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Jacobi Medical Center, Bronx, NY 10461
In response to the article written by Hertzberg et al. [1], we ask how can we make a diagnosis of an adnexal mass that is highly suggestive of ectopic pregnancy without an ovary being seen separate from the adnexal mass?
The patient described by Hertzberg et al. [1] presented with abdominal pain, right adnexal tenderness, and positive findings for human chorionic gonadotropin (HCG). No intrauterine pregnancy was present, but free fluid was seen in the cul-de-sac on sonography. Sonography also showed an adnexal mass with a cystic center with debris that may have looked like a fetal pole, but did not reveal the ovary as separate from the mass. The patient most likely had a hemorrhagic corpus luteum cyst.
Of course, the possibility of an ectopic pregnancy had to be kept in mind. What was the rush? I presume the patient was clinically stable. No quantitative HCG level was available until the next day. If the HCG value had been more than 1000 mIU/mL at the time of sonography, the diagnosis of an ectopic pregnancy would have been strongly suspected—not because of the mass—but because of the free fluid in the cul-de-sac without an intrauterine pregnancy.
References
Duke University Medical Center, Durham, NC 27710
We would like to thank Dr. Kory for the interest in our article "Adnexal Ring Sign and Hemoperitoneum Caused by Hemorrhagic Ovarian Cyst: Pitfall in the Sonographic Diagnosis of Ectopic Pregnancy" [1]. We agree with Dr. Kory that sonographic visualization of an adnexal ring and hemoperitoneum is not 100% diagnostic of ectopic pregnancy in a patient with a positive human chorionic gonadotropin (HCG). Indeed, the goal of our article, in which we describe a patient with this combination of findings who subsequently proved to have a hemorrhagic ovarian cyst and an intrauterine pregnancy rather than an ectopic pregnancy, was to illustrate this very point.
Despite the outcome in the case we described [1], it is widely accepted that in the setting of a positive HCG and no demonstrable intrauterine pregnancy, sonographic depiction of an adnexal mass with an adnexal ring sign and hemoperitoneum is highly suggestive of an ectopic pregnancy [1,2,3,4,5]. As we discussed in our article, it is important to identify the ovaries and determine the relationship of the adnexal ring to the ovaries. Visualization of the ipsilateral ovary as separate from the adnexal ring increases the likelihood that the mass represents an ectopic pregnancy, whereas visualization of the ring as originating from within the ovary strongly suggests a hemorrhagic ovarian cyst. Unfortunately, unambiguously defining the relative locations of the adnexal ring and the ovary is not always possible. The ovary and the ectopic pregnancy are frequently contiguous, and the margins of the ovary can be obscured and follicles can be difficult to identify when the ovary is enveloped by tubal or peritoneal hemorrhage. Moreover, an ectopic pregnancy is rarely intraovarian.
In the case we described [1], the relationship between the adnexal ring and the ovaries could not be determined with certainty. The adnexal ring did not appear to originate from within a structure that could be positively identified as an ovary because follicles were not seen. Ectopic pregnancy was therefore considered the most likely diagnosis. There is abundant literature that supports the concept that the overwhelmingly most likely diagnosis is ectopic pregnancy in a patient with a positive HCG; hemoperitoneum; an adnexal mass, adnexal ring sign, or both; and no intrauterine pregnancy [2,3,4,5,6]. Rarely, these findings prove attributable to something else, as in our patient with a hemorrhagic ovarian cyst, but such alternate causes are the exception rather than the rule.
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