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Current Women`s Health Reviews


ISSN (Print): 1573-4048
ISSN (Online): 1875-6581

Research Article

Management of Unusual Not Scar Ectopic Pregnancy: A Multicentre Retrospective Case Series

Author(s): Federico Ferrari*, Silvia Ficarelli, Benedetta Cornelli, Filippo Alberto Ferrari, Antonino Farulla, Carlo Alboni, Enrico Fontana, Marianna Roccio, Anna Chiara Boschi, Danilo Buca, Martina Leombroni, Isabel Peterlunger, Maria Cristina Moruzzi, Giuliana Beneduce, Giulia Bolomini, Antonio Simone Laganà, Piero Malorgio, Giuseppe Ricci, Massimo Franchi, Giovanni Scambia, Enrico Sartori and Franco Odicino

Volume 18, Issue 4, 2022

Published on: 24 February, 2021

Article ID: e111021191799 Pages: 9

DOI: 10.2174/1573404817666210224150839

Price: $65


Background: Management of unusual not scar ectopic pregnancies (UNSEPs) is an unexplored clinical field because of their low incidence and lack of guidelines.

Objective: To report the clinical presentation, the first- and second-line treatment and outcomes of UNSEPs.

Methods: We retrospectively collected patients treated for UNSEP (namely cervical, interstitial, ovarian, angular, abdominal, cornual and intramural), their baseline characteristics, risk factors, symptoms, diagnostic pathway and the type of first-line treatment (medical, surgical or combined). We further collected treatment failures and the type of second- line treatment. We assessed treatment outcomes, time to serum beta human chorionic gonadotropin (β-hCG) level negativity, length of recovery, follow up and return to a normal menstrual cycle.

Results: From 2009 to 2019, we collected 79 cases. Of them, 27 (34%), 23 (29%), 12 (15%), 8 (10%), 6 (8%) and 3 (4%) were cervical, interstitial, ovarian, angular, abdominal and cornual, respectively. Forty women (50.6%) were submitted to medical treatment, mostly methotrexate based; conversely, 36 patients (45.6%) underwent surgery and only 3 women (3.8%) received a combined treatment. The success of first-line treatment rate, regardless of UNSEP location, was 53% and 89% for medical and surgical treatment, respectively. Treatment failures (21 patients) were submitted to second-line treatment, respectively 47.6% and 52.4% to medical and surgical approach. Of interest, cervical pregnancies achieved the lowest rate of first-line medical treatment success (22%) and received more frequently (69%) a subsequent surgical approach with no hysterectomy. Interstitial pregnancies were submitted to surgery mostly for a matter of urgency (71%), otherwise, they were treated with a medical approach both at first- and second-line treatment. Ovarian pregnancies were treated with ovariectomy in 44% of the cases submitted to surgery. Angular pregnancies underwent surgery more often, while all the abdominal pregnancies underwent endoscopic or open surgery. Cornual pregnancies received cornuostomy in 75% of the cases. Overall, the need for blood transfusion was 23.1% among the patients submitted to surgery. The median length of hospitalisation was shorter for women submitted to surgical first-line treatment (5 vs. 10 days; p = 0.002). In case of first-line medical treatment and in case of failure, we found an increase of 3 days (CI95% 0.6-5.5; p = 0.01) and of 3.6 days (CI95% 0.89-6.30; p = 0.01) in the length of hospitalisation, respectively. Negative β-HCG levels were obtained earlier in the surgical group (median 25 vs. 51 days; p = 0.001), as well as the return to normal menstrual cycle (median 31 vs. 67 days; p < 0.000). Post-treatment follow-up, regardless of the failure of first-line treatment was shorter in the surgical group (median 32 versus 68 days; p= 0.003).

Conclusion: Cervical pregnancies were successfully managed with a surgical approach without hysterectomy, and hence, we suggest avoiding medical treatment. No consensus emerged for other UNSEPs. Ovarian, angular and interstitial pregnancies are burdened by a non-conservative approach on the utero-ovarian structures. The surgical approach led to shorter recovery, earlier β-hCG negativity and shorter follow-up, even though there is an increased risk for blood transfusion.

Keywords: Ectopic pregnancy, cornual pregnancy, interstitial pregnancy, cervical pregnancy, ovarian pregnancy, abdominal pregnancy, hepatic pregnancy, angular pregnancy, intramural pregnancy.

