The Ultrasonographic Appearance of Ovarian Ectopic

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

Ovarian pregnancy is a rare event, with estimates of

frequency ranging from 1 in 2,100 to 1 in 7,000 pregnancies,1 or 3% of all ectopic pregnancies.2 There is scant
information on the ultrasonographic appearance of ovarian pregnancies. We reviewed the ultrasonographic and
clinical findings in 6 cases of proven ovarian ectopic
pregnancy obtained over a 13-year period from 80,000
first-trimester scans.
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.

42

VOL. 105, NO. 1, JANUARY 2005

2005 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.

MATERIALS AND METHODS

The ultrasonographic reports, videotapes, medical
records, and operative summaries were reviewed for all
women with a confirmed diagnosis of an ovarian ectopic
pregnancy during the period of 1990 2003. Ultrasound
equipment used in these examinations included Acuson
128 and Acuson Sequoia (Mountain View, CA) systems,
with transvaginal probes of 7 or 10 MHz. Examinations
were personally performed by a physician who was
either a radiologist obstetrician or an obstetricianmaternal-fetal medicine specialist. Levels of -hCG were
determined by using the Third International Standard,
Reference Preparation Standard. A different obstetrician
managed each patient. All cases were proven by pathologic examination of the area excised. These examinations needed to show trophoblastic tissue with ovarian
tissue.
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.

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

Table 1. Ovarian EctopicsClinical and Ultrasound Findings

-hCG
(mIU)

Patient
Age (y)

Menstrual
Age (wk)

22

6.5

Abdominal pain

3,206

30

8.5

Vaginal bleeding

11,000

32

Light vaginal bleeding

with abdominal pain

2,019

32

Abdominal pain

3,535

33

8.6

Vaginal spotting, right

lower quadrant pain

8,480

36

9.3

abdominal pain after

methotrexate in
physicians office

Patient

Symptoms

315

Ultrasound Findings

Surgical Findings

No IUP, blood and clot in

the pelvis
No IUP, no free fluid, 2.5-cm
mass on surface of right
ovary with yolk sac
No IUP, moderate amount
of blood in pelvis, 2.7
4.1 cm ring in right ovary,
clot and free fluid
No IUP, 2.9 2.8 cm ring in
left adnexa adjacent to
ovary with cardiac activity
No IUP, 2.7 2.8 2.5 cm
right adnexal mass, no
cardiac activity
No IUP, 1.7 cm ring in left
ovary, small amount of
free fluid

Ruptured ovarian cyst,

free clot
Hemorrhagic cyst on
the ovarian surface
Active bleeding from a
surface ovarian cyst
Reddish ovarian cyst
Hemorrhagic ovarian
cyst
2-cm hemorrhagic area
on the ovarian
surface

IUP, intrauterine pregnancy.

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 -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 bleed-

ing (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.
At surgery the ovarian ectopic seemed to be a hemorrhagic ovarian cyst on the surface of the ovary in all 6
patients. In the patient in whom no echogenic ring was
seen by ultrasound, the mass had ruptured. Four masses
were on the left and 2 on the right side.

Fig. 1. Ovarian ectopicthick echogenic ring (arrow) around

a small echolucent area. Note the sonolucent gestational sac
(arrowhead).

Fig. 2. Ovarian ectopicthick echogenic ring with a faint

yolk sac within the gestational sac (arrow). Note that the
ring (R) is more echogenic than the ovary (O).

Comstock. Ultrasonography of Ovarian Ectopics. Obstet Gynecol 2005.

Comstock. Ultrasonography of Ovarian Ectopics. Obstet Gynecol 2005.

VOL. 105, NO. 1, JANUARY 2005

Comstock et al

Ultrasonography of Ovarian Ectopics

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

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Comstock et al

Ultrasonography of Ovarian Ectopics

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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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@beaumont.edu.
Received July 28, 2004. Received in revised form September 1, 2004.
Accepted September 29, 2004.

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Ultrasonography of Ovarian Ectopics

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