Live Births After Laparoscopic Wedge Resection for Unruptured Ovarian Pregnancy With Hemorrhagic Hypotension: A Case Report.

A 32‐year‐old gravida 1, nulliparous woman presented to our department with severe abdominal pain. She had a history of one spontaneous abortion that did not require intervention. Four weeks before admission, she underwent controlled ovarian stimulation/insemination at another clinic. A positive urine pregnancy test was noted at that clinic, but no intrauterine gestational sac (GS) was identified. On the day of admission, at 6 weeks and 5 days' gestational age, she experienced sudden abdominal pain and vaginal bleeding, leading to her transfer to our hospital.

Yuhya Hirahara: conceptualization, investigation, visualization, writing – original draft. Koichi Nagai: conceptualization, supervision, writing – review and editing. Kazunori Mukaida: conceptualization, supervision, writing – review and editing.

No ethical approval was needed for this case.

Postoperatively, the patient's hemoglobin decreased to 6.5 g/dL; however, she subsequently recovered and no blood transfusion was required. The postoperative course was uneventful, and the serum hCG level decreased shortly thereafter. She was discharged from our hospital on Day 5 postoperative. A histopathological examination confirmed the EP in the ovary (Figure  3 ). She attended the other clinic for infertility treatment. Six months later, she achieved a viable pregnancy following artificial insemination and ultimately gave birth to another child following a spontaneous pregnancy 2 years after the first delivery. Hematoxylin–eosin–stained histopathologic confirmation of ovarian pregnancy. (A) Low‐power field image of ovarian stroma with chorionic villi. (B) High‐power field image corresponding to the red square in A.

Ovarian pregnancy in the early stage mimics corpus hemorrhagicum or other common EP types [ 13 ]. The possibility of ovarian pregnancy should be considered when no GS is identified at the predilection EP sites. In the presented case, an unruptured GS was observed on the ovarian surface and weakly vigorous venous bleeding from the surrounding ovary was noted; therefore, it took 95 min for her hypovolemic hemodynamic status to become apparent. This suggests that physicians should consider the possibility of massive bleeding even in cases with unruptured GS during the early gestational weeks. ART is considered a risk factor of ovarian pregnancy [ 10 ]. In particular, women with a higher estradiol level after controlled ovarian hyperstimulation (COH) reportedly have a higher risk of EP [ 14 ]. Tubal function is regulated by the coordination of estrogen and progesterone levels [ 15 ]; however, COH may alter the balance between them and reverse embryonic implantation in the pelvic cavity may occur [ 16 ]. Our patient had received controlled ovarian stimulation/insemination, which may have influenced the ovarian pregnancy. The widely used diagnostic criteria described by Spiegelberg [ 17 ] consist of four evaluation points: the fallopian tube on the involved side must be intact and separate from the ovary; the GS is located at the normal ovarian position; the GS must be connected to the uterus by the utero‐ovarian ligament; and the ovarian tissue must be histologically proven in the GS wall. In the presented case, the patient fulfilled all the criteria and the diagnosis of ovarian pregnancy was confirmed. Although ultrasonography technology has progressed, a preoperative diagnosis remains challenging and laparoscopy appears to be the gold standard for diagnosing ovarian pregnancy. Wedge resection is possible for patients with ovarian pregnancy who plan future pregnancies, with reported subsequent spontaneous pregnancy rates of 28.6%–61.9% [ 18 , 19 ]. While consensus is lacking about whether ovarian pregnancy affects natural conception, patients with minimal risk factors for EPs have better expected reproductive outcomes [ 18 ]. As laparoscopic surgery has a lower incidence of adhesions than laparotomy [ 20 ], its choice over laparotomy may contribute to a patient's future fertility. In our case, the patient strongly desired the preservation of fertility; therefore, a right ovarian wedge resection was chosen as the surgical procedure. The surgery was performed under careful laparoscopic observation to ensure complete removal of the products of conception. Subsequently, the patient's serum hCG level promptly diminished, and no additional medical treatment with methotrexate was required. As a result, she was able to plan the next conception after the surgery and subsequently achieve two live births. With technological advancements, laparoscopic surgery for patients with an unstable hemodynamic status is becoming relatively safer than in the past. Cengiz et al. reported the feasibility of laparoscopic surgery in patients with an elevated shock index due to EPs [ 21 ]. Another retrospective cohort study reported the outcomes of operative laparoscopy in patients with hypovolemic shock [ 22 ]. Consequently, we believe that laparoscopy can be a viable treatment option in cases of EPs with hemorrhagic hypotension if there is a well‐trained surgical team with appropriate equipment. Treating postoperative shock adequately is essential to laparoscopic surgery safety for patients with such conditions. However, a thorough discussion among emergency physicians, gynecologists, anesthesiologists, and other surgical staff is imperative before this decision is made.

