case presentation about ectopic pregnancy

• Case Report
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• Published: 07 August 2009

Primary abdominal ectopic pregnancy: a case report

• Recep Yildizhan 1 ,
• Ali Kolusari 1 ,
• Fulya Adali 2 ,
• Ertan Adali 1 ,
• Mertihan Kurdoglu 1 ,
• Cagdas Ozgokce 1 &
• Numan Cim 1  

Cases Journal volume  2 , Article number:  8485 ( 2009 ) Cite this article

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Introduction

We present a case of a 13-week abdominal pregnancy evaluated with ultrasound and magnetic resonance imaging.

Case presentation

A 34-year-old woman, (gravida 2, para 1) suffering from lower abdominal pain and slight vaginal bleeding was transferred to our hospital. A transabdominal ultrasound and magnetic resonance imaging were performed. The diagnosis of primary abdominal pregnancy was confirmed according to Studdiford's criteria. A laparatomy was carried out. The placenta was attached to the mesentery of sigmoid colon and to the left abdominal sidewall. The placenta was dissected away completely and safely. No postoperative complications were observed.

Ultrasound examination is the usual diagnostic procedure of choice. In addition magnetic resonance imaging can be useful to show the localization of the placenta preoperatively.

Abdominal pregnancy, with a diagnosis of one per 10000 births, is an extremely rare and serious form of extrauterine gestation [ 1 ]. Abdominal pregnancies account for almost 1% of ectopic pregnancies [ 2 ]. It has reported incidence of one in 2200 to one in 10,200 of all pregnancies [ 3 ]. The gestational sac is implanted outside the uterus, ovaries, and fallopian tubes. The maternal mortality rate can be as high as 20% [ 3 ]. This is primarily because of the risk of massive hemorrhage from partial or total placental separation. The placenta can be attached to the uterine wall, bowel, mesentery, liver, spleen, bladder and ligaments. It can be detach at any time during pregnancy leading to torrential blood loss [ 4 ]. Accurate localization of the placenta pre-operatively could minimize blood loss during surgery by avoiding incision into the placenta [ 5 ]. It is thought that abdominal pregnancy is more common in developing countries, probably because of the high frequency of pelvic inflammatory disease in these areas [ 6 ]. Abdominal pregnancy is classified as primary or secondary. The diagnosis of primary abdominal pregnancy was confirmed according to Studdiford's criteria [ 7 ]. In these criteria, the diagnosis of primary abdominal pregnancy is based on the following anatomic conditions: 1) normal tubes and ovaries, 2) absence of an uteroplacental fistula, and 3) attachment exclusively to a peritoneal surface early enough in gestation to eliminate the likelihood of secondary implantation. The placenta sits on the intra-abdominal organs generally the bowel or mesentery, or the peritoneum, and has sufficient blood supply. Sonography is considered the front-line diagnostic imaging method, with magnetic resonance imaging (MRI) serving as an adjunct in cases when sonography is equivocal and in cases when the delineation of anatomic relationships may alter the surgical approach [ 8 ]. We report the management of a primary abdominal pregnancy at 13 weeks.

The patient was a 34-year-old Turkish woman, gravida 2 para 1 with a normal vaginal delivery 15 years previously. Although she had not used any contraceptive method afterwards, she had not become pregnant. She was transferred to our hospital from her local clinic at the gestation stage of 13 weeks because of pain in the lower abdomen and slight vaginal bleeding. She did not know when her last menstrual period had been, due to irregular periods. At admission, she presented with a history of abdominal distention together with steadily increasing abdominal and back pain, weakness, lack of appetite, and restlessness with minimal vaginal bleeding. She denied a history of pelvic inflammatory disease, sexually transmitted disease, surgical operations, or allergies. Blood pressure and pulse rate were normal. Laboratory parameters were normal, with a hemoglobin concentration of 10.0 g/dl and hematocrit of 29.1%. Transvaginal ultrasonographic scanning revealed an empty uterus with an endometrium 15 mm thick. A transabdominal ultrasound (Figure 1 ) examination demonstrated an amount of free peritoneal fluid and the nonviable fetus at 13 weeks without a sac; the placenta measured 58 × 65 × 67 mm. Abdominal-Pelvic MRI (Philips Intera 1.5T, Philips Medical Systems, Andover, MA) in coronal, axial, and sagittal planes was performed especially for localization of the placenta before she underwent surgery. A non-contrast SPAIR sagittal T2-weighted MRI strongly suggested placental invasion of the sigmoid colon (Figure 2 ).

Pelvic ultrasound scanning . Diffuse free intraperitoneal fluid was seen around the fetus and small bowel loops.

T2W SPAIR sagittal MRI of lower abdomen demonstrating the placental invasion . Placenta (a) , invasion area (b) , sigmoid colon (c) , uterine cavity (d) .

Under general anesthesia, a median laparotomy was performed and a moderate amount of intra-abdominal serohemorrhagic fluid was evident. The placenta was attached tightly to the mesentery of sigmoid colon and was loosely adhered to the left abdominal sidewall (Figure 3 ). The fetus was localized at the right of the abdomen and was related to the placenta by a chord. The placenta was dissected away completely and safely from the mesentery of sigmoid colon and the left abdominal sidewall. Left salpingectomy for unilateral hydrosalpinx was conducted. Both ovaries were conserved. After closure of the abdominal wall, dilatation and curettage were also performed but no trophoblastic tissue was found in the uterine cavity. As a management protocol in our department, we perform uterine curettage in all patients with ectopic pregnancy gently at the end of the operation, not only for the differential diagnosis of ectopic pregnancy, but also to help in reducing present or possible postoperative vaginal bleeding.

Fetus, placenta and bowels .

The patient was awakened, extubated, and sent to the room. The patient was discharged on post-operative day five with the standard of care at our hospital.

In the present case, we were able to demonstrate primary abdominal pregnancy according to Studdiford's criteria with the use of transvaginal and transabdominal ultrasound examination and MRI. In our case, both fallopian tubes and ovaries were intact. With regard to the second criterion, we did not observe any uteroplacental fistulae in our case. Since abdominal pregnancy at less than 20 weeks of gestation is considered early [ 9 ], our case can be regarded as early, and so we dismissed the possibility of secondary implantation.

The recent use of progesterone-only pills and intrauterine devices with a history of surgery, pelvic inflammatory disease, sexually transmitted disease, and allergy increases the risk of ectopic pregnancy. Our patient had not been using any contraception, and did not report a history of the other risk factors.

The clinical presentation of an abdominal pregnancy can differ from that of a tubal pregnancy. Although there may be great variability in symptoms, severe lower abdominal pain is one of the most consistent findings [ 10 ]. In a study of 12 patients reported by Hallatt and Grove [ 11 ], vaginal bleeding occurred in six patients.

Ultrasound examination is the usual diagnostic procedure of choice, but the findings are sometimes questionable. They are dependent on the examiner's experience and the quality of the ultrasound. Transvaginal ultrasound is superior to transabdominal ultrasound in the evaluation of ectopic pregnancy since it allows a better view of the adnexa and uterine cavity. MRI provided additional information for patients who needed precise diagnosing. After the diagnosis of abdominal pregnancy became definitive, it was essential to determine the localization of the placenta. Meanwhile, MRI may help in surgical planning by evaluating the extent of mesenteric and uterine involvement [ 12 ]. Non-contrast MRI using T 2 -weighted imaging is a sensitive, specific, and accurate method for evaluating ectopic pregnancy [ 13 ], and we used it in our case.

