Heterotopic pregnancy with ovarian ectopic gestation

INTRODUCTION

Heterotopic pregnancy (HTP) denotes the coexistence of an intrauterine gestation and one or more extrauterine gestations, including tubal, ovarian, cervical, or abdominal locations.^[1-4] Although historically rare after spontaneous conception, with an estimated incidence ranging from 1:10,000 to 1:30,000 pregnancies, the incidence of HTP increases substantially following assisted reproductive techniques (ARTs), such as in vitro fertilization, embryo transfer, and intracytoplasmic sperm injection (ICSI) as well as ovulation induction with agents including clomiphene citrate and gonadotropins, with reported rates as high as 1:100 pregnancies in some ART cohorts.^[1-3]

HTP poses a significant diagnostic dilemma because the presence of a confirmed intrauterine pregnancy can provide false reassurance.^[5] The sensitivity of transvaginal sonography is limited in very early gestation, particularly between 5 and 6 weeks, and may be further reduced when ovarian enlargement or physiological cysts obscure adequate visualization of the adnexa.^[2,6]

The clinical presentation of HTP is often non-specific, with features such as abdominal pain, vaginal bleeding, adnexal mass, peritoneal signs, or hemodynamic instability overlapping with other obstetric and surgical conditions, thereby complicating diagnosis. Timely diagnosis is critical, as rupture of the tubal or ovarian ectopic component may result in life-threatening intra-abdominal hemorrhage and may also jeopardize the viability of the intrauterine pregnancy.^[2,6]

We present a case of a young woman with a left-sided ovarian ectopic component of an HTP that required emergency laparotomy and oophorectomy for hemorrhage control, and we discuss the diagnostic challenges and management considerations relevant to clinical practice.

CASE REPORT

A 20-year-old woman (gravida 3, para 1, abortion 1) with a pregnancy conceived through ART, specifically ICSI, presented at 6.6 weeks of gestation with a 2–3-day history of lower abdominal pain, vaginal bleeding, nausea, vomiting, and lower back pain. On admission, her vital signs were stable with a pulse rate of 89 beats/min and blood pressure of 110/70 mmHg. Serial monitoring during the acute evaluation demonstrated stable hemodynamic parameters without tachycardia or hypotension. Serial monitoring during the acute evaluation demonstrated stable hemodynamic parameters without tachycardia or hypotension. Abdominal examination revealed lower abdominal tenderness without guarding or rigidity, and pelvic examination showed mild vaginal bleeding with adnexal tenderness.

Pre-operative laboratory investigations revealed a hemoglobin level of 12.4 g/dL, platelet count of 286 ×10³/µL, and white blood cell count of 5.88 ×10³/µL. Baseline hemoglobin values before presentation were not available for comparison. Initial transabdominal ultrasonography demonstrated a suspected intrauterine gestational sac with an adnexal abnormality. Subsequent transvaginal ultrasound provided better characterization, revealing an intrauterine gestational sac along with a left-sided adnexal mass consistent with an ovarian ectopic pregnancy and peri-ovarian free fluid suggestive of active intra-abdominal bleeding.

Given the ongoing hemorrhage and risk of rupture, the patient underwent emergency exploratory laparotomy under regional anesthesia. Intraoperatively, approximately 10–30 mL of hemoperitoneum was identified along with a ruptured left ovarian ectopic gestation. Due to significant tissue damage and active bleeding, a left oophorectomy was performed to achieve hemostasis. An intraperitoneal drain was placed, and the abdomen was closed in layers.

Postoperatively, the patient required transfusion of one unit (250 mL) of whole blood. Follow-up laboratory investigations showed hemoglobin 11.2 g/dL, platelet count 184 ×10³/µL, and white blood cell count 4.57 ×10³/µL. The post-operative course was uneventful. A follow-up transvaginal ultrasound on post-operative day 5 demonstrated no residual adnexal mass or intra-abdominal collection. The patient was discharged in stable condition with advice for regular follow-up.

