case presentation of ectopic pregnancy

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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

Fulya Adali

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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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• Sigmoid Colon
• Ectopic Pregnancy
• Pelvic Inflammatory Disease
• Lower Abdominal Pain
• Transabdominal Ultrasound

Cases Journal

ISSN: 1757-1626

ERIN HENDRIKS, MD, RACHEL ROSENBERG, MD, AND LINDA PRINE, MD

Am Fam Physician. 2020;101(10):599-606

Author disclosure: No relevant financial affiliations.

Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%, and ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain in whom intrauterine pregnancy has not yet been established. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. However, most ectopic pregnancies do not reach this stage. More often, patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make the diagnosis. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. A patient with diagnosed ectopic pregnancy should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability, if the initial beta human chorionic gonadotropin level is high, if fetal cardiac activity is detected outside of the uterus on ultrasonography, or if there is a contraindication to medical management.

Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. The prevalence of ectopic pregnancy in the United States is estimated to be 1% to 2%, but this may be an underestimate because this condition is often treated in the office setting where it is not tracked. 1 , 2 The mortality rate for ruptured ectopic pregnancy has steadily declined over the past three decades, and from 2011 to 2013 accounted for 2.7% of pregnancy-related deaths. 1 , 3 Risk factors for ectopic pregnancy are listed in Table 1 4 , 5 ; however, one-half of women with diagnosed ectopic pregnancy have no identified risk factors. 4 – 6 The overall rate of pregnancy (including ectopic) is less than 1% when a patient has an intrauterine device (IUD). However, in the rare case that a woman does become pregnant while she has an IUD, the prevalence of ectopic pregnancy is as high as 53%. 7 , 8 There is no difference in ectopic pregnancy rates between copper or progestin-releasing IUDs. 9

Making the Diagnosis

Signs and symptoms.

Ectopic pregnancy should be considered in any pregnant patient with vaginal bleeding or lower abdominal pain when intrauterine pregnancy has not yet been established ( Table 2 ) . 10 Vaginal bleeding in women with ectopic pregnancy is due to the sloughing of decidual endometrium and can range from spotting to menstruation-equivalent levels. 10 This endometrial decidual reaction occurs even with ectopic implantation, and the passage of a decidual cast may mimic the passage of pregnancy tissue. Thus, a history of bleeding and passage of tissue cannot be relied on to differentiate ectopic pregnancy from early intrauterine pregnancy failure.

The nature, location, and severity of pain in ectopic pregnancy vary. It often begins as a colicky abdominal or pelvic pain that is localized to one side as the pregnancy distends the fallopian tube. The pain may become more generalized once the tube ruptures and hemoperitoneum develops. Other potential symptoms include presyncope, syncope, vomiting, diarrhea, shoulder pain, lower urinary tract symptoms, rectal pressure, or pain with defecation. 11

The physical examination can reveal signs of hemodynamic instability (e.g., hypotension, tachycardia) in women with ruptured ectopic pregnancy and hemoperitoneum. 12 Patients with unruptured ectopic pregnancy often have cervical motion or adnexal tenderness. 13 Sometimes the ectopic pregnancy itself can be palpated as a painful mass lateral to the uterus. There is no evidence that palpation during the pelvic examination leads to an increased risk of rupture. 10

BETA HUMAN CHORIONIC GONADOTROPIN

Beta human chorionic gonadotropin (β-hCG) can be detected in pregnancy as early as eight days after ovulation. 14 The rate of increase in β-hCG levels, typically measured every 48 hours, can aid in distinguishing normal from abnormal early pregnancy. In a viable intrauterine pregnancy with an initial β-hCG level less than 1,500 mIU per mL (1,500 IU per L), there is a 99% chance that the β-hCG level will increase by at least 49% over 48 hours. 15 As the initial β-hCG level increases, the rate of increase over 48 hours slows, with an increase of at least 40% expected for an initial β-hCG level of 1,500 to 3,000 mIU per mL (1,500 to 3,000 IU per L) and 33% for an initial β-hCG level greater than 3,000 mIU per mL. 15 A slower-than-expected rate of increase or a decrease in β-hCG levels suggests early pregnancy loss or ectopic pregnancy. The rate of increase slows as pregnancy progresses and typically plateaus around 100,000 mIU per mL (100,000 IU per L) at 10 weeks' gestation. 16 A decrease in β-hCG of at least 21% over 48 hours suggests a likely failed intrauterine pregnancy, whereas a smaller decrease should raise concern for ectopic pregnancy. 17

The discriminatory level is the β-hCG level above which an intrauterine pregnancy is expected to be seen on transvaginal ultrasonography; it varies with the type of ultrasound machine used, the sonographer, and the number of gestations. A combination of β-hCG level greater than the discriminatory level and ultrasonography that does not show an intrauterine pregnancy should raise concern for early pregnancy loss or an ectopic pregnancy. 5 The discriminatory zone was previously defined as a β-hCG level of 1,000 to 2,000 mIU per mL (1,000 to 2,000 IU per L); however, this cutoff can miss some intrauterine pregnancies that do not become apparent until a slightly higher β-hCG level is achieved. Therefore, in a desired pregnancy, it is recommended that a discriminatory level as high as 3,500 mIU per mL (3,500 IU per L) be used to avoid misdiagnosis and interruption of a viable pregnancy, although most pregnancies will be visualized by the time the β-hCG level reaches 1,500 mIU per mL. 18 , 19

TRANSVAGINAL ULTRASONOGRAPHY

Intrauterine pregnancy visualized on transvaginal ultrasonography essentially rules out ectopic pregnancy except in the exceedingly rare case of heterotopic pregnancy. 5 The definitive diagnosis of ectopic pregnancy can be made with ultrasonography when a yolk sac and/or embryo is seen in the adnexa; however, ultrasonography alone is rarely used to diagnose ectopic pregnancy because most do not progress to this stage. 5 More often, the patient history is combined with serial quantitative β-hCG levels, sequential ultrasonography, and, at times, uterine aspiration to arrive at a final diagnosis of ectopic pregnancy.

PREGNANCY OF UNKNOWN LOCATION

Ultrasonography showing neither intrauterine nor ectopic pregnancy in a patient with a positive pregnancy test is referred to as a pregnancy of unknown location. In a desired pregnancy, β-hCG levels and serial ultrasonography combined with patient reports of pain or bleeding guide management. 20 In an undesired pregnancy or when the possibility of a viable intrauterine pregnancy has been excluded, manual vacuum aspiration of the uterus can evaluate for chorionic villi that differentiate intrauterine pregnancy loss from ectopic pregnancy. If chorionic villi are seen, further workup is unnecessary, and exposure to methotrexate can be avoided  ( Figure 1 ) . 5 , 15 – 17 , 21 If chorionic villi are not seen after uterine aspiration, it is imperative to initiate treatment for ectopic pregnancy or repeat β-hCG measurement in 24 hours to ensure at least a 50% decrease. Ectopic precautions and serial β-hCG levels should be continued until the level is undetectable.

