The Journal for Nurse Practitioners 15 (2019) 224e227

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The Journal for Nurse Practitioners

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Ovarian Ectopic Pregnancy: A Clinical Analysis

Cinthya Sotelo, DNP, FNP-C

a b s t r a c t
Keywords: Ovarian ectopic pregnancy is a rare form of ectopic pregnancy and constitutes approximately 3% of all ectopic
ectopic pregnancy cases. Its presentation mimics the symptoms of tubal ectopic pregnancy and can be difficult to distinguish
emergency
based on ultrasound imaging and presentation alone. Laparoscopic management is required for definitive
nurse practitioner
ovarian
diagnosis and treatment. Identifying these emergent cases early is imperative because of the high risk of
pelvic pain maternal death. The nurse practitioner should consider this emergent diagnosis in all women of childbearing
age who present to the emergency department with acute lower abdominal pain.
© 2019 Elsevier Inc. All rights reserved.

fallopian tubes are the location of 95% of ectopic pregnancies, with

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members may receive 1.0 continuing education contact
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Case Presentation
A 26-year-old gravida 2 para 1 woman presented to the emer-
gency department with 2 weeks of intermittent vaginal bleeding,
increasing left-sided pelvic pain, and a positive home pregnancy
test. Her last known menses was 4 weeks prior, but was shorter
than normal, started again 2 days later, and she had been having
intermittent bleeding and pelvic pain since. She had no prior
medical history and no use of an intrauterine contraceptive device
(IUCD) or assisted fertility treatments. She had delivered 1 child via
vaginal delivery 2 years prior and was currently breastfeeding. Her
vital signs were stable, and there were no signs of hypovolemic
shock.
The aim of this review is to present a patient with ovarian
ectopic pregnancy (OEP) who presented to the emergency
department and to discuss the clinical presentation, pathophysi-
ology, risk factors, diagnostic criteria, and available treatments of
this rare diagnosis.
Background
Ectopic pregnancy is a complication of pregnancy in which an
embryo attaches itself anywhere outside of the uterus. It is the most
commonly occurring gynecologic emergency and cause of
pregnancy-related death in the first trimester of pregnancy.1 The
the residual 5% occurring in the ovary, cervix, and abdomen.1 OEP is
a rare form of ectopic pregnancy and constitutes approximately
0.5% to 3% of all ectopic cases.2 The incidence ranges from 1 in 7,000
to 1 in 40,000 live births.3 Since the first ever reported case made by
Saint Maurice of France in 1682,4 the incidence of OEP continues to
increase.
OEP occurs when a fertilized ovum implants on the surface of
the ovary and usually terminates with rupture in the first trimester,
which can lead to internal hemorrhage and hypovolemic shock.5
Although the ovary should be able to accommodate more freely
than the fallopian tube to the size of the expanding pregnancy,
rupture at an early stage is common.1 Overall, 91% of OEPs end in
rupture during the first trimester, 5.3% end in the second trimester,
and 3.7% end in the third trimester.6 Only 1 case of an OEP that
advanced to full-term delivery has been reported.7 High levels of
maternal morbidity and mortality exist due to the infrequency of
OEP presentation and its diagnostic challenges. It is imperative for
the nurse practitioner (NP) to identify these cases early to prevent
further complications and maternal death.
Discussion
Pathophysiology
OEP occurs when a fertilized ovum implants on the surface of
the ovary. It can be categorized into primary and secondary
classifications wherein primary OEP usually occurs due to
ovulatory dysfunction and the ovum is fertilized while still
within the follicle, before the follicle being expelled from the
ovary.3 Secondary OEP occurs when fertilization takes place
within the fallopian tube and the conceptus is regurgitated and
implanted in the ovarian stroma.3

https://doi.org/10.1016/j.nurpra.2018.12.020
1555-4155/© 2019 Elsevier Inc. All rights reserved.
