Case report
Ruptured ovarian ectopic pregnancy presenting with
1
Department of Obstetrics,
Leighton Hospital, Crewe, UK
2
Department of Histo-­Pathology,
Royal Stoke University
Hospital, University Hospitals
of North Midlands NHS Trust,
Staffordshire, UK
Correspondence to
Dr Louise Dunphy;
​Louise.​Dunphy@​doctors.​org.​uk
Accepted 18 October 2022
© BMJ Publishing Group
Limited 2022. No commercial
re-­use. See rights and
permissions. Published by BMJ.
To cite: Dunphy L, Wood F,
Hallchurch J, et al. BMJ Case
Rep 2022;15:e252499.
doi:10.1136/bcr-2022-
252499
an acute abdomen
Louise Dunphy  ‍ ‍,1 Frances Wood,1 Joanne Hallchurch,2 Gill Douce,2 Shanthi Pinto1
SUMMARY
An ectopic pregnancy occurs in 2% of all pregnancies.
A primary ovarian ectopic (OP) is a rare entity and
occurs in <2% of all ectopic gestations. It may present
in those individuals who take ovulatory drugs, use
an intrauterine device or have undergone in vitro
fertilisation or embryo transfer. Multiparity and a younger
age are other recognised risk factors. Diagnosing an
OP pregnancy remains a challenge and it may be
misdiagnosed as a bleeding luteal cyst, a haemorrhagic
ovarian cyst or a tubal pregnancy by ultrasound scan.
The diagnosis is often only established at laparoscopy
following histopathological examination. A ruptured
OP is a potentially life-­threatening condition due to its
potential for haemorrhage and hemodynamic collapse.
Hence, early diagnosis is crucial to prevent serious
morbidity and mortality. The authors present the case
of a multiparous woman in her late 30s presenting
with a seizure and lower abdominal pain at 6 weeks
gestation. Her beta human chorionic gonadotropin was
>9000 Miu/mL. A transvaginal ultrasound scan showed
no evidence of an intrauterine pregnancy. There was
free fluid in the pelvis. She was hemodynamically stable.
She underwent a diagnostic laparoscopy, which showed
hemoperitoneum and a ruptured left OP pregnancy. She
underwent a left oophorectomy. Histology confirmed
chorionic villi within the ovarian stroma. This case
demonstrates the challenges in preoperative diagnosis
of a ruptured OP pregnancy and acts as a cautionary
reminder that individuals can present with hemodynamic
stability. Rarely, as in this case, an OP pregnancy can
occur without the presence of risk factors. Despite its
rarity, a ruptured OP pregnancy should be considered
in the differential diagnosis of women of reproductive
age presenting to the emergency department with acute
abdominal pain and a positive pregnancy test.
BACKGROUND
An ectopic pregnancy is the leading cause of
maternal death during the first trimester of preg-
nancy, accounting for 10% of all pregnancy-­related
deaths.1 An ovarian pregnancy, a rare form of non-­
tubal ectopic pregnancy occurs when the gestation
sac is implanted, grown and developed in the ovary.
It was first described by Saint Maurice in 1682.2
Although its pathogenesis remains to be fully eluci-
dated, possible hypothesis include interference with
ovum release from the ruptured follicle, fallopian
tube malfunction or inflammatory thickening of
the tunica albuginea. The majority of cases are
diagnosed by the seventh week of pregnancy when
the patient develops the classic clinical symptoms
of abdominal pain and vaginal bleeding. However,
Dunphy L, et al. BMJ Case Rep 2022;15:e252499. doi:10.1136/bcr-2022-252499
a plethora of common gynaecological disorders
can present with the aforementioned symptoms
such as a ruptured ovarian cyst, a tubal ectopic
pregnancy, spontaneous miscarriage or dysmen-
orrhoea. Risk factors for an ovarian ectopic (OP)
are similar to those for a tubal pregnancy, but
use of an intrauterine device (IUD) appears to be
disproportionately associated. An IUD prevents
uterine implantation but does not provide protec-
tion against ovarian implantation.3 Cheng’s multi-
centre, large sample, case–control study has shown
that the risk of an ectopic pregnancy is increased
following the failure of most contraceptives used
in the current cycle including IUDs (OR of 16.43),
oral contraceptive pills (OR 3.02), levonorgestrel
emergency contraception (OR 4.75) and female
sterilisation (OR 4.73).4 An adnexal mass may be
present on examination. Preoperative diagnosis is
challenging as it shares a similar clinical presenta-
tion with a complicated ovarian cyst, a tubal ectopic
or a haemorrhaging corpus luteal cyst. Laparoscopy
is the gold standard approach. The diagnosis is
established using the modified Spiegelberg criteria,
confirmation of non-­involvement of the fallopian
tube and histological evidence of chorionic villi in
the ovary.5 Most cases terminate with rupture in
the first trimester. However, rare cases of an OP
resulting in a live neonate have also been described.