Management of Ectopic Pregnancy

It is appropriate for family physicians to treat hemodynamically stable patients in conjunction with their primary obstetrician. Patients with suspected or confirmed ectopic pregnancy who exhibit signs and symptoms of ruptured ectopic pregnancy should be emergently transferred for surgical intervention. If ectopic pregnancy has been diagnosed, the patient is deemed clinically stable, and the affected fallopian tube has not ruptured, treatment options include medical management with intramuscular methotrexate or surgical management with salpingostomy (removal of the ectopic pregnancy while leaving the fallopian tube in place) or salpingectomy (removal of part or all of the affected fallopian tube). The decision to manage the ectopic pregnancy medically or surgically should be informed by individual patient factors and preferences, clinical findings, ultrasound findings, and β-hCG levels. 12 Expectant management is rare but can be considered with close follow-up for patients with suspected ectopic pregnancy who are asymptomatic and have β-hCG levels that are very low and continue to decrease. 5

MEDICAL MANAGEMENT

Intramuscular methotrexate is the only medication appropriate for the management of ectopic pregnancy. A folate antagonist, it interrupts the rapidly dividing cells of the ectopic pregnancy, which are then resorbed by the body. 22 Its success rate decreases with higher initial β-hCG levels ( Table 3 ) . 23 Contraindications to methotrexate include renal insufficiency; moderate to severe anemia, leukopenia, or thrombocytopenia; liver disease or alcoholism; active peptic ulcer disease; and breastfeeding. 5 Therefore, a complete blood count and comprehensive metabolic panel should be obtained before it is administered.

Several methotrexate regimens have been studied, including a single-dose protocol, a two-dose protocol, and a multi-dose protocol ( Table 4 ) . 5 The single-dose protocol carries the lowest risk of adverse effects, whereas the two-dose protocol is more effective than the single-dose protocol in patients with higher initial β-hCG levels. 24 There is no consistent evidence or consensus regarding the cutoff above which a two-dose protocol should be used, so clinicians should choose a regimen based on the initial β-hCG level and ultrasound findings, as well as patient preference regarding effectiveness vs. the risk of adverse effects. In general, the single-dose protocol should be used in patients with β-hCG levels less than 3,600 mIU per mL (3,600 IU per L), and the two-dose protocol should be considered for patients with higher initial β-hCG levels, especially those with levels greater than 5,000 mIU per mL. Multidose protocols carry a higher risk of adverse effects and are not preferred. 25

Before administering methotrexate, β-hCG levels should be measured on days 1, 4, and 7 of treatment. The first measurement helps the clinician decide between the one- and two-dose protocols. Levels commonly increase between days 1 and 4, but should decrease by at least 15% between days 4 and 7. If this decrease does not occur, the clinician should discuss with the patient whether she prefers to repeat the course of methotrexate or pursue surgical treatment. If the β-hCG level does decrease by at least 15% between days 4 and 7, the patient should return for weekly β-hCG measurements until levels become undetectable, which can take up to eight weeks. 26

Close follow-up is critical for the safe use of methotrexate in women with ectopic pregnancies. Patients should be counseled that the risk of rupture persists until β-hCG levels are undetectable, and that they should seek emergency care if signs of ectopic pregnancy occur. It is common for patients to experience some abdominal pain two to three days after administration of methotrexate. This pain can be managed expectantly as long as there are no signs of rupture. 5 Gastrointestinal adverse effects (e.g., abdominal pain, vomiting, nausea) and vaginal spotting are common. Patients should be counseled to avoid taking folic acid supplements and nonsteroidal anti-inflammatory drugs, which can decrease the effectiveness of methotrexate, and to avoid anything that may mask the symptoms of ruptured ectopic pregnancy (e.g., narcotic analgesics, alcohol) and activities that increase the risk of rupture (e.g., vaginal intercourse, vigorous exercise). Sunlight exposure during treatment can cause methotrexate dermatitis and should be avoided. 5 Other adverse effects of methotrexate include alopecia and elevation of liver enzymes. Patients should be counseled to avoid repeat pregnancy until at least one ovulatory cycle after the serum β-hCG level becomes undetectable, although some experts recommend waiting three months so that the methotrexate can be cleared completely. 27 There is no evidence that methotrexate therapy affects future fertility. 28

SURGICAL MANAGEMENT

Overall, surgical management has a higher success rate for ectopic pregnancy than methotrexate. 5 The initial β-hCG level at which to transfer a patient for possible surgical treatment depends on local standards, although a level of 5,000 mIU per mL (5,000 IU per L) is commonly used. 5 , 11 Ultrasound visualization of an embryo with fetal cardiac activity outside of the uterus is an indication for urgent transfer for surgical management. 5 , 25 Additionally, social factors that preclude frequent laboratory testing (e.g., poor telephone access, work and family obligations, lack of transportation) can make surgical management the safer option 5 ( Table 5 5 , 11 ) . In cases where methotrexate is contraindicated or not preferred by the patient, surgical management can usually be performed laparoscopically if the patient is hemodynamically stable. Surgical options include salpingostomy or salpingectomy. Randomized trials have shown no difference in sequelae between methotrexate administration and fallopian tube–sparing laparoscopic surgery, including rates of future intrauterine pregnancy and risk of future ectopic pregnancy. 29 The decision whether to remove the fallopian tube or leave it in place depends on the extent of damage to the tube (evaluated intraoperatively) and the patient's desire for future fertility.

EXPECTANT MANAGEMENT

Expectant management can be considered for patients whose peak β-hCG level is below the discriminatory zone and is decreasing, but has plateaued or is decreasing more slowly than expected for a failed intrauterine pregnancy. 30 In cases where the initial β-hCG level is 200 mIU per mL (200 IU per L) or less, 88% of patients will have successful spontaneous resolution of the pregnancy; however, rates of spontaneous resolution decrease with higher β-hCG levels. 31 Patient counseling must include the risks of spontaneous rupture, hemorrhage, and need for emergency surgery. Patients who choose expectant management should have β-hCG levels monitored every 48 hours, and medical or surgical management should be recommended if β-hCG levels do not decrease sufficiently. 5

This article updates a previous article on this topic by Barash, et al. 12

Data Sources: An evidence summary from Essential Evidence Plus was reviewed and relevant studies referenced. Additionally, a PubMed search was completed in Clinical Queries using the key terms ectopic pregnancy, first trimester bleeding, and pregnancy of unknown location. The search included meta-analyses, guidelines, and reviews. Also searched were the Cochrane database, DynaMed, and the National Guideline Clearinghouse. Search dates: October 26, 2018, through January 14, 2020.

Creanga AA, Shapiro-Mendoza CK, Bish CL, et al. Trends in ectopic pregnancy mortality in the United States: 1980–2007. Obstet Gynecol. 2011;117(4):837-843.

Marion LL, Meeks GR. Ectopic pregnancy: history, incidence, epidemiology, and risk factors. Clin Obstet Gynecol. 2012;55(2):376-386.

Creanga AA, Syverson C, Seed K, et al. Pregnancy-related mortality in the United States, 2011–2013. Obstet Gynecol. 2017;130(2):366-373.

Ankum WM, Mol BW, Van der Veen F, et al. Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril. 1996;65(6):1093-1099.

ACOG practice bulletin no. 193: tubal ectopic pregnancy [published correction appears in Obstet Gynecol . 2019;133(5):1059]. Obstet Gynecol. 2018;131(3):e91-e103.

Barnhart KT, Sammel MD, Gracia CR, et al. Risk factors for ectopic pregnancy in women with symptomatic first-trimester pregnancies. Fertil Steril. 2006;86(1):36-43.

Backman T, Rauramo I, Huhtala S, et al. Pregnancy during the use of levonorgestrel intrauterine system. Am J Obstet Gynecol. 2004;190(1):50-54.

Hardeman J, Weiss BD. HardemanJWeissBDIntrauterine devices: an update. Am Fam Physician2014;89(6):445–450. Accessed November 9, 2019. https://www.ncbi.nlm.nih.gov/pubmed/24695563?dopt=Abstract

Bosco-Lévy P, Gouverneur A, Langlade C, et al. Safety of levonorgestrel 52 mg intrauterine system compared to copper intrauterine device: a population-based cohort study. Contraception. 2019;99(6):345-349.

Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729.

Newbatt E, Beckles Z, Ullman R, et al.; Guideline Development Group. Ectopic pregnancy and miscarriage: summary of NICE guidance. BMJ. 2012;345:e8136.