Removal of the placental tissue is less difficult in early pregnancy as it is likely to be smaller and less vascular. Laparoscopic removal of more advanced abdominal ectopic pregnancies, where the placenta is larger and more invasive, is different [ 14 ]. Laparoscopic treatment must be considered for early abdominal pregnancy [ 15 ].

Complete removal of the placenta should be done only when the blood supply can be identified and careful ligation performed [ 11 ]. If the placenta is not removed completely, it has been estimated that the remnant can remain functional for approximately 50 days after the operation, and total regression of placental function is usually complete within 4 months [ 16 ].

In conclusion, ultrasound scanning plus MRI can be useful to demonstrate the anatomic relationship between the placenta and invasion area in order to be prepared preoperatively for the possible massive blood loss.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-chief of this journal.

Abbreviations

Magnetic Resonance Imaging

Spectral Presaturation Attenuated by Inversion Recovery.

Yildizhan R, Kurdoglu M, Kolusari A, Erten R: Primary omental pregnancy. Saudi Med J. 2008, 29: 606-609.

PubMed   Google Scholar  

Ludwig M, Kaisi M, Bauer O, Diedrich K: The forgotten child-a case of heterotopic, intra-abdominal and intrauterine pregnancy carried to term. Hum Reprod. 1999, 14: 1372-1374. 10.1093/humrep/14.5.1372.

Article   CAS   PubMed   Google Scholar  

Alto WA: Abdominal pregnancy. Am Fam Physician. 1990, 41: 209-214.

CAS   PubMed   Google Scholar  

Ang LP, Tan AC, Yeo SH: Abdominal pregnancy: a case report and literature review. Singapore Med J. 2000, 41: 454-457.

Martin JN, Sessums JK, Martin RW, Pryor JA, Morrison JC: Abdominal pregnancy: current concepts of management. Obstet Gynecol. 1988, 71: 549-557.

Maas DA, Slabber CF: Diagnosis and treatment of advanced extra-uterine pregnancy. S Afr Med J. 1975, 49: 2007-2010.

Studdiford WE: Primary peritoneal pregnancy. Am J Obstet Gynecol. 1942, 44: 487-491.

Google Scholar  

Wagner A, Burchardt A: MR imaging in advanced abdominal pregnancy. Acta Radiol. 1995, 36: 193-195. 10.3109/02841859509173377.

Gaither K: Abdominal pregnancy-an obstetrical enigma. South Med J. 2007, 100: 347-348.

Article   PubMed   Google Scholar  

Onan MA, Turp AB, Saltik A, Akyurek N, Taskiran C, Himmetoglu O: Primary omental pregnancy: case report. Hum Reprod. 2005, 20: 807-809. 10.1093/humrep/deh683.

Hallatt JG, Grove JA: Abdominal pregnancy: a study of twenty-one consecutive cases. Am J Obstet Gynecol. 1985, 152: 444-449.

Malian V, Lee JH: MR imaging and MR angiography of an abdominal pregnancy with placental infarction. AJR Am J Roentgenol. 2001, 177: 1305-1306.

Yoshigi J, Yashiro N, Kinoshito T, O'uchi T, Kitagaki H: Diagnosis of ectopic pregnancy with MRI: efficacy of T2-weighted imaging. Magn Reson Med Sci. 2006, 5: 25-32. 10.2463/mrms.5.25.

Kwok A, Chia KKM, Ford R, Lam A: Laparoscopic management of a case of abdominal ectopic pregnancy. Aust N Z J Obstet Gynaecol. 2002, 42: 300-302. 10.1111/j.0004-8666.2002.300_1.x.

Pisarska MD, Casson PR, Moise KJ, Di Maio DJ, Buster JE, Carson SA: Heterotopic abdominal pregnancy treated at laparoscopy. Fertil Steril. 1998, 70: 159-160. 10.1016/S0015-0282(98)00104-6.

France JT, Jackson P: Maternal plasma and urinary hormone levels during and after a successful abdominal pregnancy. Br J Obstet Gynaecol. 1980, 87: 356-362.

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Department of Obstetrics and Gynecology, School of Medicine, Yuzuncu Yil University, Van, Turkey

Recep Yildizhan, Ali Kolusari, Ertan Adali, Mertihan Kurdoglu, Cagdas Ozgokce & Numan Cim

Department of Radiology, Women and Child Hospital, Van, Turkey

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All authors were involved in patient's care. RY, AK and FA analyzed and interpreted the patient data regarding the clinical and radiological findings of the patient and prepared the manuscript. EA, MK and CO edit and coordinated the manuscript. All authors read and approved the final manuscript.

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Yildizhan, R., Kolusari, A., Adali, F. et al. Primary abdominal ectopic pregnancy: a case report. Cases Journal 2 , 8485 (2009). https://doi.org/10.4076/1757-1626-2-8485

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Received : 12 January 2009

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Published : 07 August 2009

DOI : https://doi.org/10.4076/1757-1626-2-8485

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Educational Case: Ectopic Pregnancy

Xiomara brioso rubio.

1 Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL, USA

Jesse Kresak

Melanie zona, stacy g. beal, julia a. ross.

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040 . 1

Primary Objective

Objective FDP1.1: Ectopic Pregnancy . Describe risk factors, characteristic morphologic findings, potential outcomes, and the medical/surgical options for management of ectopic pregnancy in relation to the pathogenesis and likelihood of adverse consequences.

Competency 2: Organ System Pathology; Topic: Female Reproductive—Disorders of Pregnancy (FDP); Learning Goal 1: Disorders of Pregnancy.

Patient Presentation

A 19-year-old woman presents with a 1-week history of left lower abdominal pain and vaginal spotting. She is sexually active, and her last menstrual period was 7 weeks ago. She does not use any contraception and has a history of gonorrhea diagnosed 2 years ago.

Diagnostic Findings, Part 1

The patient’s vital signs are normal. On physical examination, she appears uncomfortable and there is left adnexal tenderness, closed cervix, and scant blood in the vaginal vault. The remainder of the physical examination is noncontributory.

Questions/Discussion Points, Part 1

What is the differential diagnosis of an adnexal mass in a reproductive-age woman.

The differential diagnosis (see Table 1 ) includes functional cysts, endometriomas, tubo-ovarian abscesses, and neoplasms. Functional ovarian cysts, such as follicular cysts and corpus luteum cysts, are structures that form following normal ovarian function. Endometriomas are blood-containing cysts that are commonly associated with endometriosis. Tubo-ovarian abscesses are walled-off areas of infection associated with pelvic inflammatory disease. Neoplasms, such as germ cell tumors or yolk sac tumors, can also present as adnexal masses. 2

Differential Diagnosis of an Adnexal Mass in a Reproductive-Age Woman.

Diagnostic Findings, Part 2

The patient had a positive urine pregnancy test and a serum βhCG resulted at 4979 mIU/mL (negative is <5 mIU/mL). The patient’s transvaginal ultrasound (TVUS) is shown in Figure 1 .

Transvaginal ultrasound.

Questions/Discussion Points, Part 2

How would you describe the findings of the transvaginal ultrasound.

Transvaginal ultrasound of the uterus demonstrates an extrauterine gestational sac and yolk sac with a fetal pole in the left fallopian tube ( Figure 2 ). No fetal cardiac activity was noted.

Transvaginal ultrasound (TVUS) showing ectopic pregnancy, characterized by presence of a yolk sac, gestational sac, and fetal pole in the left adnexa with an empty uterine cavity.

What Is Your Working Diagnosis?