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy. In the form, the patient has given her consent for publication of the patient's images and other clinical information in the journal. The patient understands that the name and initials will not be published, and due efforts will be made to conceal identity, though anonymity cannot be guaranteed.

Ectopic pregnancies (EPs) account for 1.3%–2% of all pregnancies [ 1 ]. Tubal pregnancy is the most common type of EP; there are also several types of non‐tubal EPs [ 2 , 3 ]. Ovarian pregnancy, a rare type of EP, is estimated to comprise 1%–6% of all EPs [ 2 ]. This uncommon event was first reported by Saint Maurice in the 17th century [ 4 , 5 ]. Recently published data suggest that in vitro fertilization and embryo transfer may increase the risk [ 5 , 6 , 7 , 8 , 9 ]. There are two proposed mechanisms for ovarian pregnancy: (1) direct fertilization of the ovum within the ovary; and (2) inverse implantation of the conception products on the ovarian surface [ 4 ]. These mechanisms are considered associated with conditions such as endometriosis, polycystic ovarian syndrome, pelvic inflammatory disease, artificial reproductive technology (ART), and intrauterine contraceptive devices [ 5 , 10 ]. Symptoms such as abdominal pain and atypical genital bleeding are similar across all EP types [ 1 , 2 , 11 ]. A delayed diagnosis can be fatal due to massive hemorrhage and subsequent situations after hypovolemic shock. Treatment for ovarian pregnancy ranges from conservative treatment with methotrexate to laparotomy according to the patient's condition. Recent studies suggest that surgery remains the primary treatment, as the use of methotrexate may be impractical for ovarian pregnancy [ 2 , 12 ]; however, surgical excision with conservation of the ovary can be considered in certain conditions [ 11 ]. The magnitude of the effects of ovarian pregnancy on subsequent reproductive outcomes is undetermined.

The authors declare no conflicts of interest.

At the initial presentation, her general condition was good, and vital signs were normal (blood pressure [BP], 127/85 mmHg; heart rate [HR], 99 bpm). Transvaginal ultrasound revealed a GS‐like structure and small fluid collection in the right adnexal region. However, neither a yolk sac nor a fetal heartbeat was recognized (Figure  1 ). Transvaginal sonographic images taken at the patient's first presentation. (A) Confirmation of no intrauterine gestation. (B) Observation of a small fluid collection around the right adnexal region. Created in BioRender. Hirahara, Y. (2025) https://BioRender.com/n99l957 . At 30 min after presenting, her BP slightly decreased to 86/46 mmHg and HR decreased to 58 bpm. The patient received 1000 mL of crystalloids as initial fluid therapy, and her vital signs subsequently recovered (BP, 104/58 mmHg; HR, 68 bpm). We decided to wait for fully collected laboratory data, which would influence anesthesia methods, while preparing to perform emergency surgery. The patient was counseled and consented to undergo the operation. Complete laboratory data almost all normal (hemoglobin, 10.3 g/dL; hematocrit, 32.4%; platelet cells, 31.0 × 10 3 /μL; activated partial thromboplastin time, 25.3 s; and prothrombin time and international normalized ratio, 1.07). The serum human chorionic gonadotropin (hCG) level was 3153 mIU/mL. At 95 min after her presentation, BP suddenly decreased to 79/60 mmHg, and HR slightly elevated to 77 bpm. An obvious echo‐free space in the posterior cul‐de‐sac was recognized. Considering the hypotension and elevated HR, we promptly administered a bolus of 500 mL of crystalloids along with 500 mL of 6% hydroxyethyl starch (130/0.4). She responded well to resuscitation, and her BP improved to 135/66 mmHg. With the stabilized hemodynamic status, a thorough consultation among operating room staff, the anesthesiologist, and surgeons led to the consideration of laparoscopy because the patient desired another gestation as soon as possible. Consequently, we proceeded with emergent laparoscopic surgery. During laparoscopy, a non‐ruptured GS was identified in the right ovary (Figure  2A ). Active and continuous bleeding was observed from the normal ovarian tissue surrounding the GS, although the GS itself was intact. A hemoperitoneum of 1250 mL was noted. The bilateral fallopian tubes and the left ovary appeared completely normal. Consequently, a laparoscopic wedge resection of the right ovary was performed (Figure  2B ). Laparoscopic images of ovarian pregnancy. (A) Right ovarian pregnancy (black arrows) with a normal right fallopian tube. (B) Postoperative appearance of the right ovary.