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ORIGINAL RESEARCH |
From the *Division of Fetal Imaging and Department of Obstetrics and Gynecology, William Beaumont Hospital, Royal Oak, Michigan; and Departments of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, and University of Michigan, Ann Arbor, Michigan.
Address reprint requests to: Christine Comstock, MD, Division of Fetal Imaging, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak MI 48009; e-mail: ccomstock{at}beaumont.edu.
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ABSTRACT |
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METHODS: The ultrasonographic reports, videotapes, medical records, and operative summaries were reviewed for all women with a confirmed diagnosis of an ovarian ectopic pregnancy. Examinations were personally conducted by a physician who was either a radiologist-obstetrician or an obstetrician-maternal-fetal medicine specialist
RESULTS: Six cases were identified in the 13-year period studied. Menstrual ages ranged from 6 to 9 2/7 weeks. Most (5/6) patients had abdominal pain, with 3 demonstrating it before or at 7 weeks gestation. A wide echogenic ring with an internal echolucent area was seen in 5 of 6 patients; 1 of these also contained a yolk sac, and in another, fetal heart motion could be seen. The echogenic ring seemed to be on the surface of the ovary or within the substance of the ovary in all 5 patients. The echogenicity of the ring was greater than that of the ovary in the 5 patients in whom it was identified. At surgery, the ovarian pregnancies had the appearance of a hemorrhagic ovarian cyst in all 6 patients. In the patient in whom no echogenic ring was seen the pregnancy had ruptured. All 6 cases were biopsy proven.
CONCLUSION: Ovarian pregnancies usually appeared on or within the ovary as a cyst with a wide echogenic outside ring. A yolk sac or embryo was less commonly seen. The appearance of the contents lagged in comparison with the gestational age. Early abdominal pain was common.
LEVEL OF EVIDENCE: III
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MATERIALS AND METHODS |
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A search for cases of ovarian pregnancies was made using PubMed and Ovid databases. In addition, major ultrasound textbooks were reviewed to determine whether any ultrasound illustrations of ovarian pregnancies were printed.
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RESULTS |
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A wide echogenic ring with a small internal echolucent area was seen in 5 of the 6 patients (Figs. 1 and 2), 1 of which also contained a yolk sac and in another, heart motion could be seen. Echogenicity of the ring was greater than the ovary in all 5 cases. The echogenic ring seemed to be either on the surface or in the substance of the ovary in the 5 patients in which they were seen. There were no ultrasound findings in the remaining patient except for free blood and clot in the pelvis, which corresponded to 500 mL of clot and blood at surgery. At surgery, one pregnancy (patient 1) had ruptured as early as 6.5 weeks. The appearance in each unruptured ovarian pregnancy was not as advanced as one would expect from the gestation dates. That is, no yolk sac or embryo was seen in the 3 cases at a gestational age that would suggest that it should be seen. In the 5 in whom a ß-hCG was known, the maternal serum level was 3,000–4,000 mIU within 2 days of the examination in 3 patients, 400 mIU 1 day before the examination in 1 and 8,000 mIU the day of the examination in 1. Presenting symptoms included abdominal pain (5 of 6) and light vaginal bleeding (3 of 6). Abdominal pain was present as early as 6 weeks (patient 4) and 6.5 wks (patient 1). One patient had had a salpingectomy and another had an intrauterine device in place. No patients in the present study had had an intrauterine embryo transfer.
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DISCUSSION |
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Spiegelberg’s12 criteria for an ovarian pregnancy are 1) fallopian tubes, including fimbria, must be intact and separate from the ovary, 2) the pregnancy must occupy the normal position of the ovary, 3) the ovary must be attached to the uterus through the uteroovarian ligament, and 4) there must be ovarian tissue attached to the pregnancy in the specimen. Unfortunately, these are surgical criteria—none of these criteria can be established by ultrasonography.
The ultrasound findings have been reported in individual case reports or incidentally in articles on other aspects of ovarian pregnancy. Seven cases of ovarian pregnancy were reported by Marcus13 after in vitro fertilization and embryo transfer. At the time of diagnosis, all were 25–35 days after the embryo transfer. Three of the 7 occurred on the side of an obstructed tube. Although there were no ultrasonographic images published, the vaginal ultrasound findings were discussed in the text. All had a walled cystic mass, either on or in the ovary. All were associated with lower than expected levels of ß-hCG. Four had lower abdominal pain, but 3 were asymptomatic. In a separate case report, a 20-mm ring-like echogenic structure was seen within an ovary,14 a finding documented in other case reports.15–17 We visualized a ring-like structure in all of the unruptured ovarian ectopics in the present study, but not in the ruptured one.
