Twenty-one years of experience with ovarian ectopic pregnancy at one institution in Taiwan

Ovarian ectopic pregnancy: clinical characteristics, ultrasound diagnosis and management

OBJECTIVE

To compare the clinical, ultrasound and biochemical characteristics of ovarian ectopic pregnancy (OEP) with those of tubal ectopic pregnancy (TEP).

METHODS

This was a retrospective case-control study of women with OEP and those with TEP seen at a single center between December 2010 and February 2021. OEP was defined as a pregnancy located completely or partially within the ovarian parenchyma, seen separately to a corpus luteum, if a corpus luteum was present within the ipsilateral ovary. We compared demographic features, risk factors, clinical presentation, ultrasound findings and outcomes, such as blood loss at surgery, need for blood transfusion, length of hospital stay, follow-up and future pregnancy outcome, between cases of OEP and TEP.

RESULTS

Overall, 20 women with OEP were identified and compared to 100 women with TEP. A total of 15/20 (75%) OEPs were diagnosed correctly on the first ultrasound scan. There was no difference between the groups in terms of maternal age, gestational age, gravidity, parity or risk factors. Compared with TEP, OEP was more likely to present with abdominal pain without vaginal bleeding (12/20 (60%) vs 13/100 (13%); odds ratio (OR), 10.0 (95% CI, 3.45-29.20); P < 0.01), contain an embryo with cardiac activity (3/20 (15%) vs 2/100 (2%); OR, 8.7 (95% CI, 1.34-55.65); P = 0.02) and have severe hemoperitoneum on ultrasound (9/20 (45%) vs 8/100 (8%); OR, 9.4 (95% CI, 3.01-29.40); P < 0.01), and had a higher volume of blood loss at surgery (median, 700 mL vs 100 mL; P < 0.01). All surgically managed OEPs had successful laparoscopic treatment (18 excisions, one wedge resection) with preservation of the ovary. Only one (5%) case of OEP required a blood transfusion.

CONCLUSIONS

OEP is more likely than TEP to contain an embryo and to present with severe hemoperitoneum. In a dedicated early pregnancy setting, the majority of OEPs were detected on an ultrasound scan at the initial visit, facilitating optimal minimally invasive surgical management, reducing the risk of blood transfusion and oophorectomy. Our findings can be used as a reference for clinicians who may not otherwise encounter this rare condition. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The Distribution of Ectopic Pregnancy in Natural Pregnancy and the Comparison of Diagnostic Efficacy between Transabdominal Ultrasound and Transvaginal Ultrasound

Objective:

The objective of this study was to analyze the advantages and disadvantages of transabdominal and transvaginal color Doppler ultrasound in the diagnosis of early ectopic pregnancy (EP) and to evaluate the value of two kinds of ultrasonography in the diagnosis of early EP.

Patients and Methods:

One hundred and ten EP patients who underwent preoperative transvaginal and transabdominal ultrasound examinations and were confirmed by surgical pathology were included in the study. The sonographic findings of different methods were analyzed, and the diagnostic effects of the two ultrasound methods were compared.

Results:

The positive rate of transvaginal ultrasound for EP masses was 100%, while the positive rate of transabdominal ultrasound was 67.27%, with a significant difference (P < 0.0001). For 53 cases of EP located in the ampulla, the diagnostic rate of transvaginal ultrasound was 100%, while transabdominal ultrasound was only 58.49%, with a significant difference (P < 0.0001). The sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound in diagnosing EP rupture were 94.44%, 58.67%, 52.31%, and 58.67%, respectively.

Conclusions:

The diagnostic efficacy of transvaginal ultrasound for EP is significantly better than that of transabdominal ultrasound. Therefore, for patients suspected of EP and without contraindication, transvaginal ultrasound is recommended as the first choice. Both peritoneal effusion by ultrasound and intraoperative abdominal hemorrhagic effusion had low specificity in diagnosing EP rupture. The diagnosis of EP rupture requires intraoperative direct vision.

Transvaginal Ultrasound Diagnosis of Ovarian Ectopic Pregnancy

Primary ovarian pregnancies are rare and comprise less than one percent of all ectopic pregnancies. Diagnosis can be difficult as an ovarian ectopic pregnancy may share similar features on ultrasound with those of a corpus luteal cyst. Findings on transvaginal ultrasound, including a hyperechoic ring, may denote the presence of a gestational sac and therefore an ovarian ectopic pregnancy. Ultrasonographic findings, as well as a strong suspicion of an ovarian ectopic pregnancy, are critical. The report reviews the case of a 23-year-old primigravida with first trimester bleeding, an elevated human chorionic gonadotropin, an ovarian cyst, and no intrauterine pregnancy detected on ultrasound. The evaluation, diagnosis, and surgical management of an ovarian ectopic pregnancy are discussed.