The working diagnosis is an ectopic pregnancy. This is based on the patient’s clinical presentation, history of sexual activity without contraception, history of sexually transmitted illness, lack of menstrual period, elevated serum βhCG, and ultrasound finding of a definitive gestational sac, yolk sac, and fetal pole in the left adnexa, outside of the uterine cavity.

The results of the TVUS and βhCG levels in the right clinical setting are the most useful tools for diagnosing an abnormal or ectopic pregnancy. Once the βhCG crosses the discriminatory level of 3500 mIU/mL, a normal intrauterine pregnancy should be visible within the endometrial cavity. Diagnosis is made if a pregnancy is clearly identified in an ectopic location. If neither a clear ectopic nor clear intrauterine pregnancy are visualized, the provider must consider an early abortion or ectopic pregnancy. In these scenarios, βhCG levels are obtained 2 days after initial evaluation. In a normal pregnancy, βhCG is expected to at least double in 2 days. In an early abortion, βhCG decreases during repeat testing, while in an ectopic pregnancy, βhCG does not rise appropriately. 3 However, it has been noted that ectopic pregnancies do not follow a specific trend or curve when compared to the patterns seen with normal pregnancies or spontaneous abortions. 4 The ability to trend βhCG and observe a patient until a definitive diagnosis is made is based on the patient’s stability.

What Is the Clinical Presentation and Potential Outcomes for an Ectopic Pregnancy?

Ectopic pregnancies are defined as pregnancies occurring outside of the uterus. The presentation varies per patient, including absence of symptoms, but most women present for medical evaluation secondary to abdominal pain, vaginal bleeding, or amenorrhea between 6 and 8 weeks of gestation. 5 , 6 The outcomes are also variable but usually fall within 3 categories: spontaneous abortion, tubal abortion, tubal rupture. The latter is the most concerning outcome. In this scenario, the patient presents with intractable abdominal pain and unstable vital signs secondary to internal hemorrhage. If not recognized and adequately treated, a ruptured ectopic pregnancy can result in hemorrhagic shock and death. Generally, there is an increased risk of ectopic rupture with higher βhCG levels and higher gestational ages, particularly greater than 1500 IU/mL and greater than 6 weeks, respectively. 2 , 3 , 6 , 7

What Are Common Locations for an Ectopic Pregnancy and Risk Factors Associated With Them?

The most common location is the fallopian tube, with 98% of ectopic pregnancies found there. Most of these are within the ampulla (80%). 2 Other sites include the abdomen, uterine cesarean delivery scar, ovaries, or cervix. 5

Previous history of an ectopic pregnancy and previous tubal surgery or tubal sterilization are the strongest risk factors for a future episode. A woman with a history of a previous ectopic pregnancy has a 10% chance of recurrence after a single episode. Other risk factors include fallopian tube abnormalities, including scarring from pelvic inflammatory disease, other pelvic surgeries, assisted reproductive techniques, such as multiple embryo transfer and in vitro fertilization, and infertility. 3 , 8 Of note, gonorrhea and chlamydia are 2 common sexually transmitted infections that result in inflammatory damage of the fallopian tubes, leading to scar formation and disruption of their architecture. This physical roadblock interferes with the migration of a fertilized ovum and predisposes women to a tubal pregnancy. 2

What Are the Medical/Surgical Options for Management of an Ectopic Pregnancy?

Management of an ectopic pregnancy is based on patient stability, characteristics of the ectopic mass, desire for future fertility, and understanding of risks and benefits of each therapeutic option. Possibilities include expectant management, medical management, and surgical management, with either a salpingectomy or salpingostomy.

Expectant management is defined as watchful waiting with no medical intervention. Patients qualifying for expectant management are those whom are asymptomatic, have no adnexal mass on imaging, and show signs of resolution, such as a plateaued or decreasing βhCG. Patients’ βhCG must be trended to observe a quantitative decrease. Alternative treatments must be implemented if patients become symptomatic or if βhCG levels rise. 3 , 8

Medical treatment is with 50 mg methotrexate intramuscularly; there are no other medical alternatives or effective routes of administration for this medication. 3 To qualify for medical management, a patient must meet certain criteria: no methotrexate contraindications, including presence of an intrauterine pregnancy or a ruptured ectopic pregnancy, immunodeficiency, bone marrow abnormalities (severe anemia, leukopenia, thrombocytopenia), active pulmonary, renal, liver, or peptic ulcer disease, or currently breastfeeding. The patient must be hemodynamically stable and able to adhere to a strict follow-up surveillance schedule. Relative contraindications include presence of fetal heartbeat, high βhCG levels, or an ectopic mass greater than 4 cm. These have been shown to have an increased risk of treatment failure, especially in the case of a high presenting βhCG level. Currently, there are 3 available dosing schedules: single dose, 2 dose, and multiple fixed dose schedule. They differ by the simplicity of the schedule and side effect profile, but, for the most part, there have been no clinically significant differences found in relation to treatment success. 3 , 8

In hemodynamically unstable patients, surgical management is the only treatment option. It is also the standard of care for those with a ruptured ectopic pregnancy, those who failed methotrexate trial, or those who meet absolute contraindication for methotrexate therapy. Laparoscopy is the least invasive method for surgical management; however, laparotomy is indicated in cases of severe instability, uncontrolled hemorrhage, or inadequate pelvic visualization. Salpingostomy involves the removal of the ectopic mass only, leaving the fallopian tube in place, thus attempting to preserve future fertility. If a salpingostomy is done, follow-up βhCG levels are required to ensure resolution. Salpingectomy is the removal of the affected fallopian tube. There is no consensus on success rates of a salpingectomy versus salpingostomy. Some reports state there is no difference in the frequency of future intrauterine pregnancies or risk of future ectopic ones, while others state the opposite. For this reason, ample discussion with the patient is recommended. 3 , 8

If Salpingectomy Is Pursued, What Is the Histology and Morphology of an Ectopic Pregnancy?

A tubal ectopic pregnancy can be grossly described as a distended fallopian tube with a thin wall, which may be ruptured, with dusky and dark serosa ( Figure 3 ). Sectioning usually reveals hemorrhage with villous-appearing tissue. Fetal parts may be seen occasionally ( Figure 4 ). On histology, chorionic villi associated with the fallopian tube is diagnostic of an ectopic pregnancy ( Figures 5 and ​ and6). 6 ). Hemorrhage within the tubal lumen is often present.

Gross tubal ectopic pregnancy. Serosa is dusky red-purple with prominent vasculature and a small amount of adherent blood clot.

Gross tubal ectopic pregnancy. The dilated portion of the tube contains an intact fetus.

Cross section of fallopian tube diagnostic of an ectopic/tubal pregnancy. H&E-stained section at ×20. Note the fallopian tube epithelium (arrow) and luminal hemorrhage with chorionic villi (arrowhead).

Intraluminal immature chorionic villi with edematous stroma and surrounding trophoblasts. The presence of villi within the fallopian tube is diagnostic of a tubal (ectopic) pregnancy. H&E-stained section at ×100.