The differential diagnosis of an ovarian cyst in a patient with a positive pregnancy test, but no obvious intrauterine pregnancy, includes a corpus luteum in an early or failing intrauterine pregnancy or in a tubal pregnancy. A corpus luteum may have a ring-like appearance, but in the majority of cases a corpus luteum is less echogenic than the ovary itself. Frates et al18 found that in a group of tubal ectopics, the tubal ring was more echogenic than the ovary in 23 patients, equal to the ovary in 2, and less echogenic than the ovary in 1. In contrast, in a group of patients with proven corpora lutea, the wall of the corpus luteum was more echogenic than the ovary in 3 of 45, equal to the ovary in 21, and less echogenic than the ovary in 21 patients. In evaluation of the walls of corpora lutea and ectopics, Stein et al19 found that 76% of tubal ectopic rings were more echogenic than corpora lutea when compared with the ovary as opposed to 34% corpora lutea. Attempts to use color or spectral Doppler ultrasonography to reliably distinguish a gestational sac from a corpus luteum have not been successful, because overlap with a corpus luteum has been high.19 If a yolk sac or embryo can be seen within the cyst, the diagnosis is established, but this is relatively infrequent. These signs were found in only 2 of the 6 patients described here. A 10-MHz transducer may demonstrate a yolk sac in cases in which it is not seen with a 7-MHz transducer. Benaceraff20 found that increasing the frequency of a vaginal transducer from 7 MHz to 10 MHz added enough information to make a definite diagnosis in all cases in which an echolucent intrauterine collection of fluid was seen in an early pregnancy. Reexamination with a 10-MHz transducer revealed either a yolk sac or fetal heart motion or both.
If surgery is necessary, it will be important to remind the surgeon that an ovarian ectopic may resemble a hemorrhagic cyst upon direct inspection. If no evidence of a tubal ectopic can be found, biopsy of hemorrhagic ovarian cysts may provide the answer.
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Footnotes |
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doi:10.1097/01.AOG.0000148271.27446.30
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REFERENCES |
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2. Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 2002;17:3224–30.
3. Hirose M, Nomura T, Wakuda K, Ishiguro T, Yoshida Y. Combined intrauterine and ovarian pregnancy: a case report. Asia Oceania J Obstet Gynaecol 1994;20:25–9.[Medline]
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12. Spiegelberg O. Zur Cosuistik der Ovarialschwanger schalt. Arch Gynaekol 1973;13:73–6.
13. Marcus SF, Brinsden PR. Primary ovarian pregnancy after in vitro fertilization and embryo transfer: report of seven cases. Fertil Steril 1993;60:167–9.[Medline]
14. Honigl W, Reich O. Vaginal ultrasound in ovarian pregnancy [in German]. Ultraschall Med 1997;18:233–6.[Medline]
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16. Varras M, Polizos D, Kalamra C, Antypa E, Tsikini A, Tsouroulas M, et al. Primary ruptured ovarian pregnancy in a spontaneous conception cycle: a case report and review of the literature. Clin Exp Obstet Gynecol 2002;29:143–7.[Medline]
17. Athey PA, Jayson HT, Rolando E, Watson AB. Sonographic findings in primary ovarian pregnancy. J Clin Ultrasound 1990;18:730–2.[Medline]
18. Frates MC, Visweswaran A, Laing FC. Comparison of tubal ring and corpus luteum echogenicities: a differentiating characteristic. J Ultrasound Med 2001;20:27–31.[Abstract]
19. Stein MW, Ricci ZJ, Novak L, Robert SJH, Koenigsberg M. Sonographic comparison of the tubal ring of ectopic pregnancy with the corpus luteum. J Ultrasound Med 2004;23:57–62.
20. Benacerraf BR, Shipp TD, Bromley B. Does the 10-MHz transvaginal transducer improve the diagnostic certainty that an intrauterine fluid collection is a true gestational sac? J Clin Ultrasound 1999;27:374–7.[Medline]
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