Management of Non-Tubal Ectopic Pregnancies: A Single Center Experience

Abstract

Non-tubal ectopic pregnancies (NT-EPs) are rare but potentially life-threatening conditions. The incidence ranges are between 5-8.3% of all ectopic pregnancies. For this retrospective observational study, 16 patients with NT-EP and treated from January 2014 to May 2020 were recruited. Demographic details, symptoms, Beta human chorionic gonadotrophin (β-hCG) levels, ultrasound findings, management and treatment outcomes were presented. In hemodynamically stable patients, diagnosis was made using ultrasounds and β-hCG levels. Laparoscopy was essential to identify and remove the ectopic pregnancy in clinical unstable patients. A radical laparoscopic approach was chosen in one case of cervical pregnancy diagnosed late in the first trimester. Medical treatment and minimally invasive procedure, alone or combined, resulted in effective strategies in asymptomatic women with an early diagnosis of NT-EP. We report cases of cervical pregnancies successfully treated by hysteroscopy alone or combined with medical treatment, the first case of scar pregnancy treated by mini-reseptoscope and curettage and the fifth case of interstitial pregnancy treated with Methotrexate and Mifepristone. In this manuscript we report a single center experience in the management of NT-EPs with the aim of outlining the importance of the early diagnosis for a minimally invasive treatment in order to reduce maternal morbidity and mortality and preserve future fertility.

Keywords: ectopic non-tubal pregnancy; fertility sparing; hysteroscopy; laparoscopy.

Figure 1

Non-tubal ectopic distribution by location in our center: Cervical pregnancy (CP); Interstitial pregnancy (IP); Scar pregnancy (ScP); Ovarian pregnancy (OvP); Abdominal pregnancy (AbP).

Figure 2

3D Volume contrasting imaging (VCI) image of a cervical ectopic pregnancy. No evidence of intrauterine pregnancy, hourglass shape of uterus, cervical ballooning, presence of placental tissue or gestational sac within the cervical canal and closed internal uterine orifice.

Figure 3

2D Transvaginal image of an interstitial ectopic pregnancy. The empty uterine cavity, the myometrial layer of less than 5 mm surrounding the GS, a chorionic sac separated and laterally located >1 cm from the sideward portion of the uterine cavity, the visualization of the interstitial line between the GS and the lateral edge of the endometrial cavity and the myometrial mantle around the ectopic GS.

Figure 4

2D Transvaginal image of a scar pregnancy. No fetal parts in the uterus or cervix, the presence of a GS in the anterior isthmic portion covering the scar site, entirely embedded within the myometrium and absence of contact between the bladder and GS.

Figure 5

Laparoscopic image of an ovarian ectopic pregnancy.

Figure 6

Hysteroscopic view of a scar pregnancy. (a) Embryo view. (b) Embryo coagulation by a bipolar electrode. (c) Resection of the trophoblast and its detachment from the myometrium. (d) Resection of the trophoblast and its detachment from the myometrium.

Figure 6

Hysteroscopic view of a scar pregnancy. (a) Embryo view. (b) Embryo coagulation by a bipolar electrode. (c) Resection of the trophoblast and its detachment from the myometrium. (d) Resection of the trophoblast and its detachment from the myometrium.

Figure 7

Overview of managment for each type of non-tubal ectopic pregnancy. CP: the medical (n = 1), hysteroscopic (n = 2) or the combined approach (n = 2) were administrated; only in one of the cases, a radical surgical intervention with uterine arterial embolization was necessary. IP: A totally medical treatment resulted sufficient (n = 2). ScP: A minimally invasive approach (hysteroscopy and curettage) resulted effective in one case of ScP; in n = 2 patient, a combined approach was chosen (medical and hysteroscopic), and in one of these cases, it was necessary to manage the uterine curettage. OvPs and AbPs were treated by laparoscopy. In one of the cases of AbP, also a single systemic dose of MTX was administrated.