Histopathological examination was not available, as the procedure was performed as an emergency life-saving intervention.

DISCUSSION

HTP remains uncommon but clinically significant because of the risk of catastrophic hemorrhage and the inherent diagnostic difficulty. The likelihood of HTP increases with ART, ovulation induction, and prior tubal disease; however, spontaneous HTP can occur in women without identifiable risk factors.^[7-9] Among assisted reproductive methods, procedures involving embryo transfer, particularly in vitro fertilization–embryo transfer and ICSI, are associated with a higher incidence of HTP compared with ovulation-induction alone. In the present case, the young patient (gravida 3, para 1, abortion 1) presented early with non-specific symptoms, and the initial clinical assessment did not mandate immediate surgical intervention, highlighting the variable and sometimes indolent clinical presentation of HTP.^[7,9]

Transvaginal sonography is the cornerstone of diagnosis. It may demonstrate an intrauterine gestational sac along with a concurrent adnexal mass or free intraperitoneal fluid; however, its sensitivity is limited in very early gestation and in the presence of ovarian hyperstimulation or multiple corpora lutea.^[8,10,11] When transvaginal sonography is inconclusive and clinical suspicion persists, repeat ultrasonography or adjunctive magnetic resonance imaging may aid in diagnosis.^[8] Serial beta-human chorionic gonadotropin trends are of limited utility in HTP because the intrauterine gestation maintains rising hormone levels, necessitating careful adnexal evaluation rather than reliance on biochemical trends alone.^[12]

Management strategies depend on the site and viability of the ectopic component, the hemodynamic stability of the patient, and the desire to preserve the intrauterine pregnancy. Available options include expectant management in carefully selected cases, ultrasound-guided local injection or aspiration, laparoscopic intervention when feasible, and laparotomy for hemodynamically unstable patients or when minimally invasive surgery is contraindicated.^[13-15] Systemic methotrexate is contraindicated in the presence of a viable intrauterine pregnancy but may be considered for residual trophoblastic tissue in select non-viable abdominal heterotopic pregnancies.^[7,8,16,17] Conservative surgical approaches such as salpingostomy or cystectomy are preferred to preserve fertility and reduce the risk of intrauterine pregnancy loss; however, when ovarian viability is compromised or hemorrhage is extensive, oophorectomy may be required, as observed in the present case.^[12]

Ovarian ectopic pregnancies are rare among ectopic implantation sites and are frequently associated with hemoperitoneum at presentation. Published case series and reviews report variable intrauterine pregnancy survival following HTP management, with live birth rates ranging from approximately 50% to 66% when timely intervention is undertaken, and intrauterine viability is maintained.^[13,15] Laparoscopic management is generally preferred due to reduced maternal morbidity and improved preservation of the intrauterine gestation; however, the choice between laparoscopic and open surgical approaches should be guided by patient stability, surgical expertise, and institutional resources.^[12,15]

This case highlights several practical considerations for clinical practice: Maintaining a high index of suspicion for HTP even when an intrauterine pregnancy is confirmed, particularly in symptomatic patients; performing meticulous adnexal evaluation during early transvaginal sonography and repeating imaging when symptoms persist; individualizing management based on hemodynamic status and reproductive goals; and ensuring prompt multidisciplinary involvement for diagnosis and treatment.^[7,8,12] Although histopathological confirmation was not available due to the emergency nature of the procedure, the diagnosis of ovarian ectopic pregnancy was established based on intraoperative findings and characteristic transvaginal ultrasonographic features.

CONCLUSION

HTP, though uncommon, must be considered in any pregnant patient presenting with abdominal pain and vaginal bleeding, because an intrauterine pregnancy does not exclude synchronous extrauterine gestation. High-resolution transvaginal ultrasound and prompt surgical intervention remain central to diagnosis and management when hemorrhage or instability occurs. Tailored, multidisciplinary care can achieve favorable maternal outcomes and may preserve intrauterine gestation when present.