Barash JH, Buchanan EM, Hillson C. BarashJHBuchananEMHillsonCDiagnosis and management of ectopic pregnancy. Am Fam Physician2014;90(1):34–40. Accessed November 9, 2019. https://www.aafp.org/afp/2014/0701/p34.html

Ramakrishnan K, Scheid DC. Ectopic pregnancy: forget the “classic presentation” if you want to catch it sooner. J Fam Pract. 2006;55(5):388-395.

Stewart BK, Nazar-Stewart V, Toivola B. Biochemical discrimination of pathologic pregnancy from early, normal intrauterine gestation in symptomatic patients. Am J Clin Pathol. 1995;103(4):386-390.

Barnhart KT, Guo W, Cary MS, et al. Differences in serum human chorionic gonadotropin rise in early pregnancy by race and value at presentation. Obstet Gynecol. 2016;128(3):504-511.

Barnhart KT, Sammel MD, Rinaudo PF, et al. Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined. Obstet Gynecol. 2004;104(1):50-55.

Barnhart K, Sammel MD, Chung K, et al. Decline of serum human chorionic gonadotropin and spontaneous complete abortion: defining the normal curve. Obstet Gynecol. 2004;104(5 pt 1):975-981.

Doubilet PM, Benson CB, Bourne T, et al.; Society of Radiologists in Ultrasound Multispecialty Panel on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013;369(15):1443-1451.

Connolly A, Ryan DH, Stuebe AM, et al. Reevaluation of discriminatory and threshold levels for serum β-hCG in early pregnancy. Obstet Gynecol. 2013;121(1):65-70.

Rodgers SK, Chang C, DeBardeleben JT, et al. Normal and abnormal US findings in early first-trimester pregnancy: review of the Society of Radiologists in Ultrasound 2012 consensus panel recommendations. Radiographics. 2015;35(7):2135-2148.

Reproductive Health Access Project. Diagnosis and treatment of ectopic pregnancy algorithm. June 2019. Accessed June 29, 2019. https://www.reproductiveaccess.org/resource/ectopic-algorithm

Stika CS. Methotrexate: the pharmacology behind medical treatment for ectopic pregnancy. Clin Obstet Gynecol. 2012;55(2):433-439.

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;87(3):481-484.

Yang C, Cai J, Geng Y, et al. Multiple-dose and double-dose versus single-dose administration of methotrexate for the treatment of ectopic pregnancy: a systematic review and meta-analysis. Reprod Biomed Online. 2017;34(4):383-391.

Practice Committee of American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013;100(3):638-644.

Barnhart KT, Gosman G, Ashby R, et al. The medical management of ectopic pregnancy: a meta-analysis comparing “single dose” and “multidose” regimens. Obstet Gynecol. 2003;101(4):778-784.

Hospira. Methotrexate injection, USP [package insert]. October 2011. Accessed November 9, 2019. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/011719s117lbl.pdf

Ohannessian A, Loundou A, Courbière B, et al. Ovarian responsiveness in women receiving fertility treatment after methotrexate for ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod. 2014;29(9):1949-1956.

Hajenius PJ, Mol F, Mol BW, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev. 2007(1):CD000324.

van Mello NM, Mol F, Verhoeve HR, et al. Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison. Hum Reprod. 2013;28(1):60-67.

Korhonen J, Stenman UH, Ylöstalo P. Serum human chorionic gonadotropin dynamics during spontaneous resolution of ectopic pregnancy. Fertil Steril. 1994;61(4):632-636.

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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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• Published: 20 December 2015

Medical management of an ovarian ectopic pregnancy: a case report

• Ozer Birge 1 ,
• Mustafa Melih Erkan 2 ,
• Ertugrul Gazi Ozbey 3 &
• Deniz Arslan 3  

Journal of Medical Case Reports volume  9 , Article number:  290 ( 2015 ) Cite this article

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Primary ovarian ectopic pregnancy is a rare type of ectopic pregnancy which has an estimated prevalence ranging from 1:7000 to 1:70,000 accounting for almost 3 % of all ectopic cases. Here we report the case of a 25-year-old woman who presented to our clinic with abdominal pain, 6 weeks’ delay of menstruation and 3 days of vaginal bleeding, whose transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary. This case shows that early diagnosis is very important particularly in places like the Sub-Saharan region of Africa.

Case presentation

A 25-year-old African woman was referred to our clinic with 6 weeks’ delay of menstruation, frequent increasing abdominal pain and 3 days of vaginal bleeding. Her general condition was good and her vital signs were normal. She felt tenderness in an abdominal examination and had a small amount of vaginal bleeding. Transvaginal ultrasonography showed an ectopic gestational sac with yolk sac inside, in her right ovary. Our final diagnosis was ectopic ovarian pregnancy and we successfully treated her with methotrexate. After 3 weeks of methotrexate administration her beta human chorionic gonadotropin was negative and a sonographic examination was completely normal.

Conclusions

Ectopic ovarian pregnancy is a very important medical situation. It should be diagnosed in its early stages otherwise it could be life-threatening and surgical treatment may be inevitable. Because of the importance of fertility, medical treatment is an acceptable option and can be feasible with early diagnosis.

Peer Review reports

Primary ovarian ectopic pregnancy is a rare type of ectopic pregnancy which has an estimated prevalence ranging from 1:7000 to 1:70,000 accounting for almost 3 % of all ectopic cases [ 1 ]. It is usually terminated by a rupture in the first trimester and because of the increased vascularization of the ovarian tissue it leads to internal hemorrhage and hypovolemic shock status. The diagnosis is usually made by emergency laparotomies and histopathologic assessment.

Diagnosis is made using the Spiegelberg criteria [ 2 ] which include:

The gestational sac is located in the region of the ovary.

The ectopic pregnancy is attached to the uterus by the ovarian ligament.

Ovarian tissue in the wall of the gestational sac is proved histologically.

The tube on the involved side is intact.

Non-tubal pregnancies are the most common type of ectopic pregnancy and ovarian pregnancies are the second most common type; ovarian pregnancies are very common with intrauterine devices (IUDs). Surgical treatments are often performed in these cases because of the late onset of clinical symptoms which leads to late diagnosis [ 1 , 2 ]. Methotrexate (MTX) treatment can be used for patients in the early phases if their condition is stable.

A 25-year-old African obese woman with a history of two cesarean sections was referred to our clinic with 6 weeks’ delay of menstruation, frequent increasing abdominal pain and 3 days of vaginal bleeding. She had a regular menstrual period before the symptoms. In her medical history there was no record of use of an IUD, endometriosis or pelvic inflammatory disease. This was her third spontaneous pregnancy and there was no abortion. Her general condition was good and her vital signs were normal: blood pressure 110/70 mmHg, pulse 70 beats per minute (bpm), temperature 36.5 °C. A physical examination showed minimal tenderness in all sides of her abdomen with an increase in right lower pelvic section. A speculum examination showed a small amount of cervical bleeding, a palpable mass in rectouterine cavity and increased temperature and tenderness at right adnexial region. Transvaginal ultrasonography (USG) showed empty uterine cavity with 11 mm thickness. However, her rectouterine cavity was observed to be filled with heterogenous liquid including septations and hyperechogenic areas which were thought to be a coagulum. An ectopic gestational sac and yolk sac seemed to be inside her right ovary, and were identified close to the midline, which correlated with her 6 weeks’ delay of menstruation (Fig.  1 ). The fetus and fetal heart beat were not clearly seen. Vascular proliferation called ‘ring of fire’ which is typical for ectopic ovarian pregnancy was detected around the gestational sac (Fig.  1 ). Her left ovary and tubal structures seemed to be normal. She declared her previous menstrual periods were regular but that her last period was 2 months ago. Laboratory analysis showed a white blood cell count (WBC) of 11,600/mm 3 , red blood cell count (RBC) of 400000/mm 3 , hemoglobin (Hb) of 12.3 g/dl, hematocrit (Htc) of 36 %, beta human chorionic gonadotropin (HCG) of 6580 and normal urine results. She was diagnosed as having an ectopic ovarian pregnancy and was hospitalized. She and her family were informed about the stability of the condition and in view of her history of two previous cesarean sections, medical treatment of MTX was planned. A single dose of 90 mg intramuscular MTX was administered. She was stable. A progressive decrease in her beta HCG levels (4310 at fourth day, 2190 at seventh day, 210 at 14th day) as well as a diminishing of intraabdominal liquid and significant regression of her right ovarian sac were observed and she was discharged with weekly beta HCG test control advice. At the third week after the MTX treatment her beta HCG level was below 5 and her intraabdominal fluid had nearly disappeared (Fig.  2 ).