Teaching Points

• Ectopic pregnancies are pregnancies that occur outside of the uterus, most commonly in the fallopian tube.
• The clinical presentation varies but includes abdominal pain, bleeding, and amenorrhea.
• The diagnosis involves a positive pregnancy βhCG test and a TVUS showing an empty uterine cavity with a clear ectopic pregnancy. If the ectopic pregnancy is not visualized, βhCG must be trended every 2 days. If it does not double, consideration of an ectopic in an unknown location or an abortion must be made.
• The risk of a ruptured ectopic pregnancy increases with increased gestational age and βhCG levels. Rupture may result in hemorrhage and shock and can be lethal if not properly managed.
• Management of an ectopic pregnancy is based mostly on patient stability. Options include watchful waiting, methotrexate, or surgical removal of the pregnancy via a salpingostomy or salpingectomy.
• Grossly, a tubal ectopic pregnancy appears as a thin-walled fallopian tube with dusky and dark serosa containing a collection of hemorrhagic and villous tissue. Fetal parts may or may not be apparent.
• Histologically, the presence of chorionic villi within the tubal epithelium is diagnostic of a tubal ectopic pregnancy.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The article processing fee for this article was funded by an Open Access Award given by the Society of ‘67, which supports the mission of the Association of Pathology Chairs to produce the next generation of outstanding investigators and educational scholars in the field of pathology. This award helps to promote the publication of high-quality original scholarship in Academic Pathology by authors at an early stage of academic development.

Ectopic Pregnancy Clinical Presentation

• Author: Vicken P Sepilian, MD, MSc; Chief Editor: Michel E Rivlin, MD  more...
• Sections Ectopic Pregnancy
• Practice Essentials
• Epidemiology
• Patient Education
• Physical Examination
• Approach Considerations
• Beta–Human Chorionic Gonadotropin Levels
• Progesterone Levels
• Other Markers
• Ultrasonography
• Dilatation and Curettage
• Culdocentesis
• Laparoscopy
• Expectant Management
• Methotrexate Therapy
• Methotrexate Treatment Protocols
• Investigational Medical Treatments
• Salpingostomy and Salpingectomy
• Medication Summary
• Antineoplastics, Antimetabolite
• Vasopressors
• Media Gallery

The classic clinical triad of ectopic pregnancy is pain, amenorrhea, and vaginal bleeding; unfortunately, only about 50% of patients present with all 3 symptoms. About 40-50% of patients with an ectopic pregnancy present with vaginal bleeding, 50% have a palpable adnexal mass, and 75% may have abdominal tenderness. In one case series of ectopic pregnancies, abdominal pain presented in 98.6% of patients, amenorrhea in 74.1% of them, and irregular vaginal bleeding in 56.4% of patients. [ 52 ]

These symptoms overlap with those of spontaneous abortion; a prospective, consecutive case series found no statistically significant differences in the presenting symptoms of patients with unruptured ectopic pregnancies versus those with intrauterine pregnancies.

In first-trimester symptomatic patients, pain as the presenting symptom is associated with an odds ratio of 1.42, and moderate to severe vaginal bleeding at presentation is associated with an odds ratio of 1.42 for ectopic pregnancy. [ 53 ] In one study, 9% of patients with ectopic pregnancy presented with painless vaginal bleeding. [ 54 ] As a result, almost 50% of cases of ectopic pregnancy are not diagnosed at the first prenatal visit.

Patients may present with other symptoms common to early pregnancy, including nausea, breast fullness, fatigue, low abdominal pain, heavy cramping, shoulder pain, and recent dyspareunia. Painful fetal movements (in the case of advanced abdominal pregnancy), dizziness or weakness, fever, flulike symptoms, vomiting, syncope, or cardiac arrest have also been reported. Shoulder pain may be reflective of peritoneal irritation.

Astute clinicians should have a high index of suspicion for ectopic pregnancy in any woman who presents with these symptoms and who presents with physical findings of pelvic tenderness, enlarged uterus, adnexal mass, or tenderness.

Approximately 20% of patients with ectopic pregnancies are hemodynamically compromised at initial presentation, which is highly suggestive of rupture. Fortunately, using modern diagnostic techniques, most ectopic pregnancies may be diagnosed before rupture.

The physical examination of patients with ectopic pregnancy is highly variable and often unhelpful. Patients frequently present with benign examination findings, and adnexal masses are rarely found. Patients in hemorrhagic shock from ruptured ectopic may not be tachycardic.

Some physical findings that have been found to be predictive (although not diagnostic) for ectopic pregnancy include the following:

Presence of peritoneal signs

Cervical motion tenderness

Unilateral or bilateral abdominal or pelvic tenderness - Usually much worse on the affected side

Abdominal rigidity, involuntary guarding, and severe tenderness, as well as evidence of hypovolemic shock, such as orthostatic blood pressure changes and tachycardia, should alert the clinician to a surgical emergency; this may occur in up to 20% of cases. However, midline abdominal tenderness or a uterine size of greater than 8 weeks on pelvic examination decreases the risk of ectopic pregnancy. [ 55 ]

On pelvic examination, the uterus may be slightly enlarged and soft, and uterine or cervical motion tenderness may suggest peritoneal inflammation. An adnexal mass may be palpated but is usually difficult to differentiate from the ipsilateral ovary.

The presence of uterine contents in the vagina, which can be caused by shedding of endometrial lining stimulated by an ectopic pregnancy, may lead to a misdiagnosis of an incomplete or complete abortion and therefore a delayed or missed diagnosis of ectopic pregnancy.

Farquhar CM. Ectopic pregnancy. Lancet . 2005 Aug 13-19. 366(9485):583-91. [QxMD MEDLINE Link] .

Kadar N, Bohrer M, Kemmann E, Shelden R. The discriminatory human chorionic gonadotropin zone for endovaginal sonography: a prospective, randomized study. Fertil Steril . 1994 Jun. 61(6):1016-20. [QxMD MEDLINE Link] .

Stein JC, Wang R, Adler N, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med . 2010 Dec. 56(6):674-83. [QxMD MEDLINE Link] .

Hoover KW, Tao G, Kent CK. Trends in the diagnosis and treatment of ectopic pregnancy in the United States. Obstet Gynecol . 2010 Mar. 115(3):495-502. [QxMD MEDLINE Link] .

Lipscomb GH. Medical therapy for ectopic pregnancy. Semin Reprod Med . 2007 Mar. 25(2):93-8. [QxMD MEDLINE Link] .

Stovall TG, Ling FW, Gray LA. Single-dose methotrexate for treatment of ectopic pregnancy. Obstet Gynecol . 1991 May. 77(5):754-7. [QxMD MEDLINE Link] .

Riaz RM, Williams TR, Craig BM, Myers DT. Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes. Abdom Imaging . 2015 Oct. 40 (7):2589-99. [QxMD MEDLINE Link] .

Society for Maternal-Fetal Medicine (SMFM), Miller R, Gyamfi-Bannerman C, Publications Committee. Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy. Am J Obstet Gynecol . 2022 Sep. 227 (3):B9-B20. [QxMD MEDLINE Link] .

Bouyer J, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod . 2002 Dec. 17(12):3224-30. [QxMD MEDLINE Link] .

Saito M, Koyama T, Yaoi Y, Kumasaka T, Yazawa K. Site of ovulation and ectopic pregnancy. Acta Obstet Gynecol Scand . 1975. 54(3):227-30. [QxMD MEDLINE Link] .

Nkusu Nunyalulendho D, Einterz EM. Advanced abdominal pregnancy: case report and review of 163 cases reported since 1946. Rural and Remote Health 8 (online) . 2008;1087. [Full Text] .

[Guideline] ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstet Gynecol . 2018 Mar. 131 (3):e91-e103. [QxMD MEDLINE Link] .

Ankum WM, Mol BW, Van der Veen F, Bossuyt PM. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril . 1996 Jun. 65(6):1093-9. [QxMD MEDLINE Link] .

