Management of Ectopic Pregnancy in Unusual Locations: Five-Year Experience in A Single Center

Abstract

Objectives: The aim of this study is to evaluate the diagnostic and therapeutic strategies in patients with unusual ectopic pregnancy and present a brief review of the literature. Patients and methods: Twenty- seven cases with ectopic pregnancy in unusual locations were classified in five groups; two cesarean scars, six cervical, six cornual, two ovarian, and eleven heterotopic pregnancies. All of data were retrospectively analyzed according to the patient’s gestational week, gestational sac location, obstetric history, treatment modality and treatment success. Results: Eleven patients with heterotopic pregnancy treated by surgery. Five of remaining sixteen patients were treated medically and two of them required major surgical procedure (hysterectomy and bilateral internal iliac artery ligation). Minimal invasive procedures and follow-up were done each remaining patient. Conclusion: The suspicion of the ectopic pregnancy and evaluation the whole pelvic cavity through ultrasonography are crucial for diagnosis of ectopic pregnancy. Three-dimensional ultrasonography can be helpful tool for accurate diagnosis. Early diagnosis of ectopic pregnancy provides patients to utilize fertility preservation as well as choice several treatment modalities.

Keywords

• Ectopic pregnancy,unusual location,3D Ultrasonography,Laparoscopy

Kaynakça

1. 1. Carr RJ, Evans P. Ectopic pregnancy. Prim Care. 2000; 27:169–83.
2. 2. Barnhart KT, Sammel MD, Gracia CR, Chittams J, Hummel AC, Shaunik A. Risk factors for ectopic pregnancy in women with symptomatic firsttrimester pregnancies. Fertil Steril. 2006;86:36–43.
3. 3. Clayton HB, Schieve LA, Peterson HB, Jamieson DJ, Reynolds MA, Wright VC. Ectopic pregnancy risk with assisted reproductive technology procedures. Obstet Gynecol. 2006;107:595–604.
4. 4. Banhart KT. Clinical practice. Ectopic pregnancy. N Engl J Med. 2009; 361:379–87.
5. 5. Dialani V, Levine D. Ectopic pregnancy: a review. Ultrasound Q. 2004;20:105–17.
6. 6. Shaw JLV, Dey SK, Critchly HOD, Horne AW. Current knowledge of the aetiology of human tubal ectopic pregnancy. Hum Reprod Update. 2010;16:432–44.
7. 7. Deb S, Clewes J, Hewer C, Raine-Fenning N. The management of Cesarean scar ectopic pregnancy following treatment with methotrexate – a clinical challenge. Ultrasound Obstet Gynecol. 2007; 30(6), 889–92.
8. 8. Fernandez H, Gervaise. Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy. Hum Reprod Update. 2004;10(6): 503–13.