Ultrasound images of ovarian gestational sac before medical methotrexate therapy. ( a ) Ovarian gestational sac ( b ) Colour doppler image of gestational sac

Control ultrasonographic image after the methotrexate treatment

The history of ectopic pregnancy is as old as humanity. The first successful operation for ectopic pregnancy took place in 1759 in the USA but the usual treatment was still medical up to the 1800s with a maternal mortality rate reaching up to 60 % [ 3 ]. The high mortality rates drew special attention which led to crucial developments in the diagnosis and treatment of this condition. Salpingectomy, which started to be performed from the 1800s, is observed to be lifesaving because it decreased the maternal mortality rates to nearly 5 %.

Ovarian ectopic pregnancy is a rare variant of ectopic pregnancy [ 4 ]. It occurs by fertilization of an ovum retained in the peritoneal cavity leading to implantation on the ovarian surface [ 5 ]. Women with ovarian ectopic pregnancies usually present with lower abdominal pain, menstrual irregularities as in other ectopic conditions and corpus luteum cyst. Although early diagnosis and early treatment are crucial, preoperative and sometimes intraoperative diagnoses are difficult. Diagnosis is usually made by pathological assessment and therefore the Spiegelberg criteria are very important for the diagnosis of ectopic ovarian pregnancy [ 6 ].

Prediagnosis is usually supported by increased beta HCG levels. The current data inform that most cases occur in the first trimester. Early onset rupture can lead to massive intraabdominal hemorrhage resulting in hypovolemia which can be life-threatening. Some rare cases that reach second trimester are also documented [ 7 ]. There are also published cases of twin ovarian ectopic pregnancies and coincidence of uterine and ovarian ectopic pregnancies [ 7 – 10 ]. We also found some articles on ectopic pregnancies of advanced gestational age diagnosed preoperatively with USG and magnetic resonance imaging (MRI) [ 7 , 11 ]. In the study of Hallat, a preoperative diagnosis was achieved in 28 % of 25 primary ectopic pregnancy cases. All other cases were diagnosed by pathological assessment postoperatively [ 12 ]. Phupong and Ultchaswadi declared that the evaluation of beta HCG together with transvaginal USG can be helpful for early diagnosis [ 13 ].

The cause of implantation anomalies in ovarian ectopic pregnancy is not clear [ 7 , 12 , 13 ]. There are various hypotheses such as:

Delay of ovum liberation.

Thickening of tunica albuginea.

Tubal dysfunction.

Intrauterine contraception devices (for example, IUDs).

Pelvic inflammatory disease does not have an effect on ovarian ectopic pregnancy like it does on tubal pregnancy [ 9 , 14 ]. IUDs are thought to be a main factor in ovarian ectopic pregnancy cases according to the majority of studies. It is believed that IUDs trigger mild inflammation that disturbs the ciliary activity of the endosalpinx and leads to ovum transport delay and ectopic implantation [ 15 , 16 ]. In our case, ectopic pregnancy was diagnosed from clinical and laboratory examinations and evaluations of her condition. Because of her two previous cesarean sections and the suspicion of secondary salpingitis by endemic chronic pelvic infections we performed medical treatment with MTX.

Primary ovarian ectopic pregnancy is usually seen among young fertile multipara women who use an IUD [ 17 ]. Berger and Blechner documented that the ratio of ovarian ectopic pregnancy among women using an IUD to all ectopic cases is 1:9; its prevalence in the general population is detected as 1:150 to 200 [ 16 ]. Our case had no history of IUD usage. In the case series of Raziel et al ., 18 of 20 cases of ovarian pregnancy were using an IUD [ 14 ]. The link between IUDs and ovarian pregnancy in fertile patients is worthy of comment. In their study, Lehfeldt et al . detected that the IUDs prevent uterine implantation by 99.5 % and tubal implantation by 95.5 %; however, there is no preventive effect on ovarian implantation [ 18 ].

As the definitive diagnosis is made surgically and histopathologically even in patients with early onset, surgical interventions have both a diagnostic and a therapeutic value. Because oophorectomy is a radical procedure for ovarian ectopic pregnancy, consideration should be given to the patient’s age, fertility, her desire to have further pregnancies, and the size of the mass; wedge resection can also be another surgical option.

Medical and conservative treatments have also been introduced in recent years to prevent ovarian tissue loss, pelvic adhesions and to preserve the patient’s fertility. These include administration of mifepristone for patients diagnosed using a transvaginal USG, parenteral prostaglandin F2a and MTX treatment for non-ruptured cases detected with laparoscopy [ 11 , 19 ]. Pagidas and Frishman performed MTX treatment for ovarian ectopic cases diagnosed using transvaginal USG and achieved healing. They emphasized that early staged cases diagnosed by transvaginal USG, can benefit from MTX treatment [ 20 ]. Di Luigi et al. also performed and succeeded with multidose MTX treatment which they administered to a 37-year-old patient with a history of two previous cesarean sections and IUD usage; she was diagnosed at 6 weeks of ectopic ovarian pregnancy by use of a transvaginal USG. They emphasized that with careful clinical evaluation and transvaginal examination early staged ovarian ectopic cases can be treated medically which preserves the normal anatomy crucial for fertility [ 21 ]. A review of the data shows that MTX treatment is chosen after a clear diagnosis and detection of the localization of ectopic cases by laparoscopy and therefore laparoscopy is declared to be a supporting diagnostic procedure [ 22 ]. In cases in which the gestational sac is lower than 30 mm, without fetal cardiac activity, and less than 6-weeks old, MTX treatment is supported in particular and is superior to surgery because it does not disturb fertility [ 23 ].

In our case although she had pelvic fluid of hemorrhagic character that could have been caused by pelvic rupture, a clinical evaluation and consideration of her previous operations led us to treat her medically. Her beta HCG levels progressively decreased after single dose MTX and she did not face the risks of further surgery.

Although ovarian ectopic pregnancy is a rare condition, after careful evaluation, the selection of medical procedures should take into consideration the preservation of fertility particularly for young patients.

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

Abbreviations

Human chorionic gonadotropin

Intrauterine device

• Methotrexate

Ultrasonography

Marcus SM, Brinsden PR. Primary ovarian pregnancy after in vitro fertilization and embryo transfer: report of seven cases. Fertil Steril. 1993;60:167–70.

Article   CAS   PubMed   Google Scholar  

Gerin-Lajoie L. Ovarian pegnancy. Am J Obstet Gynecol. 1951;62:920–9.

Diamond MP, DeCherny AH. Ectopic pregnancy. WB Saunders. 1991;163:780–804.

Google Scholar  

Al-Meshari AA, Chowdhury N, Adelusi BX. Ovarian pregnancy. Int J Gynaecol Obstet. 1993;41(3):269–72.