Strandell A, Thorburn J, Hamberger L. Risk factors for ectopic pregnancy in assisted reproduction. Fertil Steril . 1999 Feb. 71(2):282-6. [QxMD MEDLINE Link] .

Bouyer J, Coste J, Shojaei T, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. Am J Epidemiol . 2003 Feb 1. 157(3):185-94. [QxMD MEDLINE Link] .

Fylstra DL. Ectopic pregnancy after hysterectomy: a review and insight into etiology and prevention. Fertil Steril . 2010 Jul. 94(2):431-5. [QxMD MEDLINE Link] .

Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med . 1997 Mar 13. 336(11):762-7. [QxMD MEDLINE Link] .

Furlong LA. Ectopic pregnancy risk when contraception fails. A review. J Reprod Med . 2002 Nov. 47(11):881-5. [QxMD MEDLINE Link] .

Williams S, Peipert J, Buckel C, Zhao Q, Madden T, Secura G. Contraception and the risk of ectopic pregnancy. Contraception . 2014 Sept. 90(3):326.

[Guideline] National Collaborating Centre for Women’s and Children’s Health (UK). Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception. National Institute for Health and Care Excellence: Guidance . 2005 Oct. [QxMD MEDLINE Link] . [Full Text] .

Vinson DR. Emergency contraception and risk of ectopic pregnancy: is there need for extra vigilance?. Ann Emerg Med . 2003 Aug. 42(2):306-7. [QxMD MEDLINE Link] .

Dor J, Seidman DS, Levran D, Ben-Rafael Z, Ben-Shlomo I, Mashiach S. The incidence of combined intrauterine and extrauterine pregnancy after in vitro fertilization and embryo transfer. Fertil Steril . 1991 Apr. 55(4):833-4. [QxMD MEDLINE Link] .

Svare JA, Norup PA, Thomsen SG, et al. [Heterotopic pregnancy after in vitro fertilization]. Ugeskr Laeger . 1994 Apr 11. 156(15):2230-3. [QxMD MEDLINE Link] .

Rombauts L, McMaster R, Motteram C, Fernando S. Risk of ectopic pregnancy is linked to endometrial thickness in a retrospective cohort study of 8120 assisted reproduction technology cycles. Hum Reprod . 2015 Dec. 30 (12):2846-52. [QxMD MEDLINE Link] .

Majmudar B, Henderson PH 3rd, Semple E. Salpingitis isthmica nodosa: a high-risk factor for tubal pregnancy. Obstet Gynecol . 1983 Jul. 62(1):73-8. [QxMD MEDLINE Link] .

Hoover RN, Hyer M, Pfeiffer RM, et al. Adverse health outcomes in women exposed in utero to diethylstilbestrol. N Engl J Med . 2011 Oct 6. 365(14):1304-14. [QxMD MEDLINE Link] .

Goldner TE, Lawson HW, Xia Z, Atrash HK. Surveillance for ectopic pregnancy--United States, 1970-1989. MMWR CDC Surveill Summ . 1993 Dec 17. 42(6):73-85. [QxMD MEDLINE Link] .

Zane SB, Kieke BA Jr, Kendrick JS, Bruce C. Surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the United States. Matern Child Health J . 2002 Dec. 6(4):227-36. [QxMD MEDLINE Link] .

Calderon JL, Shaheen M, Pan D, Teklehaimenot S, Robinson PL, Baker RS. Multi-cultural surveillance for ectopic pregnancy: California 1991-2000. Ethn Dis . 2005 Autumn. 15(4 Suppl 5):S5-20-4. [QxMD MEDLINE Link] .

Van Den Eeden SK, Shan J, Bruce C, Glasser M. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol . 2005 May. 105(5 Pt 1):1052-7. [QxMD MEDLINE Link] .

Mann LM, Kreisel K, Llata E, Hong J, Torrone EA. Trends in Ectopic Pregnancy Diagnoses in United States Emergency Departments, 2006-2013. Matern Child Health J . 2020 Feb. 24 (2):213-21. [QxMD MEDLINE Link] . [Full Text] .

Goyaux N, Leke R, Keita N, Thonneau P. Ectopic pregnancy in African developing countries. Acta Obstet Gynecol Scand . 2003 Apr. 82(4):305-12. [QxMD MEDLINE Link] .

Lewis G, ed. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom . London, UK: The Confidential Enquiry into Maternal and Child Health (CEMACH). 2007:92-3.:

Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ . 2003 Feb 21. 52(2):1-8. [QxMD MEDLINE Link] .

Yao M, Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril . 1997 Mar. 67(3):421-33. [QxMD MEDLINE Link] .

Dubuisson JB, Morice P, Chapron C, De Gayffier A, Mouelhi T. Salpingectomy - the laparoscopic surgical choice for ectopic pregnancy. Hum Reprod . 1996 Jun. 11(6):1199-203. [QxMD MEDLINE Link] .

Clausen I. Conservative versus radical surgery for tubal pregnancy. A review. Acta Obstet Gynecol Scand . 1996 Jan. 75(1):8-12. [QxMD MEDLINE Link] .

Maymon R, Shulman A, Halperin R, Michell A, Bukovsky I. Ectopic pregnancy and laparoscopy: review of 1197 patients treated by salpingectomy or salpingotomy. Eur J Obstet Gynecol Reprod Biol . 1995 Sep. 62(1):61-7. [QxMD MEDLINE Link] .

Parker J, Bisits A. Laparoscopic surgical treatment of ectopic pregnancy: salpingectomy or salpingostomy?. Aust N Z J Obstet Gynaecol . 1997 Feb. 37(1):115-7. [QxMD MEDLINE Link] .

Ory SJ, Nnadi E, Herrmann R, O'Brien PS, Melton LJ 3rd. Fertility after ectopic pregnancy. Fertil Steril . 1993 Aug. 60(2):231-5. [QxMD MEDLINE Link] .

Rulin MC. Is salpingostomy the surgical treatment of choice for unruptured tubal pregnancy?. Obstet Gynecol . 1995 Dec. 86(6):1010-3. [QxMD MEDLINE Link] .

Stovall TG, Ling FW, Carson SA, Buster JE. Serum progesterone and uterine curettage in differential diagnosis of ectopic pregnancy. Fertil Steril . 1992 Feb. 57(2):456-7. [QxMD MEDLINE Link] .

Xu Z, Yan L, Liu W, Xu X, Li M, Ding L, et al. Effect of treatment of a previous ectopic pregnancy on in vitro fertilization-intracytoplasmic sperm injection outcomes: a retrospective cohort study. Fertil Steril . 2015 Dec. 104 (6):1446-51.e1-3. [QxMD MEDLINE Link] .

Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing "single dose" and "multidose" regimens. Obstet Gynecol . 2003 Apr. 101(4):778-84. [QxMD MEDLINE Link] .

Alleyassin A, Khademi A, Aghahosseini M, Safdarian L, Badenoosh B, Hamed EA. Comparison of success rates in the medical management of ectopic pregnancy with single-dose and multiple-dose administration of methotrexate: a prospective, randomized clinical trial. Fertil Steril . 2006 Jun. 85(6):1661-6. [QxMD MEDLINE Link] .

Barnhart KT, Sammel MD, Hummel AC, Jain JK, Chakhtoura N, Strauss III J. A novel "two dose" regimen of methotrexate to treat ectopic pregnancy. Fertil Steril . 2005 Sept. 84(Suppl):S1:S130-S131. [Full Text] .

