Background: Management of unusual not scar ectopic pregnancies (UNSEPs)
is an unexplored clinical field because of their low incidence and lack of
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 respectively cervical,
interstitial, ovarian, angular, abdominal and cornual. 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. Successful of first-line treatment rate, regardless of
UNSEP location, was respectively 53% and 89% for medical and surgical
treatment. 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 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, 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 respectively 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. 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 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. Surgical approach led to shorter recovery, earlier β-hCG negativity and shorter follow-up, even though there is an increased risk
for blood transfusion.