Sturm JT, Hankins DG, Malo JW, Cicero JJ. Ovarian ectopic pregnancy. Ann Emerg Med. 1984;13:362–4.

Spiegelberg OX. Zur casuistic der ovarial schwangerschaft. Arch Gynekol. 1978;13:73.

Article   Google Scholar  

Stanley JR, Harris AA, Gilbert CF, Lennon YA, Dellinger EH. Magnetic resonance imaging in evaluation of a second trimester ovarian twin pregnancy. Obstet Gynecol. 1994;84:648–51.

CAS   PubMed   Google Scholar  

Panda JK. Primary ovarian twin pregnancy. Case report. Br J Obstet Gynecol. 1990;97:540–1.

Article   CAS   Google Scholar  

Bernabei A, Morgante G, Mazzini M, Guerrini E, Fava A, Danero S. Simultaneous ovarian and intrauterine pregnancy: Case report. Am J Obstet Gynecol. 1992;167:134–5.

Kalfayan B, Gundersen JH. Ovarian twin pregnancy. Report of a case. Obstet Gynecol. 1963;21:126–8.

Levin JH, Lacarra M, d’Ablaing G, Grimes DA, Vaermesh M. Mifepristone (RU 486) failure in an ovarian heterotopic pregnancy. Am J Obstet Gynecol. 1990;163:543–4.

Hallat J. Primary ovarian pregnancy. A report of twenty-five cases. Am J Obstet Gynecol. 1982;143:50–60.

Phupong V, Ultchaswadi P. Primary ovarian pregnancy. J Med Assoc Thai. 2005;88(4):527–9.

PubMed   Google Scholar  

Raziel A, Golan A, Pansky M, Ron-El R, Bukovsky I, Caspi E. Ovarian pregnancy: a report of twenty cases in one institution Cases Report. Am J Obstet Gynecol. 1990;163:1182–5.

Herbertsson G, Magnusson S, Benediktsdottir K. Ovarian pregnancy and IUCD use in a defined complete population. Acta Obstet Gynecol Scand. 1987;66:607–10.

Berger B, Blechner JN. Ovarian pregnancy associated with copper-7 intrauterine device. Obstetr Gynecol. 1978;52:597–600.

CAS   Google Scholar  

Schwartz LB, Carcangiu ML, DeCherney AHX. Primary ovarian pregnancy: a case report. J Reprod Med. 1993;38:155–8.

Lehfeldt H, Tietze C, Gorstein F. Ovarian pregnancy and the intrauterine device. Am J Obstet Gynecol. 1970;108(7):1005–9.

Shamma FN, Schwartz LB. Primary ovarian pregnancy successfully treated with methotrexate. Am J Obstet Gynecol. 1992;167:1307–8.

Pagidas K, Frishman GN. Nonsurgical management of primary ovarian pregnancy with transvaginal ultrasound-guided local administration of methotrexate. J Minim Invasive Gynecol. 2013;20(2):252–4.

Article   PubMed   Google Scholar  

Di Luigi G, Patacchiola F, La Posta V, Bonitatibus A, Ruggeri G, Carta G. Early ovarian pregnancy diagnosed by ultrasound and successfully treated with multidose methotrexate. A case report. Clin Exp Obstet Gynecol. 2012;39(3):390–3.

Chelmow D, Gates E, Penzias AS. Laparoscopic diagnosis and methotrexate treatment of an ovarian pregnancy: a case report. Fertil Steril. 1994;62(4):879–81.

Annunziata N, Malignino E, Zarcone R. Ovarian pregnancies treated with methotrexate. Panminerva Med. 1996;38(3):190–2.

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Acknowledgements

We would like to thank the staff of Nyala Sudan Turkey Research and Training Hospital, the patient and relatives who were kind enough to give their consent to publish this case report.

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BO, AD, and OEG were involved in management of the patient. BO and EMM drafted the manuscript. EMM and BO provided valuable input and guidance during the preparation of the manuscript. BO was responsible for overall management of the patient and supervised the writing critically. All authors read and approved the final manuscript.

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Birge, O., Erkan, M.M., Ozbey, E.G. et al. Medical management of an ovarian ectopic pregnancy: a case report. J Med Case Reports 9 , 290 (2015). https://doi.org/10.1186/s13256-015-0774-6

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Chronic ectopic pregnancy: case report and systematic review of the literature

• General Gynecology
• Published: 23 July 2019
• Volume 300 , pages 651–660, ( 2019 )

Cite this article

• Clemens B. Tempfer 1 , 3 ,
• Askin Dogan 1 ,
• Iris Tischoff 2 ,
• Ziad Hilal 1 &
• Günther A. Rezniczek   ORCID: orcid.org/0000-0002-0852-6002 1 , 3  

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Chronic ectopic pregnancy (CEP) is a variant of ectopic pregnancy (EP) characterized by low or absent serum human chorionic gonadotropin (hCG) levels, resistance to methotrexate (MTX), and an adnexal mass with fibrosis, necrosis, and blood clots due to repeated and gradual fallopian tube wall disintegration. CEP may complicate the course of patients with EP and is difficult to diagnose.

Case presentation

The case of a 36-year-old woman with EP, low serum hCG levels, a small echogenic adnexal mass, and resistance to MTX is presented. Salpingectomy was performed and histology demonstrated CEP with fibrosis, necrosis, and a hematocele within degenerated chorionic villi.

Systematic literature review

In a database search, 19 case reports, 3 case–control studies, and 3 case series describing 399 patients with CEP were identified. Serum hCG was negative in 40/124 cases (32%) with reported levels of serum hCG. The most common presenting symptom was abdominal pain (284/399 [71%]), followed by irregular vaginal bleeding (219/399 [55%]), and fever (20/399 [5%]). 73/399 (18%) women were asymptomatic. An adnexal mass was seen in 144/298 (48%) cases with perioperative ultrasound examination and with a mean largest diameter of 6.8 cm. Data on treatment modalities and outcomes were available for 297 women. Of these, 89% underwent surgery as first-line therapy. Laparoscopy was performed in most cases. MTX was the first-line therapy in a minority of cases. Complete resolution was achieved by first-line therapy in 287/297 (97%) cases. Adverse events were reported in 218 patients with CEP. Among those, adverse events ≥ grade 3 were seen in 186/218 (85%) cases. There was no case of treatment-related mortality.

CEP is a variant of EP with low or absent trophoblast activity. A prolonged clinical course is typical and surgery is the mainstay of treatment.

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A 20 year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital – a retrospective review

Pregnancy of Unknown Location and Ectopic Pregnancy

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Abbreviations

Case–control study

• Chronic ectopic pregnancy

Case report

C-reactive protein

Case series

Common toxicity criteria for adverse events

Ectopic pregnancy

Human chorionic gonadotropin

Laparoscopy

• Methotrexate

White blood cell count

Kouam L, Kamdom-Moyo J, Essame JL (1995) Fertility after chronic, undiagnosed, ectopic pregnancy. A case observed during a myomectomy. Contracept Fertil Sex 23:407–410

CAS   PubMed   Google Scholar  

Abramov Y, Nadjari M, Shushan A, Prus D, Anteby SO (1997) Doppler findings in chronic ectopic pregnancy: case report. Ultrasound Obstet Gynecol 9:344–346. https://doi.org/10.1046/j.1469-0705.1997.09050344.x

Article   CAS   PubMed   Google Scholar  

Bedi DG, Fagan CJ, Nocera RM (1984) Chronic ectopic pregnancy. J Ultrasound Med 3:347–352

Bedi DG, Moeller D, Fagan CJ, Winsett MZ (1987) Chronic ectopic pregnancy. A comparison with acute ectopic pregnancy. Eur J Radiol 7:46–48