Ectopic pregnancy mortality - Florida, 2009-2010. MMWR Morb Mortal Wkly Rep . 2012 Feb 17. 61(6):106-9. [QxMD MEDLINE Link] .

Anderson FW, Hogan JG, Ansbacher R. Sudden death: ectopic pregnancy mortality. Obstet Gynecol . 2004 Jun. 103(6):1218-23. [QxMD MEDLINE Link] .

Grimes DA. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999. Am J Obstet Gynecol . 2006 Jan. 194(1):92-4. [QxMD MEDLINE Link] .

Hollier LM, Busacker A, Njie F, Syverson C, Goodman DA. Pregnancy-Related Deaths Due to Hemorrhage: Pregnancy Mortality Surveillance System, 2012-2019. Obstet Gynecol . 2024 Aug 1. 144 (2):252-5. [QxMD MEDLINE Link] . [Full Text] .

Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet . 2006 Apr 1. 367(9516):1066-74. [QxMD MEDLINE Link] .

Alsuleiman SA, Grimes EM. Ectopic pregnancy: a review of 147 cases. J Reprod Med . 1982 Feb. 27(2):101-6. [QxMD MEDLINE Link] .

Barnhart KT, Sammel MD, Gracia CR, Chittams J, Hummel AC, Shaunik A. Risk factors for ectopic pregnancy in women with symptomatic first-trimester pregnancies. Fertil Steril . 2006 Jul. 86(1):36-43. [QxMD MEDLINE Link] .

Kaplan BC, Dart RG, Moskos M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med . 1996 Jul. 28(1):10-7. [QxMD MEDLINE Link] .

Dart RG, Kaplan B, Varaklis K. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Ann Emerg Med . 1999 Mar. 33(3):283-90. [QxMD MEDLINE Link] .

Huchon C, Panel P, Kayem G, et al. Is a standardized questionnaire useful for tubal rupture screening in patients with ectopic pregnancy?. Acad Emerg Med . 2012 Jan. 19(1):24-30. [QxMD MEDLINE Link] .

Mol F, van den Boogaard E, van Mello NM, et al. Guideline adherence in ectopic pregnancy management. Hum Reprod . 2011 Feb. 26(2):307-15. [QxMD MEDLINE Link] .

Pereira N, Bender JL, Hancock K, et al. Routine monitoring of liver, renal, and hematologic tests after single- or double-dose methotrexate treatment for ectopic pregnancies after in vitro fertilization. J Minim Invasive Gynecol . 2015 Nov-Dec. 22 (7):1266-70. [QxMD MEDLINE Link] .

Shepherd RW, Patton PE, Novy MJ, Burry KA. Serial beta-hCG measurements in the early detection of ectopic pregnancy. Obstet Gynecol . 1990 Mar. 75(3 Pt 1):417-20. [QxMD MEDLINE Link] .

Barnhart KT, Sammel MD, Rinaudo PF, Zhou L, Hummel AC, Guo W. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol . 2004 Jul. 104(1):50-5. [QxMD MEDLINE Link] .

Lin R, DiCenzo N, Rosen T. Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment. Fertil Steril . 2023 Sep. 120 (3 Pt 2):563-72. [QxMD MEDLINE Link] .

Condous G, Kirk E, Lu C, et al. Diagnostic accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women with a pregnancy of unknown location. Ultrasound Obstet Gynecol . 2005 Dec. 26(7):770-5. [QxMD MEDLINE Link] .

Taran FA, Kagan KO, Hubner M, Hoopmann M, Wallwiener D, Brucker S. The diagnosis and treatment of ectopic pregnancy. Dtsch Arztebl Int . 2015 Oct 9. 112 (41):693-704. [QxMD MEDLINE Link] .

Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA . 2013 Apr 24. 309(16):1722-9. [QxMD MEDLINE Link] .

Barnhart K, Mennuti MT, Benjamin I, Jacobson S, Goodman D, Coutifaris C. Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet Gynecol . 1994 Dec. 84(6):1010-5. [QxMD MEDLINE Link] .

Verma U, English D, Brookfield K. Conservative management of nontubal ectopic pregnancies. Fertil Steril . 2011 Dec. 96(6):1391-1395.e1. [QxMD MEDLINE Link] .

Bonin L, Pedreiro C, Moret S, Chene G, Gaucherand P, Lamblin G. Predictive factors for the methotrexate treatment outcome in ectopic pregnancy: A comparative study of 400 cases. Eur J Obstet Gynecol Reprod Biol . 2017 Jan. 208:23-30. [QxMD MEDLINE Link] .

Menon S, Colins J, Barnhart KT. Establishing a human chorionic gonadotropin cutoff to guide methotrexate treatment of ectopic pregnancy: a systematic review. Fertil Steril . 2007 Mar. 87(3):481-4. [QxMD MEDLINE Link] .

Thurman AR, Cornelius M, Korte JE, Fylstra DL. An alternative monitoring protocol for single-dose methotrexate therapy in ectopic pregnancy. Am J Obstet Gynecol . 2010 Feb. 202(2):139.e1-6. [QxMD MEDLINE Link] .

Ozcan MCH, Wilson JR, Frishman GN. A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy. J Minim Invasive Gynecol . 2021 Mar. 28 (3):656-67. [QxMD MEDLINE Link] .

Medical treatment of ectopic pregnancy. Fertil Steril . 2008 Nov. 90(5 Suppl):S206-12. [QxMD MEDLINE Link] .

Stovall TG, Kellerman AL, Ling FW, Buster JE. Emergency department diagnosis of ectopic pregnancy. Ann Emerg Med . 1990 Oct. 19(10):1098-103. [QxMD MEDLINE Link] .

• Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; and (G) Cervical, 0.2%.
• Laparoscopic picture of an unruptured right ampullary tubal pregnancy; bleeding out of the fimbriated end has resulted in hemoperitoneum.
• A 12-week interstitial gestation, which eventually resulted in a hysterectomy. Courtesy of Deidra Gundy, MD, Department of Obstetrics and Gynecology at Medical College of Pennsylvania and Hahnemann University (MCPHU).
• An endovaginal sonogram reveals an intrauterine pregnancy at approximately 6 weeks. A yolk sac (ys), gestational sac (gs), and fetal pole (fp) are depicted.
• Linear incision being made at the antimesenteric side of the ampullary portion of the fallopian tube.
• Laparoscopic picture of an ampullary ectopic pregnancy protruding out after a linear salpingostomy was performed.
• Schematic of a tubal gestation being teased out after linear salpingostomy.

Contributor Information and Disclosures

Vicken P Sepilian, MD, MSc Medical Director, Reproductive Endocrinology and Infertility, CHA Fertility Center Vicken P Sepilian, MD, MSc is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Society for Reproductive Medicine Disclosure: Nothing to disclose.

Ellen Wood, DO, FACOG Voluntary Assistant Professor, University of Miami, Leonard M Miller School of Medicine Ellen Wood, DO, FACOG is a member of the following medical societies: American Society for Reproductive Medicine Disclosure: Nothing to disclose.

Frances E Casey, MD, MPH Associate Professor, Director of Family Planning Services, Department of Obstetrics and Gynecology, VCU Medical Center Frances E Casey, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Reproductive Health Professionals , National Abortion Federation , Physicians for Reproductive Health , Society of Family Planning Disclosure: Nothing to disclose.

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Medical Association , Mississippi State Medical Association , Royal College of Surgeons of Edinburgh , Royal College of Obstetricians and Gynaecologists Disclosure: Nothing to disclose.