CASE PRESENTATION
A woman in her late 30s presented to the acute
medicine unit at 6 weeks gestation by her last
menstrual period with a seizure following alcohol
withdrawal. Her medical history included anxiety,
depression and alcohol dependence. Her surgical
history was unremarkable. There was no gynae-
cological history of intrauterine contraceptive
devices, hormonal contraception, fertility treat-
ment or assisted reproductive techniques. She
denied a history of pelvic inflammatory disease,
endometriosis or previous ectopic pregnancy. She
was gravida 6, parous 2 (3 miscarriages at <6
weeks gestation). Her obstetric history included
three normal deliveries at term. She had an irreg-
ular menstrual cycle. She was a smoker but denied
smoking for 3 months prior to conception. She
had a history of binge drinking alcohol. Following
termination of her seizure with intramuscular
(IM) lorazepam, she commenced treatment with
chlordiazepoxide and pabrinex. Twenty-­four hours
following admission, she developed lower abdom-
inal pain and right shoulder tip pain. There was
no history of vaginal bleeding. She was hemody-
namically stable. Physical examination showed no
1
 Case report

Table 1  Laboratory investigations on admission showed an

electrolyte imbalance and a raised BHCG
Full blood count Bone profile
Haemoglobin 123  g/L(115-­165) Calcium 2.31 mmol/L (2.20–2.60)
White cell count 12.2×109/L (4–11) Alkaline phosphatase 39 iu/L (30-­150)
Platelets 164×109/L (150–450) Phosphate 0.72 mmol/L (0.8–1.5)
Mean cell volume 102.5 fL (80–100)
Liver function tests
Renal function tests Albumin 44  g/L(35-­50)
Sodium 134  mmol/L(133-­146) Alanine transaminase 47 iu/L(10-­50)
Potassium 2.8 mmol/L (3.5–5.3) Total bilirubin 20 umol/L(0–21)
Urea 3.8 mmol/L (2.5–7.8) Amylase 118 iu/L(0–110)
Creatinine 118 umol/L (50–100) Figure 2  Ultrasound scan of the left ovary.
EGFR 51 mL/min/1.73 m2 (60–150) Magnesium 0.69 mmol/L(0.7–1.00)
BHCG 9436 mIU/mL (0–5)
TREATMENT
BHCG, beta human chorionic gonadotropin; eGFR, estimated glomerular filtration rate. She was transfused two units of packed red blood cells. An
indwelling urinary catheter was inserted. She received analgesia
and antiemetics.
adnexal excitation or mass. The cervical os was closed. There
was no evidence of vaginal bleeding. OUTCOME AND FOLLOW-UP
She underwent a diagnostic laparoscopy. An infraumbilical
INVESTIGATIONS incision was performed. Low pressure, high flow pneumo-
Laboratory investigations on admission showed electrolyte imbal- peritoneum was established. Hemoperitoneum was evident.
ances (K+ 2.8mmol/L, phosphate 0.72 mmol/L and magnesium Both fallopian tubes and the right ovary appeared normal.