Cole T, Corlett RC (1982) Chronic ectopic pregnancy. Obstet Gynecol 59:63–68

Turan C, Uğur M, Dogan M, Ekici E, Vicdan K, Gökmen O (1996) Transvaginal sonographic findings of chronic ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 67:115–119

Barnhart KT, Rinaudo P, Hummel A, Pena J, Sammel MD, Chittams J (2003) Acute and chronic presentation of ectopic pregnancy may be two clinical entities. Fertil Steril 80:1345–1351

Article   PubMed   Google Scholar  

Drakopoulos P, Pluchino N, Yaron M, Dällenbach P (2014) Chronic tubal ectopic pregnancy: a rare but challenging diagnosis. BMJ Case Rep. https://doi.org/10.1136/bcr-2014-205715

Article   PubMed   PubMed Central   Google Scholar  

Fujita K, Iyoshi S, Watanabe K, Takeda A (2018) Chronic tubal pregnancy manifesting as a heterogeneous adnexal mass with prominent neovascularization in a woman with a negative serum β-human chorionic gonadotropin level. J Obstet Gynaecol Res. https://doi.org/10.1111/jog.1386

Vukas-Radulovic N, Bullarbo M, Ekerhovd E (2017) A case of chronic ectopic pregnancy manifested by rectal bleeding. Case Rep Obstet Gynecol. https://doi.org/10.1155/2017/5974590 (Article ID 5974590)

Curry NS, Blackwood GA, Tsai CC (1999) Diagnosis of chronic ectopic gestation by hysterosalpingography. Abdom Imaging 24:98–99

Carty MJ, Barr RD, Ouna N (1976) Coagulation and fibrinolytic properties of peripheral venous blood in chronic ectopic pregnancy. S Afr Med J 50:1147–1148

Nacharaju M, Vellanki VS, Gillellamudi SB, Kotha VK, Alluri A (2014) A rare case of chronic ectopic pregnancy presenting as large hematosalpinx. Clin Med Insights Reprod Health 8:1–4. https://doi.org/10.4137/CMRH.S13110

Harada M, Hiroi H, Fujiwara T, Fujimoto A, Kikuchi A, Osuga Y et al (2010) Case of chronic ectopic pregnancy diagnosed in which the complete shape of the fetus was visible by ultrasonography. J Obstet Gynaecol Res 36:462–465. https://doi.org/10.1111/j.1447-0756.2009.01154.x

Su C-C, Tzeng C-C, Huang K-F (2009) Chronic ovarian pregnancy mimicking an ovarian tumor diagnosed by peritoneal washing cytology: a case report. Acta Cytol 53:195–197. https://doi.org/10.1159/000325124

Allen W-L, Subba B, Yoong W, Fakokunde A (2007) Chronic abdominal pregnancy following rupture from a bicornuate uterus. Arch Gynecol Obstet 275:393–395. https://doi.org/10.1007/s00404-006-0249-5

Di Spiezio Sardo A, Mastrogamvrakis G, Taylor A, Sharma M, Buck L, Magos A (2004) Chronic ectopic pregnancy diagnosed incidentally in an infertile woman: a case report. J Reprod Med 49:992–996

Google Scholar  

Walter J-E, Buckett WM (2004) Spontaneous bilateral chronic and acute tubal ectopic pregnancies following methotrexate treatment. Aust N Z J Obstet Gynaecol 44:267. https://doi.org/10.1111/j.1479-828X.2004.00189.x

Brennan DF, Kwatra S, Kelly M, Dunn M (2000) Chronic ectopic pregnancy—two cases of acute rupture despite negative beta hCG. J Emerg Med 19:249–254

Porpora MG, Alò PL, Cosmi EV (1999) Unsuspected chronic ectopic pregnancy in a patient with chronic pelvic pain. Int J Gynaecol Obstet 64:187–188

Dunn RC, Taskin O (1995) Chronic ectopic pregnancy after clinically successful methotrexate treatment of ectopic pregnancy. Int J Gynaecol Obstet 51:247–249

Romer JH, Bluth EI (1981) An unusual case of chronic ectopic pregnancy. South Med J 74:1263–1264

Uğur M, Turan C, Vicdan K, Ekici E, Oğuz O, Gökmen O (1996) Chronic ectopic pregnancy: a clinical analysis of 62 cases. Aust N Z J Obstet Gynaecol 36:186–189

Kamau RK, Rogo KO (1988) Chronic ectopic pregnancy with perforation vaginal fornix: case report. East Afr Med J 65:57–59

Avery DM, Silverman JF, Mazur MT (1984) Retained fetal bones in chronic tubal pregnancy. Am J Obstet Gynecol 149:794–795

Levy NB, Goldberger SB, Batchelder CS (1984) Chronic ectopic pregnancy. A survey of 54 cases. S Afr Med J 65:727–729

Collier CB, Birrell WR (1983) Chronic ectopic pregnancy complicated by shock and disseminated intravascular coagulation. Anaesth Intensive Care 11:246–248

Glukhovets VI (1981) Causes for the acute and chronic course of extrauterine pregnancy. Sov Med 1981(5):112–114

Ohel G, Katz M (1979) Lactic dehydrogenase measurement in chronic ectopic pregnancy. Am J Obstet Gynecol 135:149–150

Peterek J, Horoszko B (1979) Importance of the Arias-Stella syndrome in the diagnosis of a chronic form of tubal pregnancy. Wiad Lek 32:547–549

Rogers WF, Shaub M, Wilson R (1977) Chronic ectopic pregnancy: ultrasonic diagnosis. J Clin Ultrasound 5:257–260

Livnat EJ, Scommegna A (1977) Bilateral ureteral obstruction in ruptured chronic ectopic pregnancy. Am J Obstet Gynecol 127:330–332

Menon R (1973) Chronic ectopic pregnancy—a challenge in diagnosis. Med J Malays 28:88–90

CAS   Google Scholar  

Hovadhanakul P, Eachempati U, Cavanagh D (1971) Ureteral obstruction in chronic ectopic pregnancy. Am J Obstet Gynecol 110:311–313

Parker SL, Parker RT (1957) Chronic ectopic tubal pregnancy. Am J Obstet Gynecol 74:1174–1180

Clark JF, Bryant W (1975) Chronic ectopic pregnancy. J Natl Med Assoc 67:118–121

CAS   PubMed   PubMed Central   Google Scholar  

Kasaven LS, Shah A, Sadoon S (2018) Chronic tubal ectopic pregnancy following clinically successful methotrexate treatment for an acute ectopic: a review of the literature. J Obstet Gynaecol. https://doi.org/10.1080/01443615.2018.1517150

O'Neill D, Pounds R, Vella J, Singh K, Yap J (2018) The diagnostic conundrum of chronic ectopic pregnancy: a case report. Case Rep Womens Health 20:e00086. https://doi.org/10.1016/j.crwh.2018.e00086

National Cancer Institute. Common terminology criteria for adverse events (CTCAE) v5.0. (2017) https://ctep.cancer.gov/protocoldevelopment/electronic_applications/ctc.htm . Accessed 5 Jan 2019

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Tempfer, C.B., Dogan, A., Tischoff, I. et al. Chronic ectopic pregnancy: case report and systematic review of the literature. Arch Gynecol Obstet 300 , 651–660 (2019). https://doi.org/10.1007/s00404-019-05240-7

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DOI : https://doi.org/10.1007/s00404-019-05240-7

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Affiliations.