9. 9. Ash A, Smith A, Maxwell D. Cesarean scar pregnancy. BJOG. 2007; 114(3): 253 – 63.
10. 10. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. Firsttrimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Ultrasound Obstet Gynecol. 2003; 21(3): 220 – 27.
11. 11. Ahmadi F, Moinian D, Pooransari P, Rashidi Z, Haghighi H. Ectopic pregnancy within a cesarean scar resulting in live birth: a case report. Arch Iran Med. 2013;16: 679-82.
12. 12. Sadeghi H, Rutherford T, Rackow BW, Campbell KH, Duzyj CM, Guess MK. et al. Cesarean scar ectopic pregnancy: case series and review of the literature. Am J Perinatol. 2010;27:111 – 20.
13. 13. Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol. 2004;23: 247-53.
14. 14. Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A. Ectopic pregnancies in a caesarean scar: review of the medical approach to and iatrogenic complication. Hum Reprod Update. 2004;10:515–23.
15. 15. Arslan M, Pata O, Dilek TU, Aktas A, Aban M, Dilek S. Treatment of viable cesarean scar ectopic pregnancy with suction curettage. Int J Gynaecol Obstet 2005;89:163-6.
16. 16. Ben Farhat L, Ben Salah Y, Askri A, Dali N, Hendaoui L. Conservative treatment of a cervical twin pregnancy with uterine artery embolization. Diagn Interv Radiol. 2010;16:248-50.
17. 17. Radpour CJ, Keenan JA. Consecutive cervical pregnancies. Fertil Steril. 2004;81:210-13.
18. 18. Hidalgo LA, Peñafiel J, Chedraui PA. Management of cervical pregnancy: risk factors for failed systemic methotrexate. J Perinat Med. 2004;32:184- 6.
19. 19. Oliver R, Malik M, Coker A, Morris J. Management of extra-tubal and rare ectopic pregnancies: case series and review of current literature. Arch Gynecol Obstet. 2007;276:125-31.
20. 20. Chaudhary V, Sachdeva P, Kumar D, Arora R, Banavaliker J, Khan M. Conservative management of cervical pregnancy: a report of two cases. J Reprod Med. 2013;58:451-7.
21. 21. Ranade V, Palermino A, Tronik B. Cervical pregnancy. Obstet Gynecol. 1978;51:502-3.
22. 22. Ng S, Hamontri S, Chua I, Chern B, Siow A. Laparoscopic management of 53 cases of cornual ectopic pregnancy Fertil Steril. 2009;92:448-52.
23. 23. Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril. 1999;72:207-15.
24. 24. Tulandi T, Al-Jaroudi D. Interstitial pregnancy: results generated from the Society of Reproductive Surgeons Registry. Obstet Gynecol. 2004;103:47-50.
25. 25. Lee GS, Hur SY, Kown I, Shin JC, Kim SP, Kim SJ. Diagnosis of early intramural ectopic pregnancy. J Clin Ultrasound. 2005;33:190-2.
26. 26. Jermy K, Thomas J, Doo A, Bourne T. The conservative management of interstitial pregnancy. BJOG. 2004;111: 1283-8.
27. 27. Lin YS, Chen CL, Yuan CC, Wang PH. Successful rescue of an early interstitial pregnancy after failed systemic methotrexate treatment: a case report. J Reprod Med. 2007;52:332-4.
28. 28. Soriano D, Vicus D, Mashiach R, Schiff E, Seidman D, Goldenberg M. Laparoscopic treatment of cornual pregnancy: a series of 20 consecutive cases. Fertil Steril. 2008;90:839-43.
29. 29. Gleicher N, Karande V, Rabin D, Pratt D. Laparoscopic removal of twin cornual pregnancy after in vitro fertilization. Fertil Steril.1994;61:1161-2.
30. 30. Meyer WR, Mitchell DE. Hysteroscopic removal of an interstitial ectopic gestation. A case report. J Reprod Med.1989;34:928-9.
31. 31. Comstock C, Huston K, Lee W. The ultrasonographic appearance of ovarian ectopic pregnancies. Obstet Gynecol. 2005;105:42-5.
32. 32. Das S, Kalyani R, Lakshmi V, Harendra Kumar ML. Ovarian pregnancy. Indian J Pathol Microbiol. 2008;51:37-8.
33. 33. Berek JS, editor.Berek and Novak’s Gynecology. 13th ed. Philadelphia, PA. Lippincott Williams & Wilkins; 2002. p. 533–4.
34. 34. Soriano D, Vicus D, Schonman R, Mashiach R, Shashar-Levkovitz D, Schiff E. et al. Long-term outcome after laparoscopic treatment of heterotopic pregnancy: 19 cases. J Minim Invasive Gynecol. 2010;17:321- 4.
35. 35. Clayton HB, Schieve LA, Peterson HB, Jamieson DJ, Reynolds MA, Wright VC. A comparison of heterotopic and intrauterine-only pregnancy outcomes after assisted reproductive technologies in the United States from 1999 to 2002. Fertil Steril.2007;87: 303-9.