A David Barnes, MD, PhD, MPH, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)

A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners , American College of Obstetricians and Gynecologists , American Medical Association , Association of Military Surgeons of the US , and Utah Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert K Zurawin, MD Associate Professor, Director of Baylor College of Medicine Program for Minimally Invasive Gynecology, Director of Fellowship Program, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

Robert K Zurawin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists , American College of Obstetricians and Gynecologists , American Society for Reproductive Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Harris County Medical Society , North American Society for Pediatric and Adolescent Gynecology , and Texas Medical Association

Disclosure: Johnson and Johnson Honoraria Speaking and teaching; Conceptus Honoraria Speaking and teaching; ConMed Consulting fee Consulting

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Successful management of a patient with ovarian ectopic pregnancy by the end of the first trimester: a case report

• Sara Kasraei 1 ,
• Akram Seifollahi 2 ,
• Faezeh Aghajani 3 ,
• Amin Nakhostin-Ansari 4 ,
• Neda Zarei 1 &
• Afsaneh Tehranian 1 , 3  

Journal of Medical Case Reports volume  16 , Article number:  175 ( 2022 ) Cite this article

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Among all ectopic pregnancies, between 0.5% and 3.5% are ovarian ectopic pregnancies, a potentially life-threatening condition when ruptured due to its serious potential for hemorrhaging. A majority of ovarian ectopic pregnancies are diagnosed by the 7th week of pregnancy when the patient becomes symptomatic, and ultrasound can be used to diagnose this condition.

Case presentation

We present the case of a 39-year-old Persian woman in the 12th week of gestation who presented with vaginal bleeding and abdominal pain and was diagnosed with ovarian ectopic pregnancy. Her notable laboratory finding was β-human chorionic gonadotropin > 15,000, which indicates definite pregnancy. Transvaginal ultrasound (TVS) revealed no evidence of intrauterine pregnancy, but a well-circumscribed gestational sac in the left ovary. The patient was successfully treated with resection of the gestational sac and partial left salpingo-oophorectomy. Histopathological studies confirmed the diagnosis of ovarian ectopic pregnancy.

The case emphasizes the ability of ovarian ectopic pregnancy to develop asymptomatically through the course of pregnancy and points to the necessity for high-quality prenatal care and the importance of determining the fetal site during pregnancy.

Peer Review reports

Ectopic pregnancy constitutes 1–2% of all pregnancies and is among the leading causes of maternal morbidity and mortality. Ovarian ectopic pregnancy (OEP) is one of the rarest subtypes, with an estimated incidence of 0.5–3.5% of all ectopic pregnancies, which is increasing in the past decades [ 1 , 2 ]. In most cases, ovarian pregnancies terminate with rupture in the first trimester, which has potential for life-threatening massive internal hemorrhage [ 3 ]. OEP shares a similar clinical presentation with complicated ovarian cyst and tubal ectopic pregnancy [ 4 ], thus its preoperative diagnosis is challenging, and most cases of OEP are diagnosed intraoperatively [ 5 ]. The etiology of OEP is not fully understood, but it has been reported to be associated with utilizing an intrauterine device (IUD) in many cases [ 6 ]. We report a case of OEP with an accurate preoperative diagnosis by transvaginal ultrasound (TVS) with confirmation during laparotomy and histopathological examination.

The patient was a 39-year-old pregnant Iranian woman, G4P3L3 (gravidity 4, parity 3, live births 3), who presented to the emergency department of a specialized women’s and neonatal hospital with spotting and abdominal pain at the 6th week of gestation based on the reported last menstrual period (LMP). In her obstetrician history, she had three pregnancies delivered by natural vaginal delivery (NVD) at term without any complications. She had a history of contraceptive IUD use for the last 3 years, which was removed 2 months before the current admission due to spotting. The patient did not mention any other symptoms. Her past medical history, drug history, and family history were otherwise unremarkable. The patient mentioned no history of smoking or drinking alcohol.

On physical examination, her vital signs were in normal ranges. Her abdomen was firm, without tenderness, rebound tenderness, guarding, or rigidity. Otherwise, her physical examination was unremarkable. Her notable laboratory finding was β-human chorionic gonadotropin (HCG) > 15,000, which indicates definite pregnancy. Transvaginal ultrasound (TVS) showed no evidence of intrauterine pregnancy, but a well-circumscribed gestational sac in the left ovary with crown–rump length (CRL) of 55 mm, compatible with a gestational age of 12 weeks and 1 day and visible fetal heart rate (FHR) of the fetus, highly suggestive of left ovarian ectopic pregnancy (Fig. 1 ). TVS also revealed mild pelvic free fluid.

Evidence of ovarian ectopic pregnancy (EP) in the Transvaginal sonography (TVS)

The patient was diagnosed with OEP and underwent laparotomy surgery, which revealed a gestational sac in the left ovary with visible FHR and about 100 mL of blood, which was evacuated. The gestational sac was surgically removed, and a partial left salpingo-oophorectomy was performed. Concerning the patient's gravidity and age, the patient's left fallopian tube was completely resected for ovarian cancer prophylaxis [ 7 ]. We resected the left ovary partially to remove the gestational sac, which was entirely in the left ovary. A live fetus was in the gestational sac at 12 weeks gestational age (Fig. 2 ). Her post-op β-HCG level was 1901. She was discharged in a stable condition 2 days postoperatively. The histopathological examination of the samples confirmed the diagnosis of OEP (Fig. 3 ). In the histopathological examination, the tube was intact and clearly separated from the ovary. In addition, ovarian tissue was present in the sack wall (Fig. 3 ). The patient was followed for 1 month; β-HCG decreased gradually, with no complications in this period.

Intraoperative pictures. A Resection of the gestational sack from the ovary. B Gestational sack. C Fetus in the gestational sack

Histopathological examination of the samples. A Corpus albicans is in the sack wall. B Luteinized follicular cyst is in the sack wall

In the past few years, ectopic pregnancy rates have increased in Iran from 1.9 to 3.7 per 1000 pregnancies [ 8 ]. The incidence of OEP has also increased over the past decades, from 0.7% to 1% of all ectopic pregnancies in the 1950s to up to 3.5% in recent studies [ 9 , 10 ]. Although there is no known definite association, the incidence of OEP is reported to be higher among IUD users [ 11 ], which was the case in the reported patient. The patient’s parity was 3, and there are controversies in studies on the association between parity and risk of ectopic pregnancy. While some studies have reported a higher incidence of ectopic pregnancy in patients with higher parity, others have mentioned otherwise [ 12 , 13 , 14 ]. In a study by Ehsan et al. , mean parity was 2.66 in patients with ectopic pregnancy, which is similar to our case [ 15 ]. The assisted reproductive technique (ART) is another probable risk factor for OEP [ 16 ].

In previous studies, the mean gestational age at time of diagnosis of OEP was about 7 weeks in the majority of cases [ 1 , 17 ]. In this case, the patient was unique in this regard as the OEP had lasted for 12 weeks. Different institutes have reported similar OEPs in the first trimester of pregnancy, especially in the earlier stages. Ghasemi Tehran et al. reported a patient with a ruptured OEP who had presented with severe abdominal pain at the end of the second month of pregnancy, and the patient was treated by wedge resection of the ovary [ 18 ]. Birge et al. reported another case of OEP that presented with abdominal pain and vaginal bleeding in the 6th week of pregnancy, which was treated with methotrexate [ 19 ]. There are also studies reporting OEPs lasting full-term pregnancy [ 20 , 21 ]. Huang et al. reported a woman in the 36th week of pregnancy diagnosed with OEP and who gave birth to the infant following a laparotomy [ 20 ]. Sehgal et al. reported the finding of an OEP during a planned cesarean section, which was undiagnosed until that time [ 21 ]. These cases indicate the potential for OEP to grow until the later stages of pregnancy, leading to devastating outcomes if rupturing in the late stages. The patient in our study presented with symptoms of abdominal pain and vaginal bleeding, which are the most common in patients with OEP. However, there is still a need for high suspicion to diagnose these patients considering the low prevalence of OEP, especially in the later stages of pregnancy, and unspecific symptoms. Our patient sought medical care immediately after developing symptoms, which led to timely diagnosis. In this case report, the timely diagnosis was key for proper surgical intervention at the right time, and successful management of the patient.