0.69 mmol/L), which had been corrected. Her urine pregnancy The left ovary showed a ruptured ectopic with active bleeding
test- was positive and her beta human chorionic gonadotropin (figures 3 and 4). Saline wash and suction of the peritoneum was
(BHCG) was also elevated at 9,436 indicating a definitive preg- performed. Her BHCG (10, 141 iu/L) and ovarian findings were
nancy (table 1). Her haemoglobin was within normal range at consistent with a ruptured ovarian pregnancy. As there was no
123 g/L. An arterial blood gas confirmed a metabolic acidosis. evidence of haemorrhagic infiltration of the suspensory ligament
An early pregnancy viability scan (transvaginal ultrasound) or haematoma formation at the level of the broad ligament, a
was performed. There was no evidence of an intrauterine preg- left oophorectomy was performed using Vyant diathermy. The
nancy. The endometrium appeared regular with an estimated pedicle was checked for haemostasis. The estimated blood loss
thickness of 9.8 mm. There was extensive free fluid within the was 1.5 L. Her post-­transfusion haemoglobin was 97 g/L, there-
pelvis extending to the lower liver margin (figure 1). Hence, fore, she commenced treatment with oral iron tablets, ferrous
evaluation of the adnexa was difficult and the left ovary could sulphate 200 mg two times per day. On histological examina-
not be visualised optimally (figure 2). tion, the left ovary showed surface rupture with haemorrhage
measuring 18 mm in maximum dimension. No fetal parts were
DIFFERENTIAL DIAGNOSIS visualised macroscopically. Thrombus attached to the surface of
As the adnexa and the left ovary could not be visualised, the the ovary contained chorionic villi and the implantation site was
diagnosis of an ectopic pregnancy could not be excluded. A identified (figures 5 and 6). There was no evidence of tropho-
haemorrhagic cyst or a bleeding corpus luteal cyst was also blastic disease. Her recovery was uneventful. The remaining
considered in the differential diagnosis. Her recent BHCG was ovarian tissue should help preserve normal fertility.
10,141 iu/L (range: 0–5) and a repeat haemoglobin was 77 g/L
(range: 115–165), from an admission haemoglobin of 123 g/L. DISCUSSION
Therefore, the diagnosis of a ruptured ectopic pregnancy was An ectopic pregnancy occurs in up to 2% of all pregnancies.6
considered most likely. She remained hemodynamically stable. Indeed, it is among the leading cause of maternal morbidity

Figure 1  The ultrasound scan showed free fluid in the pelvis. Figure 3  Diagnostic laparoscopy showed hemoperitoneum.
2 Dunphy L, et al. BMJ Case Rep 2022;15:e252499. doi:10.1136/bcr-2022-252499

Figure 4  Diagnostic laparoscopy showed a left ovarian ectopic
pregnancy.
and mortality. Approximately, 98% of ectopic pregnancies are
located in the fallopian tubes, with 70% occurring in the ampulla.
Primary OP pregnancy is the implantation of the gestation sac
in the ovary. A secondary OP occurs if fertilisation takes place
in the tube with posterior regurgitation of the conceptus back
to the ovarian stroma.7 An OP pregnancy is a rare occurrence
with an estimated incidence of 0.5%–3% of all ectopic preg-
nancies.8 The first case was described by St. Maurice in 1682.2
The mean gestational age at diagnosis is 7 weeks.9 Ninety-­one
per cent of cases of OP are diagnosed and managed in the first
trimester due to frequent ovarian rupture, 5.4% continue into
the second trimester and 3.7% will reach the third trimester.10
The risk factors for developing an OP include the use of an IUD
such as the mirena coil, a history of tubal surgery, a previous
ectopic pregnancy, endometriosis, pelvic inflammatory disease
or ovarian hyperstimulation during assisted reproductive tech-
nology.11 In vitro fertilisation is associated with 28.5% of OP,
thus supporting the idea of trans-­tubal reflux of the fertilised
oocyte into the ovary.12
Its aetiology remains to be fully elucidated, but it appears to be
secondary to reflux of the fertilised oocyte to the ovary.13 Inter-
ference in the release of the ovum from the ruptured follicle,
malfunctioning of the fallopian tubes and inflammatory thick-
ening of the ovarian tunica albuginea have also been suggested.
Its pathogenesis includes fertilisation occurring outside of the
fallopian tube, followed by implantation within the ovary. The
surface of the ovary is covered by tunica albuginea. It lacks
muscle fibres. Loose connective tissue and blood vessels are
found inside the ovary. Therefore, early rupture may occur.
Figure 5  Histopathological examination confirmed the presence of
chorionic villi.
Dunphy L, et al. BMJ Case Rep 2022;15:e252499. doi:10.1136/bcr-2022-252499
Case report
Figure 6  Chorionic villi were noted confirming the diagnosis of a
ruptured ovarian ectopic pregnancy.
An OP may present with a history of amenorrhoea, abdominal
pain, vaginal bleeding and a positive pregnancy test. Chronic
pelvic pain frequently occurs. Individuals may present with
hypovolaemic shock secondary to an acute intra-­ abdominal
haemorrhage, although women may be hemodynamically stable,
as in this case. A ruptured ectopic may present with dizziness,
syncope or hemorrhagic shock. Speculum and bimanual exam-
ination may reveal an adnexal mass.