• 1 Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Bochum, Germany. [email protected].
• 2 Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Marien Hospital Herne, Hölkeskampring 45, 44625, Herne, Germany. [email protected].
• 3 Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Bochum, Germany.
• 4 Department of Pathology, Ruhr-Universität Bochum, Bochum, Germany.
• 5 Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Bochum, Germany. [email protected].
• 6 Department of Obstetrics and Gynecology, Ruhr-Universität Bochum, Marien Hospital Herne, Hölkeskampring 45, 44625, Herne, Germany. [email protected].
• PMID: 31338659
• DOI: 10.1007/s00404-019-05240-7

Background: Chronic ectopic pregnancy (CEP) is a variant of ectopic pregnancy (EP) characterized by low or absent serum human chorionic gonadotropin (hCG) levels, resistance to methotrexate (MTX), and an adnexal mass with fibrosis, necrosis, and blood clots due to repeated and gradual fallopian tube wall disintegration. CEP may complicate the course of patients with EP and is difficult to diagnose.

Case presentation: The case of a 36-year-old woman with EP, low serum hCG levels, a small echogenic adnexal mass, and resistance to MTX is presented. Salpingectomy was performed and histology demonstrated CEP with fibrosis, necrosis, and a hematocele within degenerated chorionic villi.

Systematic literature review: In a database search, 19 case reports, 3 case-control studies, and 3 case series describing 399 patients with CEP were identified. Serum hCG was negative in 40/124 cases (32%) with reported levels of serum hCG. The most common presenting symptom was abdominal pain (284/399 [71%]), followed by irregular vaginal bleeding (219/399 [55%]), and fever (20/399 [5%]). 73/399 (18%) women were asymptomatic. An adnexal mass was seen in 144/298 (48%) cases with perioperative ultrasound examination and with a mean largest diameter of 6.8 cm. Data on treatment modalities and outcomes were available for 297 women. Of these, 89% underwent surgery as first-line therapy. Laparoscopy was performed in most cases. MTX was the first-line therapy in a minority of cases. Complete resolution was achieved by first-line therapy in 287/297 (97%) cases. Adverse events were reported in 218 patients with CEP. Among those, adverse events ≥ grade 3 were seen in 186/218 (85%) cases. There was no case of treatment-related mortality.

Conclusion: CEP is a variant of EP with low or absent trophoblast activity. A prolonged clinical course is typical and surgery is the mainstay of treatment.

Keywords: Chronic ectopic pregnancy; Methotrexate; Pregnancy; Pregnancy complication; Trophoblast.

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• Ectopic pregnancy

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When to see a doctor, risk factors, complications.

Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches to the lining of the uterus. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus.

An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the ovaries to the uterus. This type of ectopic pregnancy is called a tubal pregnancy. Sometimes, an ectopic pregnancy occurs in other areas of the body, such as the ovary, abdominal cavity or the lower part of the uterus (cervix), which connects to the vagina.

An ectopic pregnancy can't proceed normally. The fertilized egg can't survive, and the growing tissue may cause life-threatening bleeding, if left untreated.

In a healthy pregnancy, the fertilized egg attaches itself to the lining of the uterus. In an ectopic pregnancy, the egg attaches itself somewhere outside the uterus usually to the inside of a fallopian tube.

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You may not notice any symptoms at first. However, some women who have an ectopic pregnancy have the usual early signs or symptoms of pregnancy — a missed period, breast tenderness and nausea.

If you take a pregnancy test, the result will be positive. Still, an ectopic pregnancy can't continue as normal.

As the fertilized egg grows in the improper place, signs and symptoms become more noticeable.

Early warning of ectopic pregnancy

Often, the first warning signs of an ectopic pregnancy are light vaginal bleeding and pelvic pain.

If blood leaks from the fallopian tube, you may feel shoulder pain or an urge to have a bowel movement. Your specific symptoms depend on where the blood collects and which nerves are irritated.

Emergency symptoms

If the fertilized egg continues to grow in the fallopian tube, it can cause the tube to rupture. Heavy bleeding inside the abdomen is likely. Symptoms of this life-threatening event include extreme lightheadedness, fainting and shock.

Seek emergency medical help if you have any signs or symptoms of an ectopic pregnancy, including:

• Severe abdominal or pelvic pain accompanied by vaginal bleeding
• Extreme lightheadedness or fainting
• Shoulder pain

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A tubal pregnancy — the most common type of ectopic pregnancy — happens when a fertilized egg gets stuck on its way to the uterus, often because the fallopian tube is damaged by inflammation or is misshapen. Hormonal imbalances or abnormal development of the fertilized egg also might play a role.

Some things that make you more likely to have an ectopic pregnancy are:

• Previous ectopic pregnancy. If you've had this type of pregnancy before, you're more likely to have another.
• Inflammation or infection. Sexually transmitted infections, such as gonorrhea or chlamydia, can cause inflammation in the tubes and other nearby organs, and increase your risk of an ectopic pregnancy.
• Fertility treatments. Some research suggests that women who have in vitro fertilization (IVF) or similar treatments are more likely to have an ectopic pregnancy. Infertility itself may also raise your risk.
• Tubal surgery. Surgery to correct a closed or damaged fallopian tube can increase the risk of an ectopic pregnancy.
• Choice of birth control. The chance of getting pregnant while using an intrauterine device (IUD) is rare. However, if you do get pregnant with an intrauterine device (IUD) in place, it's more likely to be ectopic. Tubal ligation, a permanent method of birth control commonly known as "having your tubes tied," also raises your risk, if you become pregnant after this procedure.
• Smoking. Cigarette smoking just before you get pregnant can increase the risk of an ectopic pregnancy. The more you smoke, the greater the risk.

An ectopic pregnancy can cause your fallopian tube to burst open. Without treatment, the ruptured tube can lead to life-threatening bleeding.

There's no way to prevent an ectopic pregnancy, but here are some ways to decrease your risk:

• Limiting the number of sexual partners and using a condom during sex helps to prevent sexually transmitted infections and may reduce the risk of pelvic inflammatory disease.
• Don't smoke. If you do, quit before you try to get pregnant.

Mar 12, 2022

• Cunningham FG, et al., eds. Implantation and placental development. In: Williams Obstetrics. 25th ed. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. Accessed Dec. 4, 2019.
• Tulandi T. Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites. https://www.uptodate.com/contents/search. Accessed Dec. 4, 2019.
• Cunningham FG, et al., eds. Ectopic pregnancy. In: Williams Obstetrics. 25th ed. McGraw-Hill Education; 2018. https://accessmedicine.mhmedical.com. Accessed Dec. 4, 2019.
• Frequently asked questions. Pregnancy FAQ 155. Ectopic pregnancy. American College of Obstetricians and Gynecologists. https://www.acog.org/Patients/FAQs/Ectopic-Pregnancy. Accessed Dec. 4, 2019.
• Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. https://www.uptodate.com/contents/search. Accessed Dec. 29, 2017.
• Burnett TL (expert opinion). Mayo Clinic. Dec. 4, 2019.
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• Hippokratia
• v.18(3); Jul-Sep 2014

A unique case of ruptured ectopic pregnancy in a patient with negative preg-nancy test - a case report and brief review of the literature

A daniilidis.

1 2 nd University Department of Obstetrics and Gynecology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece

D Balaouras

2 2 nd University Department of Obstetrics and Gynecology, Aretaieio General Hospital, Kapodistrian University of Athens, Greece

Introduction:

Despite the major advances made in the diagnosis and management of ectopic pregnancies in the last two decades, an accurate diagnosis can sometimes still be quite challenging, since it relies on the combination of ultrasound findings and serial serum beta-human chorionic gonadotrophin (β-hCG) measurements.

Case presentation:

This paper describes the case of a 36-year-old woman of Caucasian origin who was admitted to the emergency department of our clinic with clinical symptoms of hemorrhagic shock in combination with two negative pregnancy tests done by her at home and a negative urine test which was performed on her admission to the hospital. Quantitative measurement of β-hCG in the serum of the patient was 13 mIU/mL. On admission, right tubal pregnancy was diagnosed on ultrasound and she underwent an emergency laparotomy due to signs of hemodynamic shock.