In our patient, β-HCG levels were elevated and TVS revealed the site of the fetus, which were critical for timely diagnosis and intervention. However, diagnostic assessments, such as ultrasound, may not always be indicative. Lee et al. reported a patient with OEP who presented with decreased fetal movements in the 38th week of gestation. Ultrasound was not able to detect the OEP in this case and showed a fetus in a vertex position, but a gestational sac was discovered in the left ovary and the definite diagnosis was made intraoperatively [ 22 ]. Even though ultrasound has an essential role in diagnosing EP, a high level of suspicion is still needed, as it may fail to diagnose EP in some cases. Routine prenatal assessments may help diagnose EPs in earlier stages and improve outcomes [ 23 ]; however, some patients may remain undiagnosed despite routine care [ 24 ], adding to the complexity of diagnosis.

Laparoscopic surgery is the preferred intervention for the treatment of patients with OEP. However, as our patient's hemodynamic status was unstable, we performed the laparotomy and resected the fallopian tube entirely, in addition to the gestational sac and surrounding ovarian tissue, reserving the affected ovary by part. As the patient did not have any other pathology, it seemed an appropriate approach, which was successfully done for her [ 5 ].

OEP has the ability to grow until the late stages of pregnancy and may remain asymptomatic or minimally symptomatic even in the late stages. This indicates the importance of prenatal care and careful determination of the fetus site, considering the rise in incidence of EP and OEP. Also, OEP cannot be ruled out in patients of any gestational age, and it should be considered as one of the possible differential diagnoses in females presenting with abdominal pain and vaginal bleeding.

Availability of data and materials

All related information are reported in this manuscript.

Goyal LD, et al . Ovarian ectopic pregnancy: a 10 years’ experience and review of literature. Iran J Reprod Med. 2014;12(12):825–30.

PubMed   PubMed Central   Google Scholar  

Gaudoin MR, et al . Is the incidence of ovarian ectopic pregnancy increasing? Eur J Obstet Gynecol Reprod Biol. 1996;70(2):141–3.

Article   CAS   Google Scholar  

Melcer Y, et al . Primary ovarian ectopic pregnancy: still a medical challenge. J Reprod Med. 2016;61(1–2):58–62.

PubMed   Google Scholar  

Begum J, Pallavee P, Samal S. Diagnostic dilemma in ovarian pregnancy: a case series. J Clin Diagn Res. 2015;9(4):Qr11–3.

Google Scholar  

Joseph RJ, Irvine LM. Ovarian ectopic pregnancy: Aetiology, diagnosis, and challenges in surgical management. J Obstet Gynaecol. 2012;32(5):472–4.

Ko PC, et al . Twenty-one years of experience with ovarian ectopic pregnancy at one institution in Taiwan. Int J Gynaecol Obstet. 2012;119(2):154–8.

Article   Google Scholar  

Kotsopoulos J, Narod SA. Prophylactic salpingectomy for the prevention of ovarian cancer: who should we target? Int J Cancer. 2020;147(5):1245–51.

Hasani M, et al . Prevalence of ectopic pregnancy in Iran: a systematic review and meta-analysis. Iran J Obstet Gynecol Infertility. 2016;19(23):15–23.

Johnston B. Ovarian pregnancy in association with a Copper 7 intrauterine contraceptive device. J R Army Med Corps. 1987;133(2):94–5.

Ribeiro K, El Shamy T, Miskry T. Ovarian ectopic pregnancy after in vitro fertilisation treated by laparoscopic excision with ovarian preservation. BMJ Case Rep. 2020;13(11):e236680.

Gaskins AJ, et al . Demographic, lifestyle, and reproductive risk factors for ectopic pregnancy. Fertil Steril. 2018;110(7):1328–37.

Chung CS, et al . Induced abortion and ectopic pregnancy in subsequent pregnancies. Am J Epidemiol. 1982;115(6):879–87.

Hallatt JG. Primary ovarian pregnancy: a report of twenty-five cases. Am J Obstet Gynecol. 1982;143(1):55–60.

Choi H-J, et al . Clinical analysis of ovarian pregnancy: a report of 49 cases. Eur J Obstet Gynecol Reprod Biol. 2011;158(1):87–9.

Ehsan N, Mehmood A. Ectopic pregnancy: an analysis of 62 cases. J Pak Med Assoc. 1998; 48.

Grimes HG, Nosal RA, Gallagher JC. Ovarian pregnancy: a series of 24 cases. Obstet Gynecol. 1983;61(2):174–80.

CAS   PubMed   Google Scholar  

Ko P-C, Lo L-M, Cheng P-J. Twenty-one years of experience with ovarian ectopic pregnancy at one institution in Taiwan. Int J Gynecol Obstet. 2012;119(2):154–8.

Tehrani HG, et al . Ovarian ectopic pregnancy: a rare case. Iran J Reprod Med. 2014;12(4):281.

Birge O, et al . Medical management of an ovarian ectopic pregnancy: a case report. J Med Case Rep. 2015;9(1):1–4.

Huang J, et al . Primary unruptured full term ovarian pregnancy with live female infant: case report. Arch Gynecol Obstet. 2011;283(1):31–3.

Sehgal A, et al . Full term ovarian pregnancy: a case report. Aust N Z J Obstet Gynaecol. 2005;45(2):165–6.

Lee ML, et al . Live full-term ovarian ectopic pregnancy: a case report. J Reprod Med. 2014;59(11–12):607–10.

Stulberg DB, et al . Pre-pregnancy and early prenatal care are associated with lower risk of ectopic pregnancy complications in the medicaid population: 2004–08. Paediatr Perinat Epidemiol. 2017;31(1):4–10.

del Pilar Álvarez-Goris M, et al . Ovarian ectopic pregnancy with little common clinical presentation. A case report and bibliographical review. Ginecol Obstet Mex. 2015;83(09):545–50.

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Department of Obstetrics and Gynecology, Arash Women’s Hospital, Tehran University of Medical Sciences, Rashid Ave, Resalat Highway, Tehranpars, Tehran, Iran

Sara Kasraei, Neda Zarei & Afsaneh Tehranian

Department of Pathology, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran

Akram Seifollahi

Research Development Center, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran

Faezeh Aghajani & Afsaneh Tehranian

Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

Amin Nakhostin-Ansari

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All authors contributed in collecting the data, and preparing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Afsaneh Tehranian .

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Kasraei, S., Seifollahi, A., Aghajani, F. et al. Successful management of a patient with ovarian ectopic pregnancy by the end of the first trimester: a case report. J Med Case Reports 16 , 175 (2022). https://doi.org/10.1186/s13256-022-03403-w

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Received : 24 May 2021

Accepted : 06 April 2022

Published : 02 May 2022

DOI : https://doi.org/10.1186/s13256-022-03403-w

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