Live ovarian ectopic pregnancy: A rare clinical encounter

A 28-year-old female patient presented with symptoms of lower abdomen pain, nausea, and dizziness. The obstetric history was primigravida, with IVF conception through embryo transfer. Beta-human chorionic gonadotropin (HCG) levels were 24,000 mIU/mL, increasing to 40,000 mIU/mL within 48 hours. There is no history of bleeding per vaginum.

Transvaginal ultrasonography revealed a well-defined, thick-walled left adnexal lesion inside the left ovarian stroma adjacent to the follicles, corresponding to a gestational age of 5 weeks and 5 days showing peripheral vascularity—the “ring of fire” sign (Figure 1). It depicts the foetal pole with a crown-rump length of 4.3 mm (Figure 2). Foetal cardiac activity was detected, and the foetal heart rate was 117 bpm (Figure 3). A simple cyst was also seen in the left ovary (Figure 6). A decidual reaction was seen within the uterus (Figure 4). The right ovary revealed a cystic lesion with internal septations, retracted clot and dependent debris—haemorrhagic cyst (Figure 5).

Background

Ectopic pregnancies are the leading cause of first-trimester haemorrhages. While the ampulla of the fallopian tube accounts for around 95% of ectopic pregnancies, there is also a small prevalence of ectopic pregnancies in other locations, such as the ovaries, cervix, abdomen, and caesarean scar site. Risk factors include vaginal infections, ovulation induction, endometriosis in the past, and other assisted reproductive technologies [1]. With an incidence rate of between 1% and 6% of all confirmed ectopic pregnancies, ovarian ectopic pregnancies are among the rarest presentations [2,3].

Clinical Perspective

Females may present with lower abdominal pain, a palpable adnexal mass, elevated beta-HCG levels, and potential haemodynamic instability. If beta-HCG levels rise but do not double within 48 hours, and there is no intrauterine gestational sac, an ectopic pregnancy should be suspected.

Imaging Perspective

Transvaginal and transabdominal sonography are the first-line investigations for diagnosing an ovarian ectopic. On ultrasound, ovarian ectopics appear as thick-walled, echogenic rings with anechoic centres. They can be detected inside or outside the ovary, with or without a yolk sac or a foetal pole [4]. Both corpus luteum (CL) cyst and ovarian ectopics may show strong peripheral vascularity, popularly known as the “ring of fire” sign, but the ovarian ectopic exhibits more echogenicity than the ovarian stroma, while CL cyst is less echogenic. A true ovarian pregnancy is inseparable from ovarian tissue (a negative “sliding organ sign”), whereas a tubal ectopic is separable from the ovary (positive “sliding sign”) [5]. Histopathology is considered the final diagnosis of ovarian ectopic pregnancy because, while laparoscopy is the gold standard for definitive diagnosis and treatment, it can still be mistaken for a haemorrhagic cyst, which shows thin internal septations, retracted clots and dependent debris [6]. The diagnosis of ovarian ectopic pregnancy was made in this case due to the presence of a foetal pole and foetal heart rate within the thick-walled echogenic cystic lesion. Beta-HCG level was 24,000 mIU/mL, which had risen to 40,000 mIU/mL after 48 hours. Left ovarian tissue was sent for histopathological examination, which confirmed the presence of products of conception in the left ovary and post-surgery, the beta-HCG level was reduced to 5,000 mIU/mL.

Outcome

Clinical and radiological findings should always be correlated to make a diagnosis. Methotrexate is the medical treatment for ectopic pregnancies [7]. However, because ovarian ectopic pregnancies typically result in rupture, internal haemorrhage, and hypovolemic shock during the first trimester, the definitive management often involves laparoscopic oophorectomy or ovarian wedge resection.

Take Home Message / Teaching Points

Ovarian ectopic pregnancies require a high index of suspicion and are associated with a poor prognosis; therefore, early diagnosis and prompt management are crucial for a successful outcome.

Written informed patient consent for publication has been obtained.