 C. Sotelo / The Journal for Nurse Practitioners 15 (2019) 224e227
OEP can also be further characterized into intrafollicular and
extrafollicular.3 Intrafollicular OEP, also called failure of follicular
expulsion, occurs when the ovum is fertilized within the follicle
inside of the ovary and is very rare.8 Extrafollicular OEP occurs
when the ovum is fertilized and subsequently migrates to and
implants on the ovary.8 Intrafollicular OEP occurs as mostly pri-
mary, whereas extrafollicular can be primary or secondary.3 Clas-
sification of OEP into primary or secondary does not affect the
overall management of the patient because both are managed in a
similar manner.9
Risk Factors
The risk factors of OEP include history of IUCD use, pelvic
inflammatory disease (PID), sexually transmitted infections (STIs),
use of assisted reproductive technologies, prior pelvic surgery,
endometriosis, previous ectopic pregnancy, salpingitis, advanced
maternal age, multiparity, and more rarely, infertility (Box 1).2,10
The actual cause of abnormal implantation is unclear. Some the-
ories suggest that the abnormal implantation that occurs in OEP is a
result of the following:
1. Embryo migration related to the presence of certain conditions
that cause fallopian tube epithelial damage that alters tubal
motility6
2. A hindrance in the release of the ovum from the ruptured
follicle2
3. Inflammatory thickening of the tunica albuginea.5
An IUCD is the most significant risk factor, accounting for up to
57% to 90% of patients with primary OEP.5,6 The theory behind this
is that although the IUCD provides protection from intrauterine
implantation, it does not prevent ovarian implantation.11 Specif-
ically, it is thought that the IUCD may potentiate ovarian implan-
tation due to changes in prostaglandin synthesis that subsequently
increases tubal peristalsis.11
Although there is a known correlation between a history of PID
and prior pelvic surgery in tubal ectopic pregnancies, these risk
factors may not play a significant role in OEP.2 PID can lead to a
reduction of tubal motility or thickening of the ovarian albuginea
caused by the natural inflammatory response. Theoretically, this
thickening can result in a reduction of follicular dehiscence sub-
sequently leading to an increased risk of OEP.10 It is also suggested
that scarring of the fallopian tube from PID can prevent the fertil-
ized ovum from migrating into the uterus and lead to tubal im-
plantation. However, this scarring-impaired migration is less likely
to result in ovarian implantation.
Box 1
Risk Factors of Ovarian Ectopic Pregnancy
History of intrauterine contraceptive device use
Pelvic inflammatory disease
Sexually transmitted infections
Use of assisted reproductive technologies
Prior pelvic surgery
Endometriosis
Previous ectopic pregnancy
Salpingitis
Advanced maternal age
Multiparity
Infertility (rare)
225
Box 2
Signs and Symptoms of Ovarian Ectopic Pregnancy
Mild to moderate pelvic or lower abdominal pain
Vaginal bleeding
Amenorrhea/menstrual irregularities
Nausea
Vomiting
Constipation
Hypovolemic shock (if ruptured)
Clinical Presentation
OEP should be suspected in any female patient of reproductive
age who presents with lower abdominal or pelvic pain, or both. The
patient may be asymptomatic or present with signs and symptoms
similar to those of tubal pregnancy, including the classic triad of
mild to moderate pelvic or lower abdominal pain, vaginal bleeding,
and amenorrhea/menstrual irregularities (Box 2).3 Other common
symptoms include nausea, vomiting, and constipation.9 Less
commonly, the patient may present in hypovolemic shock resulting
from acute intra-abdominal bleeding from rupture.10
Examination Findings
Clinical examination and laboratory findings include lower
abdominal tenderness with or without rigidity or guarding, vaginal
bleeding, adnexal tenderness, palpable adnexal mass, positive
pregnancy test, and elevated beta-human chorionic gonadotropin
(b-hCG) level.12 A positive qualitative pregnancy test and single
measurement of the quantitative b-hCG level alone cannot differ-
entiate an intrauterine pregnancy from an ectopic pregnancy.
Diagnostic Evaluation
In the hemodynamically stable patient, further diagnostic
evaluation should include transvaginal ultrasound (TV-US).13 Cor-
relation of serial quantitative b-hCG level measurements with
TV-US findings can aid in accurate interpretation in regards to an
ectopic pregnancy. Usually, an intrauterine gestational sac can be
visualized on TV-US when the quantitative b-hCG level is greater
than 2,000 to 3,000 IU/L.14 An empty uterine cavity with a b-hCG
level less than 2,000 to 3,000 IU/L can signify an intrauterine
pregnancy too early to visualize. Therefore, serial quantitative
b-hCG levels correlated with serial TV-US findings are recom-
mended to determine an early intrauterine pregnancy from ectopic
pregnancy.
Historically, the use of ultrasound was not ideal for diagnosing
ectopic pregnancies because of the limited quality of the images.
The quality of ultrasound has improved dramatically, and TV-US
findings are now considered an integral part of the workup.
