Title:Management of Unusual Not Scar Ectopic Pregnancy: A Multicentre Retrospective
Case Series
Volume: 18
Issue: 4
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, Italy
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 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.