Despite advances in modern sonography, a ruptured OP is still
difficult to diagnose on preoperative ultrasound scan. Indeed,
the diagnosis of an OP is only established preoperatively in
between 5.3% and 25% of cases.14 Ultrasonography may show
a wide hyperechoic ring or mass formed by gestational tropho-
cytes infiltrating into the surrounding tissues, which is greater
than the echogenicity of a normal ovary and corpus luteum.15
Other findings may include a complex adnexal mass with or
without fluid in the pouch of Douglas and ovarian enlargement.
It is difficult to differentiate between a ruptured OP, a ruptured
tubal pregnancy, a haemorrhagic corpus luteum or a chocolate
cyst due to the similar ultrasonographic appearances. Terzić et al
have suggested that a ruptured OP sonographically is confused
with a ruptured corpus luteum in 75% of cases.16
Surgery remains the mainstay of treatment with minimal access
surgery the preferred option. Spiegelberg described criteria for
establishing the diagnosis intraoperatively (box 1).5 17 The aim
of surgery is to remove the ectopic pregnancy, while preserving
as much ovarian tissue as possible, especially in women of repro-
ductive age.18 Wedge resection and oophorectomy are commonly
preferred.
There remains a paucity of reported cases regarding medical
management of an OP using methotrexate (MTX), probably
because an OP is diagnosed acutely when surgical management
remains the gold standard. The first case successfully treated
with MTX was described by Kudo et al, followed by Shamma
and Schwartz who used a single IM injection.19 20 Mittal was
the first to report an MTX injection directly into the gestational
sac.21 It has a high treatment failure rate and there is a risk of
Box 1  -­Spiegelberg's criteria for intraoperative
diagnosis.17
► An intact ipsilateral tube, clearly separate from the ovary.
► Gestational sac occupying the normal position of the ovary.
► Gestational sac connected to the uterus by the utero-­ovarian
ligament.
► Ovarian tissue in the wall of the gestation sac.
3
 Case report
ovarian bleeding.22 There are also cases reporting OPs resulting
in full term pregnancies. Huang reported the case of a woman
presenting at 36 weeks gestation diagnosed with an OP. She gave
birth to a live infant following a laparotomy.23 Sehgal described
an undiagnosed OP during an elective caesarean section.24 Patel
et al also presented a rare case of a twin ovarian pregnancy diag-
nosed by ultrasound.25 These cases demonstrate the potential for
an OP to grow until the later stages of pregnancy with devas-
tating consequences if rupture occurs. Recurrence of an OP has
been described involving the contralateral ovary.26 A successful
intrauterine pregnancy has been described by Koo et al in 46.4%
of women following an OP.14 10.7% were diagnosed with a
tubal pregnancy and only 3% were diagnosed with secondary
infertility.14
This case highlights the diagnostic challenges in women of
reproductive age presenting to the emergency department with
acute abdominal pain and a positive pregnancy test. A high index
of clinical suspicion is required to establish the diagnosis of an
OP and indeed, the diagnosis is rarely established preoperatively.
Learning points
► The diagnosis is challenging due to its non-­specific clinical
presentation. It may be misdiagnosed as a haemorrhagic
ovarian cyst, a bleeding corpus luteum or a tubal ectopic
pregnancy. The sonographic appearances may be hampered
by the presence of a haematocele and hemoperitoneum.
Individuals may also be hemodynamically stable.
► Laparoscopy remains the gold standard for management.
The Spiegelberg criteria is used to establish the diagnosis
intraoperatively.
► Early diagnosis is crucial to preserve fertility, avoid an
emergency laparotomy and improve clinical outcomes.
Contributors  LD: wrote the case report. FW: performed the literature review. SP:
edited the paper. JH and GD provided the histopathology input and the histology
slides from the case.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Consent obtained directly from patient(s).
Provenance and peer review  Not commissioned; externally peer reviewed.
Case reports provide a valuable learning resource for the scientific community and
can indicate areas of interest for future research. They should not be used in isolation
to guide treatment choices or public health policy.
ORCID iD
Louise Dunphy http://orcid.org/0000-0001-5499-415X
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4 Dunphy L, et al. BMJ Case Rep 2022;15:e252499. doi:10.1136/bcr-2022-252499
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