Abstract
Introduction The majority of ectopic pregnancies (close to 90 percent) implant within the ampullary portion of the fallopian tube. However, implantation in other locations occurs in approximately 10 percent of all ectopic pregnancies. Nontubal ectopic pregnancies include those that implant within the abdominal cavity, cervix, ovary, interstitial portion of the fallopian tube, broad ligament, uterine cornua and within a prior cesarean section scar (1). Such ectopics are associated with increased maternal morbidity and mortality given their tendency for later presentation as compared to tubal ectopic pregnancies (2). Recent advances in both ultrasound technology and delineation of clear criteria for diagnosing nontubal ectopic pregnancies have enabled earlier diagnosis of these rare types of ectopic pregnancies. This has contributed to the introduction of novel treatment options including local injection to complement or replace traditional medical or surgical management in select patients. Traditional treatment options for tubal ectopic pregnancies have included medical management with methotrexate, surgical management in hemodynamically unstable patients, and expectant management in select candidates (1,3). In contrast, local injection of nontubal ectopics as well as heterotopic pregnancies is a viable option for many patients and offers several advantages over administration of systemic methotrexate or surgical management. Specifically, local injection allows for a concentrated delivery of methotrexate or potassium chloride (KCl) directly at the site of the ectopic pregnancy, potentially resulting in prolonged therapeutic levels and possibly fewer side effects when compared to systemic therapy (4). Furthermore, for pregnancies with fetal cardiac activity, local injection offers immediate feedback regarding the success of the intervention with the cessation of cardiac activity. This is in contrast to systemic injection where an ectopic pregnancy with known cardiac activity is observed in an outpatient setting while waiting to assess treatment efficacy. With respect to heterotopic pregnancies, systemic therapy with methotrexate is contraindicated, and local injection with KCl enables successful treatment while trying to preserve the intrauterine pregnancy. Finally, current evidence supports the option of a combination of local therapy with systemic methotrexate to optimize success with nonsurgical management of nontubal ectopic pregnancies. This chapter will provide a general overview of nontubal ectopic pregnancies, patient selection criteria for local treatment, available agents for local injection, and overall treatment outcomes.
Highlights
Introductory Chapter: An Overview of the Diagnosis and Treatment of Non-tubal Ectopic Pregnancy Julio Elito Jr
In a study by Jurkovic et al of 232 women with Cesarean scar pregnancy (CSP), suction curettage was an effective method for the treatment of 191 pregnancies implanted into the lower uterine segment cesarean section scar because of the 116 women who had a follow up visit, only 7 (6.0%), 95% CI 1.7–10.3% required a repeat surgical procedure for retained products of conception
In case of spontaneous miscarriage in progress, an avascular gestational sac is seen in the cervical canal indicating that it has been detached from its implantation site, in contrast to the well-perfused Caesarean scar ectopic pregnancy (CSEP) located in the anterior lower uterine wall [5, 13]
Summary
Non-tubal ectopic pregnancies represent 7–10% of all ectopic pregnancies [1]. The incidence is increasing in the past years especially because of assisted reproduction treatment, IVF, and the high rates of cesarean sections [2]. Non-tubal locations of ectopic pregnancies are cervix, cesarean section scar, interstitial portion of the fallopian tube, cornual, ovary, abdominal cavity, and broad ligament (Figure 1). The management of non-tubal ectopic pregnancy depends on their location. The cases of abdominal pregnancy must be individualized and the treatment is different from the other sites of ectopic pregnancy. This book aims to provide the reader with a concise, comprehensive, and updated review of the epidemiology, diagnosis, and treatment of non-tubal ectopic pregnancy. As there is a lack of consensus on the guideline for the treatment of non-tubal ectopic pregnancy, this book intends to fill this gap in the literature, compiling the best evidences in the medical literature guiding the reader on choosing the adequate treatment. An overview of each non-tubal ectopic pregnancy site will be presented in this introductory chapter
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