Sonographic criteria for the presence of OEP has been suggested
and includes:
1. an empty endometrial cavity;
2. a gestational sac that is inseparable from adjacent ovarian
parenchyma;
3. a yolk sac and fetal pole, with or without cardiac motion,
depending on gestational age;
4. a wide echogenic ring with an internal echolucent area on the
ovarian surface (“ring of fire” sign);
226 C. Sotelo / The Journal for Nurse Practitioners 15 (2019) 224e227

5. the presence of an ovarian cortex, including corpus luteum or evaluated. Follow-up ultrasound findings should demonstrate that a
follicles near the mass; and corpus luteum cyst shows progressive involution with increasing
6. echogenicity of the ring that is usually larger than the ovary crenulation of its margins, whereas an OEP will grow, with marked
itself.10 thickening of the circumferential echogenic margins and develop-
ment of a yolk sac and fetal pole within the gestational sac.13
The “ring of fire” sign can also be seen with a corpus luteum cyst Most cases demonstrate these ultrasonographic differences;
and is therefore not considered a definitive criterion for diagnosis however, there is some similarity that remains when distinguishing
based on ultrasound alone but can be considered if and when it is these finding from OEP on ultrasound. This ultimately results in the
available.13 use of laparoscopy for definitive diagnosis.
One case report discussed the use of magnetic resonance imaging
(MRI) for the diagnosis of OEP and suggested that MRI is useful for
Diagnosis and Diagnostic Criteria
localizing the implantation site when it is unclear on TV-US.15 The use
of MRI for this specific diagnosis is limited at this time.
The gold standard for definitive diagnosis and management of
Laboratory findings in the case patient were unremarkable, with
OEP is surgical laparoscopy or laparotomy with histopathologic
a positive serum pregnancy test and b-hCG level of 3,609 IU/L. On
confirmation. Advantages of laparoscopic surgery versus laparot-
physical examination, there was tenderness to the left lower
omy include shorter operating times, less intraoperative blood loss,
quadrant of the abdomen without any rebound tenderness,
shorter hospital stay, and decreased need for postoperative
guarding, or rigidity. Pelvic examination revealed a small amount of
analgesia.7
cervical bleeding, left adnexal tenderness without palpable mass,
The Spiegelberg criteria, created by Dr. Otto Spiegelberg in 1878,
and no cervical motion tenderness.
continue to be the standard for the diagnosis of OEP at the time of
surgery and include: (1) an intact ipsilateral tube that is clearly
Differential Diagnosis
separate from the ovary; (2) a gestational sac occupying the posi-
tion of the ovary; (3) a gestational sac connected to the uterus by
Ectopic pregnancy should be included in the differential di-
the ovarian ligament; and (4) histologically proven ovarian tissue
agnoses when there is a positive pregnancy test and an empty
located in the sac wall (Box 3).4 The criteria were established to
endometrial cavity on ultrasound. Differential diagnoses for OEP
differentiate OEP from other types of ectopic pregnancy and to
include corpus luteum cyst, hemorrhagic ovarian cyst, endometri-
confirm the diagnosis OEP, along with histopathologic findings, at
otic ovarian cyst/chocolate cyst, tubal ectopic pregnancy, early or
the time of surgery. Unfortunately, the Spiegelberg criteria can only
failed intrauterine pregnancy, and in the presence of a negative
be seen laparoscopically and cannot be proven on ultrasound.
pregnancy test, appendicitis.10
That the incidence of OEP could be as high as 1 in 1,400 de-
An early or failed intrauterine pregnancy on ultrasound
liveries if criteria other than Spiegelberg criteria are used has been
consists of findings that include the absence of a visible intra-
suggested.11 The suggested criteria combine laboratory and TV-US
uterine pregnancy or the absence of an intrauterine gestational
findings and include (1) b-hCG level > 1,000 IU/L; (2) no gesta-
sac or yolk sac, or both. Until subsequent serial quantitative
tional sac is seen on TV-US; (3) ovarian involvement is confirmed
b-hCG levels with repeat ultrasound imaging can demonstrate
on laparoscopy, and with bleeding, visualization of chorionic villi,
an intrauterine pregnancy, ectopic pregnancy, including OEP,
or presence of atypical cysts on the ovary; (4) normal fallopian
should be a consideration.
tubes; and (5) absence of serum b-hCG level after treatment.11
Ultrasound findings that show a distal tubal ectopic pregnancy
Although the Spiegelberg criteria remain valid, the patient’s pre-
that is close to the ovary can be misdiagnosed as an OEP.13 It has
sentation and TV-US findings continue to be an essential part of the
been demonstrated that free movement between the ovary and an
overall diagnostic work-up.
