# Pathogenesis and symptom of early hemorrhage in extrafollicular ovarian pregnancy onset at 4weeks gestation: A case report

## TL;DR

A rare case of early ovarian pregnancy with bleeding is reported, highlighting the challenges in diagnosis and the effectiveness of laparoscopic surgery for treatment.

## Contribution

This case report provides insights into secondary extrafollicular ovarian pregnancy with vascular invasion and emphasizes the role of minimally invasive surgery.

## Key findings

- A 34-year-old woman with hypovolemic shock was diagnosed with a bleeding ovarian pregnancy at 4 weeks gestation.
- Laparoscopic wedge resection and pathological analysis confirmed secondary extrafollicular implantation with vascular invasion.
- Minimally invasive surgery enabled successful hemostasis and preserved fertility in this rare case.

## Abstract

Ovarian pregnancy is a rare form of ectopic pregnancy, accounting for approximately 3 % of cases, with an incidence ranging from 1 in 2100 to 1 in 7000 pregnancies. Its diagnosis is challenging due to nonspecific symptoms and difficulty distinguishing it from corpus luteum cysts or tubal pregnancies. Delayed recognition can lead to life-threatening hemorrhage.

A 34-year-old gravida 3 para 3 Japanese woman presented with acute abdominal pain and hypovolemic shock 33 days after her last menstrual period. Imaging revealed a right ovarian cystic mass, intra-abdominal bleeding, and an empty uterus. Emergency laparoscopy identified a 5-mm gestational sac-like lesion on the right ovary. Laparoscopic wedge resection was performed. Pathological analysis confirmed extravillous trophoblast invasion into ovarian stromal vessels. A corpus luteum was observed at a separate location, supporting the diagnosis of secondary extrafollicular ovarian pregnancy. The patient recovered uneventfully.

Ovarian pregnancies are classified as primary or secondary, and intrafollicular or extrafollicular. This case demonstrated secondary extrafollicular implantation with vascular invasion. Updated diagnostic criteria emphasize intact fallopian tubes, hemorrhagic ovarian lesions, and pregnancy tissue identification. Early detection remains difficult, particularly before 5 weeks gestation, and diagnosis often requires surgical and pathological confirmation.

This case underscores the importance of early recognition and laparoscopic management of ovarian pregnancy. Pathological findings aid in understanding implantation mechanisms and differentiating from similar adnexal conditions. Minimally invasive surgery enabled successful hemostasis and fertility preservation. Improved clinical awareness is essential to reduce complications associated with this rare condition.

Proposed Mechanism: Extrafollicular Ovarian Pregnancy from Tubal Fertilization to Ovarian Implantation.Unlabelled Image

Proposed Mechanism: Extrafollicular Ovarian Pregnancy from Tubal Fertilization to Ovarian Implantation.

•Ovarian pregnancy is rare and has ambiguous clinical and imaging criteria.•A 34-year-old woman was diagnosed with an actively bleeding ovarian pregnancy.•Following wedge resection, she recovered without complications.•Surgical intervention is crucial in ovarian pregnancy management.

Ovarian pregnancy is rare and has ambiguous clinical and imaging criteria.

A 34-year-old woman was diagnosed with an actively bleeding ovarian pregnancy.

Following wedge resection, she recovered without complications.

Surgical intervention is crucial in ovarian pregnancy management.