Case Report: Ovarian Heterotopic Pregnancy with Subsequent Missed Miscarriage

Introduction
We report a rare case of ovarian heterotopic pregnancy in a 32-year-old female presenting with acute abdominal pain and hemodynamic instability. Prompt surgical intervention preserved the ovary and confirmed the diagnosis, although the associated intrauterine pregnancy subsequently resulted in a missed miscarriage.

Discussion
Heterotopic pregnancy, defined as the simultaneous occurrence of intrauterine and extrauterine pregnancies, is a rare but potentially life-threatening condition. While more commonly associated with assisted reproductive techniques, spontaneous cases are exceedingly uncommon. Ovarian ectopic pregnancies are particularly rare, accounting for less than 3% of ectopic pregnancies. Prompt surgical intervention is critical to manage the life-threatening haemorrhage while attempting to preserve fertility. This case highlights the importance of maintaining a high index of suspicion for heterotopic pregnancy in patients presenting with acute abdominal pain, even in the absence of assisted reproduction. It also underscores the importance of postoperative follow-up to evaluate the viability of any concurrent intrauterine pregnancy

Case report
A32-year-old woman, gravida 2 para 1, presented to the emergency department with severe lower abdominal pain radiating to the left shoulder tip. A urine pregnancy test was positive. On examination, she was tachycardic and hypotensive, necessitating immediate resuscitation. Her medical and surgical history was unremarkable. While awaiting ultrasound imaging, the patient’s condition deteriorated rapidly, with increasing pallor and hemodynamic instability. She was urgently transferred to theatre for diagnostic laparoscopy. Intraoperative findings revealed a ruptured left ovarian ectopic pregnancy with approximately 1 litre of hemoperitoneum. Haemostasis was achieved laparoscopically, and the left ovary was successfully conserved using continuous V-Loc 3/0 sutures. Postoperative follow-up with transvaginal ultrasound unexpectedly identified a viable intrauterine pregnancy, confirming the diagnosis of a spontaneous ovarian heterotopic pregnancy—a rare and challenging clinical entity. Despite initial viability, the intrauterine pregnancy progressed to a missed miscarriage, which was managed expectantly without complications.

Conclusion
This case emphasizes the complexity of diagnosing and managing heterotopic pregnancy, particularly when involving rare locations such as the ovary. While timely surgical intervention preserved ovarian function, the associated intrauterine pregnancy unfortunately culminated in a missed miscarriage, managed conservatively. This report aims to enhance awareness and understanding of this rare condition among clinicians.

References
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