing the importance of timely detection and management to preserve fertility and avoid complications.

OEP remains a challenging entity in both diagnosis and treatment due to its rarity, unusual presentation, and frequent association with other adnexal diseases. The literature predominantly emphasizes the diagnostic challenge of differentiating OEP from other benign gynecological pathologies, including corpus luteum cysts and tubal EPs, particularly when clinical and imaging findings are inconclusive [ 7 , 10 , 11 ] . The diagnostic dilemma is even more confounded where advanced imaging or histopathological expertise is scarce, as shown in reports from resource-poor environments [ 12 ] . It has been reported that only a small percentage of OEPs are accurately diagnosed preoperatively, and the majority are diagnosed during or after surgery following histopathological examination [ 7 , 13 ] . Ultrasonography, although a necessary investigation, frequently demonstrates non-pathognomonic findings, including an empty uterus and complex ovarian masses, resulting in a wide differential diagnosis [ 10 , 14 ] . In this case, the patient presented with lower abdominal pain, spotting, and elevated β-hCG (2678 mIU/mL), mimicking a tubal EP or miscarriage. Transvaginal ultrasound revealed an empty uterus and a left ovarian mass (45 × 44 mm) with an echogenic gestational sac but no fetal cardiac activity, raising suspicion for OEP [ 10 , 13 ] . Compared to tubal EPs, OEP is harder to distinguish from corpus luteal cysts or hemorrhagic ovarian masses [ 7 ] . However, the present case fulfilled all the following criteria proposed by Spiegelberg for the diagnosis of OEP: (1) the fallopian tube of the affected side must be intact, (2) gestational sac must be in the same location as an ovary, (3) ovary must be attached to the uterus by utero-ovarian ligament, and (4) ovarian tissue must be in the wall of the gestational sac [ 15 ] . Laparoscopy is the preferred approach when feasible, allowing direct visualization, targeted excision of ectopic tissue, and preservation of ovarian function [ 11 , 13 ] . Wedge resection or cystectomy is generally favored over oophorectomy, especially in women of reproductive age who desire future fertility. The reviewed cases and recent reports confirm that conservative surgery can be performed safely in hemodynamically stable patients, with favorable outcomes and rapid postoperative recovery [ 11 , 13 ] . However, in cases of rupture, extensive ovarian involvement, or uncontrolled hemorrhage, more radical procedures may be necessary to ensure patient safety [ 7 , 11 ] . Despite the fact, histopathology continues to be the gold standard for OEP diagnosis. The presence of chorionic villi or trophoblastic tissue within the ovarian parenchyma, without tubal invasion, met the classic diagnostic criteria [ 7 , 15 ] . This is an essential step, as misdiagnosis can arise from a lack of or incomplete pathological assessment, as emphasized in several case reports [ 10 ] . The literature we reviewed strongly supports the need to have a high level of suspicion of OEP in a woman of childbearing age who is experiencing abdominal pain and an adnexal mass, whether or not they have traditional risk factors [ 7 , 14 ] . Clinician recognition, interdisciplinary cooperation, and availability of proper surgical and histopathological materials are essential for early diagnosis and better patient prognosis in this rare entity.

OEP usually presents with a nonspecific clinical picture and can be mistaken for various gynecologic disorders, leading to delayed or misdiagnosis. Ultrasound is an important tool, but it may not be 100% diagnostic. Clinical symptoms, laboratory results, and imaging are useful for a diagnosis. Laparoscopic surgery is an excellent diagnostic and therapeutic tool in such cases because it offers direct visualization of the lesion and the possibility of extended resection of the ectopic tissue in situ , with preservation of the ovary. Serial monitoring of serum hCG levels and a follow-up ultrasound are essential for the resolution of the entity. The OEP management is difficult, and cooperation of the gynecologist with the radiologist and pathologist is essential for early diagnostics and patient treatment.