Conclusion:

It is sometimes a considerable challenge to identify a patient with an ectopic pregnancy at risk of rupture. This case of ectopic pregnancy which was followed by a negative pregnancy test illustrates the magnitude of the difficulties involved in the diagnosis of ectopic pregnancy. It also demonstrates the need to maintain a high clinical index of suspicion and to undertake careful clinical examination of the patient on the basis of the clinician's diagnostic research. Hippokratia 2014; 18 (3): 282-284.

Introduction

A ruptured tubal ectopic pregnancy is likely to lead to hemorrhagic shock or even death if there is no timely diagnosis and treatment. In Britain it remains the fourth leading cause of maternal death 1 . Over the last decade, the incidence of ectopic pregnancies has been approximately 1/100 pregnancies, but this figure rises to as high as 2-3/100 in assisted conceptions techniques where the mortality rate is estimated at 0.4/1,000 births 2 . The diagnosis of ectopic pregnancy, which can be quite challenging, relies on the combination of ultrasound findings and serial serum beta-human chorionic gonadotrophin (β-hCG) measurements 3 . A pregnancy test carried out by measuring the β-hCG in serum, which is a glycoprotein hormone produced by the syncytiotrophoblast cells precisely at the time of implantation (6 th day after fertilization), is a way of demonstrating the presence of a pregnancy while usually a negative value of this hormone in serum rules out any pregnancy 4 . Thanks to recent advances, transvaginal ultrasound (TVS) is providing ever increasing sensitivity in diagnosing a pregnancy sited outside the uterus, thus ectopic pregnancies are usually diagnosed at an early stage before rupturing. The etiology still remains under debate, although a certain number of risk factors have been identified 5 . It is of considerable interest that in about 5%-31% of women admitted to hospital with early pregnancy problems, while pregnancy cannot be located during the first assessment, ultimately only 6-9% of them prove to be ectopic pregnancies 6 . This is a case report of a patient who was admitted to the emergency department of our clinic with clinical signs and symptoms of hemorrhagic shock in combination with two negative pregnancy tests done by her at home and a negative urine test which was performed on her admission to the hospital. We also present a brief review of the literature on this rare event.

Case presentation

A 36-year-old nulliparous woman of Caucasian origin, with a past history of polycystic ovaries and a corpus luteum rupture in 2009 which was treated conservatively, was admitted via ambulance to the emergency department of our clinic with symptoms of acute lower abdominal pain and two episodes of blackouts within the last 12 hours at home, with a few minutes of unconsciousness in the second one. The patient reported 6 weeks of amenorrhea and spotting per vagina for 5 days and two negative urine pregnancy tests at home the day before.

On her admission to our hospital, there were clinical signs of hemodynamic compromise, with marked tenderness on superficial and deep abdominal palpation, rebound tenderness, sweating, pallor, palpitation (110/min) and low blood pressure (80/60 mm Hg). There was also intense reflex sensitivity in the right shoulder (Kerk-sign positive), the patient's temperature was 36.2 C°, while ECG revealed only tachycardia with sinus rhythm. On pelvic examination, there was marked cervical excitation. Blood results were the following: Hematocrit: 27.1% with Hemoglobin: 9.3 g/dl, white blood cells: 21.3 m/ml with Neutrophils: 73.1%, and platelets: 260,000/mL. The urine pregnancy test which was conducted in our hospital was negative (UCG-Rapid ambotest devise, Croma test Linear Chemicals). The measurement of β-hCG in the serum of the patient was 13 IU/l, a result that was lower than the threshold that could be detected by the specific kit (Instant-View®) pregnancy test that is used in our hospital, with a limit of 40 IU/L β-hCG. At this point, an urgent transvaginal ultrasound was performed, which demonstrated no evidence of intrauterine pregnancy, a large amount of free liquid and blood clots in the pouch of Douglas, a corpus luteum ovarian cyst on the left ovary and a cystic mass suspicious for tubal pregnancy with hyper-echoic decidual reaction on the right adnexa ( Figure 1 and Figure 2 ).

At that point, we suspected the possibility of tubal pregnancy and, due to the patient's hemodynamic instability she was transferred urgently to the operating room where an exploratory Pfannenstiel incision was conducted. On laparotomy, a ruptured right tubal pregnancy, a left corpus luteum cyst, with a normal fallopian tube and a significant hemoperitoneum (of approximately 500-700 ml of blood) were confirmed. A right salpingectomy and peritoneal lavage were performed and the tissue section was sent for histological examination. During and post operation she was transfused with four units of packed red cells in total.

The postoperative course was uneventful and she was discharged after 3 days. The histological examination confirmed a case of right tubal pregnancy.

The diagnosis of ectopic pregnancy is based on the measurement of the beta subgroup of human chorionic gonadotrophin in blood (via immunological methods) as well as on ultrasonography and physical examination findings. This means that during pregnancy, the hormone concentration is increased to high rates, doubling every 48 hours, peaking at 60-90 days after conception and subsequently dropping and stabilizing at the lowest level. This increase is demonstrated in the 71% of pregnant women with normal pregnancies and the 15% of women with ectopic pregnancies 3 , 7 . According to the literature, a negative pregnancy test via urine or low β-hCG in serum of pregnant women is 3.1% and 2.6% respectively in ectopic pregnancies 8 - 10 . In addition, more than 1% of ectopic pregnancies are associated with undetectable levels of β-hCG. One hypothesized mechanism to account for the low β-hCG values is its reduction or cessation of production of the degenerate trophoblastic tissue and another likely explanation is the existence of low-mass chorionic villi which produce this hormone and their increased clearance from the circulation. The first author to report a case of burst ectopic pregnancy together with a negative pregnancy test was Lonky in 1987 11 . Other cases mentioned in the literature are depicted in Table 1 9 , 10 , 12 - 15 . One report showed that 88% of ectopic pregnancies with levels of β-hCG less than 200 IU/L have an automatic resolution, though when levels are more than 2000 IU/L β-hCG this percentage drops to 25% of cases 12 . Quantitative measurement of β-hCG in the serum of the patient in our case was 13 IU/L, a value that was less than the threshold that could be detected by the pregnancy test kit that is used in our hospital, with a limit of 40 IU/L β-hCG. The accuracy of TVS findings in ectopic pregnancies is variable. In 20-25% of cases a live ectopic pregnancy is found, while the bagel sign with a hyper-echoic tubal ring with or without hemorrhage, or presence of intrauterine pseudo-sac along with complex inhomogeneous mass next to the ovary and free fluid in the pouch of Douglas, are the most frequent findings 16 . According to the metanalysis of Brown et al 17 , any non cystic adnexal mass on TVS has a positive predictive value of 96.3%, negative predictive value of 94.8%, specificity of 98.9% and sensitivity of 84.4%. An interesting finding which in our case rendered the diagnosis by ultrasound even more difficult was the site of the ovarian corpus luteum (left ovary), which was on the opposite side of the right tubal ectopic, while in more than 80% of ectopic pregnancies it is situated on the same adnexa 18 .

It is at times a considerable challenge to identify a patient with an ectopic pregnancy at risk of rupture. This case of an ectopic pregnancy which was followed by a negative pregnancy test illustrates the magnitude of the difficulties involved in the diagnosis of ectopic pregnancy while demonstrating the need to maintain a high clinical index of suspicion and to undertake careful clinical examination of the patient on the basis of the clinician';s diagnostic research. The possibility of an ectopic pregnancy should be considered in every woman with hemorrhagic shock, even with a negative pregnancy test.

Conflict of interest

None declared by authors.