Conservative Methotrexate Management of Ovarian Ectopic Pregnancy in a Resource-Constrained Setting: A Rare Case Report

Abstract

Introduction: Ovarian ectopic pregnancy is a rare form of ectopic implantation and can be difficult to distinguish from common ovarian findings such as a corpus luteum cyst, particularly in settings with limited diagnostic and surgical resources. Early recognition using transvaginal ultrasonography and appropriate patient selection are essential to reduce the risk of rupture and preserve fertility. Case Presentation: A 27-year-old woman (gravida 7, para 4+2) with five weeks of amenorrhea and a previous vaginal birth after cesarean section presented with five days of nausea and right-sided pelvic pain, without vaginal bleeding. She was hemodynamically stable, with marked right adnexal tenderness. Serum β-hCG was 3233.83 IU/L. Transvaginal ultrasound demonstrated an empty anteverted uterus with an 11.27 mm endometrial thickness and a gestational sac located within the right ovarian tissue, without a yolk sac or embryo, consistent with ovarian ectopic pregnancy. After counseling, conservative medical management with methotrexate was initiated. The patient remained clinically stable, and serial β-hCG levels declined appropriately (2095.41 IU/L on day 4 and 1318.43 IU/L on day 7), with sonographic regression of the ovarian gestational sac. She was discharged with weekly follow-up, and by the third week her β-hCG level fell to < 5 IU/L. Follow-up ultrasound confirmed complete resolution. Conclusion: Ovarian ectopic pregnancy is a rare but important diagnosis in early pregnancy and may be difficult to distinguish from other adnexal lesions. In this patient, transvaginal ultrasound and serum β-hCG findings supported the diagnosis of presumed ovarian ectopic pregnancy. Conservative management with methotrexate was chosen because the patient was hemodynamically stable and could undergo close follow-up. Serial β-hCG monitoring and follow-up ultrasound demonstrated progressive regression and complete resolution without surgery. This case highlights that carefully selected patients may be managed successfully with fertility-preserving medical treatment, even in a resource-constrained setting. Keywords: ovarian ectopic pregnancy, methotrexate, medical management, transvaginal ultrasound, β-hCG monitoring, early pregnancy, fertility preservation, resource-limited setting