adnexal mass on palpation during ultrasound (sliding organs sign)
The TV-US in the case patient showed a left adnexal ectopic
can assist in differentiating intraovarian from extraovarian
pregnancy with identifiable gestational sac, secondary yolk sac, and
masses.13 However, this is not useful when attempting to distin-
a live embryonic pole demonstrating cardiac activity with a small
guish between OEP, corpus luteum cyst, and hemorrhagic ovarian
amount of free fluid in the pelvis. A diagnosis of left adnexal ectopic
cyst. The use of 3-dimensional ultrasound has been suggested to
pregnancy was made, and the on-call obstetrician/gynecologist was
make a difference in differentiating OEP from a corpus luteum cyst
consulted. The diagnostic test results were discussed with the pa-
or hemorrhagic cyst; however, use of this technology is limited.15
tient, she was made aware of what the next steps would likely
Although corpus luteum cysts, tubal ectopic pregnancies, and
entail, and all of her questions and concerns were addressed. It is
OEPs all have a ring-like appearance, differences on ultrasound are
important for the NP to address the patient’s thoughts and feelings
usually evident. A corpus luteum cyst appears less echogenic than
the ovary, the OEP has a ring-like structure that appears more
echogenic than the ovary itself,10 and a tubal ectopic pregnancy
ring has a much thinner wall by comparison.9 Ultrasonographic Box 3
differences in the appearance of an endometriotic ovarian cyst, or Spiegelberg Criteria
chocolate cyst, versus an OEP include the appearance of homoge-
nous low-level echoes with some area of increased echogenicity
(which signifies clot), without demonstrating any evidence of in-
ternal blood flow.16 1. Intact ipsilateral tube that is clearly separate from the
If the patient appears clinically stable at the time of the ovary
diagnostic evaluation and early OEP versus corpus luteum cyst is 2. Gestational sac occupying the position of the ovary
suspected, close follow-up with serial b-hCG measurements and 3. Gestational sac connected to the uterus by the ovarian
TV-US in 2 to 3 days can be considered after consultation with ligament
obstetrics-gynecology.13 The clinician should be very careful in 4. Histologically proven ovarian tissue located in the sac
making this determination, and if any suspicion or possibility of pa- wall
tient decompensation is suspected, the patient should be surgically
 C. Sotelo / The Journal for Nurse Practitioners 15 (2019) 224e227
about the psychological and emotional stress regarding the loss of a
pregnancy.
Management
Careful consideration of the patient’s desire to have more chil-
dren should be given when determining the management of OEP.
Conservative management with wedge resection, enucleation,
cystectomy, or trophoblast curettage with coagulation or hemo-
static suture is preferred over oophorectomy because it allows for
preservation of the patient’s fertility.5 Smaller lesions are typically
managed with wedge resection or cystectomy, whereas larger
lesions may require oophorectomy.7
Medical management using a single dose of intramuscular
methotrexate or etoposide has been reported but is uncommon and
remains controversial. Little evidence is available regarding medi-
cal management of OEP using methotrexate; however, some case
reports have described successful treatment.5 Although a metho-
trexate injection is less invasive than surgery, higher treatment
failure rates and risk for ovarian bleeding have been seen with the
use of methotrexate.8
Green-top criteria have been developed suggesting that the use
of methotrexate can be considered if the following criteria are met:
(1) no signs of hemodynamic compromise; (2) no evidence of blood
in the pelvis; (3) pregnancy size must be < 3.5 cm with no fetal
heart activity; and (4) b-hCG level should be < 3,500 IU/L.12 If used,
a single dose of methotrexate by laparoscopic-assisted injection
into the ectopic site is recommended.9 Higher failure rates have
been reported if the gestational sac is > 3.5 mm or if the serum
b-hCG level is < 5,000 IU/L.9 There are few recommendations for
medical management to be appropriate when the risks of surgery
are high.8 The American Society for Reproductive Medicine does
not recommend methotrexate as the first-line treatment of OEP.14
Most patients who are surgically managed are admitted and
discharged home without any complications within several days
and with close outpatient follow-up. Sequential serum b-hCG levels
should be performed, with the level decreasing steadily until it is
undetectable. Subsequent fertility in patients who have had an OEP
has not been shown to be affected, and no cases of recurring OEP
have been documented.9
In this case, the patient was sent immediately to the operating
room where laparoscopy was performed and showed an unrup-
tured left ovarian pregnancy with a gestational sac structure con-
taining a live fetus at the left ovarian fossa. Wedge resection was
performed, and the patient did well postoperatively. Histopatho-
logic evaluation confirmed a left ovarian gestation demonstrating
chorionic villi, trophoblasts, and ovarian stroma consistent with the
criteria needed for diagnosis.