Graphical Abstract
Elson C, Salim R, Potdar N, et al. Diagnosis and management of ectopic pregnancy (green-top guideline no. 21). BJOJ 2016; 123(13): e15-55.
[PMID: 27813249]
Shan N, Dong D, Deng W, Fu Y. Unusual ectopic pregnancies: a retrospective analysis of 65 cases. J Obstet Gynaecol Res 2014; 40(1): 147-54.
[] [PMID: 24033915]
Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update 2014; 20(2): 250-61.
[] [PMID: 24101604]
Arleo EK, DeFilippis EM. Cornual, interstitial, and angular pregnancies: clarifying the terms and a review of the literature. Clin Imaging 2014; 38(6): 763-70.
[] [PMID: 25156020]
Trivedi K, Singh L. Advanced abdominal pregnancy with a healthy newborn: a rare case report. Int J Reprod Contracept Obstet Gynecol 2016; 5(10): 3583-6.
Ciavattini A, Cerè I, Tsiroglou D, Caselli FM, Tranquilli AL. Angular-interstitial pregnancy treated with minimally invasive surgery after adjuvant methotrexate medical therapy. JSLS 2007; 11(1): 123-6.
[PMID: 17651573]
Garzon S, Laganà AS, Pomini P, Raffaelli R, Ghezzi F, Franchi M. Laparoscopic reversible occlusion of uterine arteries and cornuostomy for advanced interstitial pregnancy. Minim Invasive Ther Allied Technol 2019; 28(6): 359-62.
[] [PMID: 30514139]
Panelli DM, Phillips CH, Brady PC. Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. Fertil Res Pract 2015; 1(15): 15.
[] [PMID: 28620520]
Raskin MM. Diagnosis of cervical pregnancy by ultrasound: a case report. Am J Obstet Gynecol 1978; 130(2): 234-5.
[] [PMID: 619667]
Condous G, Timmerman D, Goldstein S, Valentin L, Jurkovic D, Bourne T. Pregnancies of unknown location: consensus statement. Ultrasound Obstet Gynecol 2006; 28(2): 121-2.
[] [PMID: 16933302]
Kirk E, Condous G, Haider Z, Syed A, Ojha K, Bourne T. The conservative management of cervical ectopic pregnancies. Ultrasound Obstet Gynecol 2006; 27(4): 430-7.
[] [PMID: 16514619]
Nabeshima H, Nishimoto M, Utsunomiya H, et al. Total laparoscopic conservative surgery for an intramural ectopic pregnancy. Diagn Ther Endosc 2010; 2010
[] [PMID: 20981282]
Timor-Tritsch IE, Monteagudo A, Bennett TA, Foley C, Ramos J, Kaelin Agten A. A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy. Am J Obstet Gynecol 2016; 215(3): 351.e1-8.
[] [PMID: 26979630]
Grant A, Murji A, Atri M. Can the presence of a surrounding endometrium differentiate eccentrically located intrauterine pregnancy from interstitial ectopic pregnancy? J Obstet Gynaecol Can 2017; 39(8): 627-34.
[] [PMID: 28729096]
Comstock C, Huston K, Lee W. The ultrasonographic appearance of ovarian ectopic pregnancies. Obstet Gynecol 2005; 105(1): 42-5.
[] [PMID: 15625140]
Bollig KJ, Schust DJ. Refining angular pregnancy diagnosis in the first trimester: A case series of expectant management. Obstet Gynecol 2020; 135(1): 175-84.
[] [PMID: 31809430]
Mazzon I, Gerli S, Di Angelo Antonio S, Assorgi C, Villani V, Favilli A. The technique of vaginal septum as uterine septum: a new approach for the hysteroscopic treatment of vaginal septum. J Minim Invasive Gynecol 2020; 27(1): 60-4.
[] [PMID: 30904487]
Grimbizis GF, Campo R. On behalf of the scientific committee of the congenital uterine malformations (CONUTA) common ESHRE/ESGE working group: Stephan Gordts, Sara Brucker, Marco Gergolet, Vasilios Tanos, T.-C. Li, Carlo De Angelis, Attilio Di Spiezio Sardo. Clinical approach for the classification of congenital uterine malformations. Gynecol Surg 2012; 9(2): 119-29.
[] [PMID: 22611348]