Ruptured ovarian ectopic pregnancy presenting with an acute abdomen

An ectopic pregnancy occurs in 2% of all pregnancies. A primary ovarian ectopic (OP) is a rare entity and occurs in <2% of all ectopic gestations. It may present in those individuals who take ovulatory drugs, use an intrauterine device or have undergone in vitro fertilisation or embryo transfer. Multiparity and a younger age are other recognised risk factors. Diagnosing an OP pregnancy remains a challenge and it may be misdiagnosed as a bleeding luteal cyst, a haemorrhagic ovarian cyst or a tubal pregnancy by ultrasound scan. The diagnosis is often only established at laparoscopy following histopathological examination. A ruptured OP is a potentially life-threatening condition due to its potential for haemorrhage and hemodynamic collapse. Hence, early diagnosis is crucial to prevent serious morbidity and mortality. The authors present the case of a multiparous woman in her late 30s presenting with a seizure and lower abdominal pain at 6 weeks gestation. Her beta human chorionic gonadotropin was >9000 Miu/mL. A transvaginal ultrasound scan showed no evidence of an intrauterine pregnancy. There was free fluid in the pelvis. She was hemodynamically stable. She underwent a diagnostic laparoscopy, which showed hemoperitoneum and a ruptured left OP pregnancy. She underwent a left oophorectomy. Histology confirmed chorionic villi within the ovarian stroma. This case demonstrates the challenges in preoperative diagnosis of a ruptured OP pregnancy and acts as a cautionary reminder that individuals can present with hemodynamic stability. Rarely, as in this case, an OP pregnancy can occur without the presence of risk factors. Despite its rarity, a ruptured OP pregnancy should be considered in the differential diagnosis of women of reproductive age presenting to the emergency department with acute abdominal pain and a positive pregnancy test.

Successful management of a patient with ovarian ectopic pregnancy by the end of the first trimester: a case report

BACKGROUND

Among all ectopic pregnancies, between 0.5% and 3.5% are ovarian ectopic pregnancies, a potentially life-threatening condition when ruptured due to its serious potential for hemorrhaging. A majority of ovarian ectopic pregnancies are diagnosed by the 7th week of pregnancy when the patient becomes symptomatic, and ultrasound can be used to diagnose this condition.

CASE PRESENTATION

We present the case of a 39-year-old Persian woman in the 12th week of gestation who presented with vaginal bleeding and abdominal pain and was diagnosed with ovarian ectopic pregnancy. Her notable laboratory finding was β-human chorionic gonadotropin > 15,000, which indicates definite pregnancy. Transvaginal ultrasound (TVS) revealed no evidence of intrauterine pregnancy, but a well-circumscribed gestational sac in the left ovary. The patient was successfully treated with resection of the gestational sac and partial left salpingo-oophorectomy. Histopathological studies confirmed the diagnosis of ovarian ectopic pregnancy.

CONCLUSION

The case emphasizes the ability of ovarian ectopic pregnancy to develop asymptomatically through the course of pregnancy and points to the necessity for high-quality prenatal care and the importance of determining the fetal site during pregnancy.

First-trimester emergencies: a radiologist's perspective

The purpose of this article is to help the practitioner ensure early diagnosis and response to emergencies in the first trimester by reviewing anatomy of the developing embryo, highlighting the sonographic appearance of common first-trimester emergencies, and discussing key management pathways for treating emergent cases. First-trimester fetal development is a stepwise process that can be challenging to evaluate in the emergency department (ED) setting. This is due, in part, to the complex anatomy of early pregnancy, subtlety of the sonographic findings, and the fact that fewer than half of patients with ectopic pregnancy present with the classic clinical findings of a positive pregnancy test, vaginal bleeding, pelvic pain, and tender adnexa. Ultrasound (US) has been the primary approach to diagnostic imaging of first-trimester emergencies, with magnetic resonance imaging (MRI) and computed tomography (CT) playing a supportive role in a small minority of cases. Familiarity with the sonographic findings diagnostic of and suspicious for early pregnancy failure, ectopic pregnancy, retained products of conception, gestational trophoblastic disease, failed intrauterine devices, and complications associated with assisted reproductive technology (ART) is critical for any emergency radiologist. Evaluation of first-trimester emergencies is challenging, and knowledge of key imaging findings and familiarity with management pathways are needed to ensure early diagnosis and response.

[Indications for methotrexate in gynecology outside the first-line treatment of ectopic tubal pregnancies]

The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.

Risk factors and clinical features of ovarian pregnancy: a case-control study

OBJECTIVE

To identify risk factors for ovarian pregnancy (OP) and compare clinical features between OP and tubal pregnancy (TP) patients.

DESIGN

Case-control study.

SETTING

University hospital.

PARTICIPANTS

A case-control study was conducted from January 2005 to May 2014. Women diagnosed with OP were recruited as the case group (n=71), 145 women with TP and 146 with intrauterine pregnancy (IUP) were matched as controls at a ratio of 1:2:2. Women who refused interviews or provided incomplete information were excluded.

RESULTS

OP risk was lower than TP risk in women with serological evidence of Chlamydia trachomatis infection (adjusted OR1 0.17, 95% CI 0.06 to 0.52), previous adnexal surgery (adjusted OR1 0.25, 95% CI 0.07 to 0.95), and current levonorgestrel emergency contraceptive use (adjusted OR1 0.24, 95% CI 0.07 to 0.78). In vitro fertilisation-embryo transfer (IVF-ET) carried a higher risk of OP (adjusted OR1 12.18, 95% CI 2.23 to 66.58) than natural conception. When Controlled by IUP women, current users of intrauterine devices (IUDs) carried a higher risk of OP than non-users of any contraceptives (adjusted OR2 9.60, 95% CI 1.76 to 42.20). β-Human chorionic gonadotropin (hCG) levels on the day of surgery were higher in OP patients than in TP patients (p<0.01). Women with OP were less likely to initially present with vaginal bleeding than those with TP (p=0.02). Moreover, shock (p=0.02), rupture (p<0.01), haemoperitoneum (p<0.01) and emergency laparotomy (p<0.01) were more common in the OP group than in the TP group.

CONCLUSIONS

IVF-ET and IUD use may be risk factors for OP, and OP patients tend to have high β-hCG levels and a poor clinical outcome (shock, rupture, haemoperitoneum and need for emergency laparotomy). Our findings may contribute to the prevention and early diagnosis of OP.