Conclusion
The incidence of OEP has been steadily increasing, likely related
to better identification of the presenting symptoms as well as the
227
use of improved TV-US technology. Despite these improvements,
the presentation of OEP mimics the symptoms of tubal ectopic
pregnancy, among other lower abdominal etiologies, and can be
difficult to distinguish based on ultrasound and presentation alone.
Laparoscopy is considered the gold standard for definitive diagnosis
with histopathologic confirmation. Management usually consists of
wedge resection versus oophorectomy. Medical management with
the use of methotrexate has been successful but remains contro-
versial. The NP should have a high index of suspicion of OEP in
female patients of childbearing age who present with acute lower
abdominal pain. Early diagnosis and management is vital to
prevent associated maternal morbidity and death.
References
1. Kadau JV. Sonographic detection of ovarian ectopic pregnancy: a case
study. J Diagn Med Sonogr. 2016;32(5):299-303. https://doi.org/10.1177/
8756479316663163.
2. Melcer Y, Maymon R, Vaknin Z, et al. Primary ovarian ectopic pregnancy: still a
medical challenge. J Reprod Med. 2016;61(1-2):58-62.
3. Begum J, Pallavee P, Samal S. Diagnostic dilemma in ovarian pregnancy: a case
series. J Clin Diagn Res. 2015;9(4):1-3. https://doi.org/10.7860/JCDR/2015/
11501.5772.
4. Spiegelberg O. The causes of ovarian pregnancy. Arch Gynaekol. 1878;13:73.
5. Birge O, Erkan MM, Ozbey EG, Arslan D. Medical management of an ovarian
ectopic pregnancy: a case report. J Med Case Rep. 2015;9(290):1-4. https://
doi.org/10.1186/s13256-015-0774-6.
6. Mathur SK, Parmar P, Gupta P, Kumar M, Gilotra M, Bhatia Y. Ruptured primary
ovarian ectopic pregnancy: case report and review of the literature. J Gynecol
Surg. 2015;31(6):354-356. https://doi.org/10.1089/gyn.2015.0018.
7. Tehrani HG, Hamoush Z, Ghasemi M, Hashemi L. Ovarian ectopic pregnancy: a
rare case. Iran J Reprod Med. 2014;12(4):281-284.
8. Conner EV, Huber WJ 3rd, Matteson KA. Ovarian ectopic pregnancy contra-
lateral to unicornuate uterus. Clin Obstet Gynecol Reprod Med. 2015. https://
doi.org/10.15761/COGRM.1000118.
9. Ogundobe OO, Aremu OO, Okolo CA. Primary ovarian pregnancy mimicking
abdominal pregnancy. Niger Postgrad Med J. 2017;22(3):185-188. https://
doi.org/10.4103/1117-1936.170739.
10. Roy J, Babu AS. Ovarian pregnancy: two case reports. Australas Med J.
2013;6(8):406-410. https://doi.org/10.4066/AMJ.2013.1760.
11. Goyal LD, Tondon R, Goel P, Sehgal A. Ovarian ectopic pregnancy: a 10 years’
experience and review of literature. Iran J Reprod Med. 2014;12(12):825-830.
12. Hassan S, Arora R, Bhatia K. Primary ovarian pregnancy: case report and review
of literature. BMJ Case Rep. 2012;2012:1-4. https://doi.org/10.1136/bcr-2012-
007112.
13. Chukus A, Tirada N, Restrepo R, Reddy N. Uncommon implantation sites of
ectopic pregnancy: thinking beyond the complex adnexal mass. Radiographics.
2015;35(3):946-959. https://doi.org/10.1148/rg.2015140202.
14. Dibble EH, Lourenco AP. Imaging unusual pregnancy implantations: rare
ectopic pregnancies and more. AJR Am J Roentgenol. 2016;207(6):1380-1392.
https://doi.org/10.2214/AJR.15.15290.
15. Io S, Hasegawa M, Koyama T. A case of ovarian ectopic pregnancy diagnosed by
MRI. Case Rep Obstet Gynecol. 2015;2015:143031. https://doi.org/10.1155/2015/
143031.
16. Asch E, Levine D. Variations in appearance of endometriomas. J Ultrasound
Med. 2007;26:993-1002.
Cinthya Sotelo, DNP, FNP-C, is an assistant professor, California State University Los
Angeles, Los Angeles, CA. She can be reached at cvasqu36@calstatela.edu.
In compliance with national ethical guidelines, the author reports no relationships
with business or industry that would pose a conflict of interest.