Title:Management of unusual not scar ectopic pregnancy: a multicentre retrospective case series
VOLUME: 17
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
Affiliation:Department of Obstetrics and Gynecology, Spedali Civili, Brescia, Department of Obstetrics and Gynecology, Spedali Civili, Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Spedali Civili, Brescia, Department of Obstetrics and Gynecology, University of Verona, AOUI Verona, Policlinico di Modena, University of Modena and Reggio Emilia, Policlinico Sant’Orsola-Malpighi, University of Bologna, Policlinico di Modena, University of Modena and Reggio Emilia, Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, Pavia, Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, Pavia, Centre for High Risk Pregnancy and Fetal Care, University of Chieti, Centre for High Risk Pregnancy and Fetal Care, University of Chieti, Department of Medicine, Surgery and Health Sciences, University of Trieste, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Roma, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Roma, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Roma, Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Department of Obstetrics and Gynecology, University of Verona, AOUI Verona, Institute for Maternal and Child Health, IRCCS Burlo Garofalo, Trieste, Department of Obstetrics and Gynecology, University of Verona, AOUI Verona, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Roma, Italy 11 Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Department of Clinical and Experimental Sciences, University of Brescia, Spedali Civili, Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Spedali Civili, Brescia
Keywords:ectopic pregnancy, cornual pregnancy, interstitial pregnancy, cervical
pregnancy, ovarian pregnancy, abdominal pregnancy, hepatic pregnancy,
angular pregnancy, intramural pregnancy
Abstract: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 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.