Liu NN, Han XS, Guo XJ, Sun LT, Kong XC. Ultrasound diagnosis of intramural pregnancy. J Obstet Gynaecol Res 2017; 43(6): 1071-5.
[] [PMID: 28422362]
Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively. Ultrasound Obstet Gynecol 1996; 8(6): 373-80.
[] [PMID: 9014275]
Jurkovic D, Mavrelos D. Catch me if you scan: ultrasound diagnosis of ectopic pregnancy. Ultrasound Obstet Gynecol 2007; 30(1): 1-7.
[] [PMID: 17587215]
Ackerman TE, Levi CS, Dashefsky SM, Holt SC, Lindsay DJ. Interstitial line: sonographic finding in interstitial (cornual) ectopic pregnancy. Radiology 1993; 189(1): 83-7.
[] [PMID: 8372223]
Barut A, Barut F, Arikan I, Harma M, Harma MI, Ozmen Bayar U. Comparison of the histopathological diagnoses of preoperative dilatation and curettage and hysterectomy specimens. J Obstet Gynaecol Res 2012; 38(1): 16-22.
[] [PMID: 21917068]
Gerli S, Rossetti D, Baiocchi G, Clerici G, Unfer V, Di Renzo GC. Early ultrasonographic diagnosis and laparoscopic treatment of abdominal pregnancy. Eur J Obstet Gynecol Reprod Biol 2004; 113(1): 103-5.
[] [PMID: 15036722]
Zhang Q, Xing X, Liu S, et al. Intramural ectopic pregnancy following pelvic adhesion: case report and literature review. Arch Gynecol Obstet 2019; 300(6): 1507-20.
[] [PMID: 31729562]
Tozzi R, Ferrari F, Nieuwstad J, Campanile RG, Soleymani Majd H. Tozzi classification of diaphragmatic surgery in patients with stage IIIC-IV ovarian cancer based on surgical findings and complexity. J Gynecol Oncol 2020; 31(2): e12.
[] [PMID: 31912672]
Moini A, Hosseini R, Jahangiri N, Shiva M, Akhoond MR. Risk factors for ectopic pregnancy: A case-control study. J Res Med Sci 2014; 19(9): 844-9.
[PMID: 25535498]
Anwar S, Uppal T. Recurrent viable ectopic pregnancy in the salpingectomy stump. Australas J Ultrasound Med 2010; 13(3): 37-40.
[] [PMID: 28191089]
Ferrari F, Forte S, Prefumo F, Sartori E, Odicino F. Opportunistic salpingectomy during postpartum contraception procedures at elective and unscheduled cesarean delivery. Contraception 2019; 99(6): 373-6.
[] [PMID: 30898658]
Di Spiezio Sardo A, da Cunha Vieira M, Laganà AS, et al. Servikal gebelikte histeroskopik rezeksiyon ile ilişkili kombine sistemik ve histeroskopik intra-amniyotik metotreksat enjeksiyonu: Nadir bir durum için en yeni yaklaşım. Eurasian J Med 2017; 49(1): 66-8.
[PMID: 28416938]
Fylstra DL. Cervical pregnancy: 13 cases treated with suction curettage and balloon tamponade. Am J Obstet Gynecol 2014; 210(6): 581.e1-5.
[] [PMID: 24704060]
Vitale SG. The Biopsy snake grasper sec. VITALE: A new tool for office hysteroscopy. J Minim Invasive Gynecol 2020; 27(6): 1414-6.
Stone K. Acute abdominal emergencies associated with pregnancy. Clin Obstet Gynecol 2002; 45(2): 553-61.
[] [PMID: 12048412]
Lagana AS, Vitale SG, De Dominici R, et al. Fertility outcome after laparoscopic salpingostomy or salpingectomy for tubal ectopic pregnancy A 12-years retrospective cohort study. Ann Ital Chir 2016; 87(5): 461-5.
[PMID: 27480601]
Hasanzadeh M, Dadgar S, Arian Y, Yousefi Y. Angular ectopic pregnancy presenting as rupture of lateral wall of the uterus: Late presentation in gestation week 20. Iran J Med Sci 2017; 42(3): 314-7.
[PMID: 28533582]
Alves JAG, Alves NG, Alencar Júnior CA, Feitosa FE, da Silva Costa F. Term angular pregnancy: successful expectant management. J Obstet Gynaecol Res 2011; 37(6): 641-4.
[] [PMID: 21375673]
Parekh VK, Bhatt S, Dogra VS. Abdominal pregnancy: an unusual presentation. J Ultrasound Med 2008; 27(4): 679-81.
[] [PMID: 18359918]

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