Академический Документы
Профессиональный Документы
Культура Документы
Pregnancies
Christine Comstock, MD, Kathleen Huston, MD, and Wesley Lee, MD
OBJECTIVE: To evaluate the ultrasonographic findings of
ovarian ectopic pregnancies.
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 obstetricianmaternal-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.
(Obstet Gynecol 2005;105:425. 2005 by The American
College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: III
42
RESULTS
Six cases were identified in the 13-year period under
consideration and are summarized in Table 1. The average maternal age was 30 years, with a range of 2236
years. Five had had at least 1 previous full-term delivery.
Menstrual ages at the time of ultrasound examination
ranged from 6 to 9 2/7 weeks. No patients had a coexisting intrauterine pregnancy.
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
0029-7844/05/$30.00
doi:10.1097/01.AOG.0000148271.27446.30
-hCG
(mIU)
Patient
Age (y)
Menstrual
Age (wk)
22
6.5
Abdominal pain
3,206
30
8.5
Vaginal bleeding
11,000
32
2,019
32
Abdominal pain
3,535
33
8.6
8,480
36
9.3
Patient
Symptoms
315
Ultrasound Findings
Surgical Findings
Comstock et al
43
DISCUSSION
Ovarian pregnancies constitute about 3% of ectopic
pregnancies, similar to the incidence of interstitial ones.
Ovarian pregnancies can (rarely) be part of a heterotopic
pregnancy3 6or of a twin ovarian pregnancy.7,8 There
seems to be an especially strong association of ovarian
pregnancies with intrauterine devices (IUD). In the 25
cases of ovarian pregnancy reported by Sandvei,9 17 had
had an IUD; 80% of those reported by Herbertsson,10
and 73% of 37 patients in a study by Raziel11 had had an
IUD. Only 1 of the patients in the present study had had
an IUD in place. We attribute the low incidence of
ovarian pregnancy in the present study to the relatively
low usage of IUDs in our population.
Spiegelbergs12 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 criterianone 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 2535 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 -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.1517 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
44
Comstock et al
REFERENCES
1. Hage PS, Arnouk IF, Zarou DM, Kim BK, Wehbeh HA.
Laparoscopic management of ovarian ectopic pregnancy.
J Am Assoc Gynecol Laparosc 1994;1:2835.
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;20:259.
4. Melilli GA, Avantario C, Farnelli C, Papeo R, Savona A.
Combined intrauterine and ovarian pregnancy after in
vitro fertilization and embryo transfer: a case report. Clin
Exp Obstet Gynecol 2001;28:100 1.
5. Selo-Ojeme DO, GoodFellow CF. Simultaneous intrauterine and ovarian pregnancy following treatment with clomiphene citrate. Arch Gynecol Obstet 2002;266:232 4.
6. Shahabuddin AK, Chowdhury S. Primary term ovarian
pregnancy superimposed by intrauterine pregnancy: a
case report. J Obstet Gynaecol Res 1998;23:109 14.
7. Marret H, Hamamah S, Alonso AM, Oierre F. Case report
and review of the literature: primary twin ovarian pregnancy. Hum Reprod 1997;12:18135.
8. Tuncer R, Sipahi T, Erkaya S, Akar NK, Baysar NS,
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Comstock et al
45