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www.AJOG.org General Gynecology Expert Reviews

Ectopic pregnancy not within the (distal) fallopiantube: etiology, diagnosis, and treatment
Donald L. Fylstra, MD
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Ectopic pregnancy, the implantationof a fertilized ovum outside the uter-

ine cavity, has been increasing in numberand now accounts for 2% of all pregnan-cies in the United States.1 Nearly all ec-opic pregnancies (97%) are implantedithin the fallopian tube, and a common

actor for the development of such ec-opics is the presence of a pathologic fal-opian tube. Causes of such pathologynclude genital tract infection caused byonorrhea and chlamydia, tubal surgeryncluding tubal sterilization, previousctopic pregnancy, and in utero expo-ure to diethylstilbestrol.2,3 Other risk

factors for tubal ectopic pregnancy in-clude conception with an intrauterinedevice (IUD) in place and conceptionwhile using a progesterone only contra-ceptive method.4,5

Tubal ectopic pregnancy within thetubal ampulla (Figure 1), 70% of all ec-topics, and fimbriae, 11% of all ectop-ics,6 when treated laparoscopically, areamendable to salpingectomy, linear sal-pingostomy, or fimbrial expression withonly a small risk of residual trophoblastictissue left behind (persistent ectopicpregnancy), and the need for rescuetherapy. With the use of the publishedrecommendations for the medical treat-ment of ectopic pregnancy,7 many such

regnancies can be treated nonsurgi-ally. Any ectopic with a pretreatmentass diameter greater than 3.5 cm, a

uman chorionic gonadotropin levelbove 5000 mIU/mL, and/or an em-

From the Department of Obstetrics andGynecology, Medical University of SouthCarolina, Charleston, SC.

Received July 7, 2011; revised Sept. 29, 2011;accepted Oct. 16, 2011.

The author reports no disclosures or conflictsof interest.

Reprints not available from the author.

0002-9378/$36.00© 2012 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2011.10.857
ryo present is more likely to failedical therapy7 and may be more

successfully treated surgically. Specialconsideration to pregnancies at risk offailure with single-dose methotrexatemay be successfully treated with a mul-tidose methotrexate protocol.7

Ectopic implantation can also occuroutside of the fallopian tube, withinthe cervix, ovary, abdomen, uterinecornua, and cesarean scars. These ex-tratubal implantations may not be as-sociated with tubal pathology or theexpected preexisting risk factors fortubal ectopic implantation, and thereare no prospective studies publishedto guide management.8 Regardless ofocation, however, when diagnosedarly, before symptoms of rupture,any ectopic pregnancies can be suc-

essfully treated conservatively.7

Cervical pregnancyLess than 1%, and the rarest, of ectopicsare implanted within the cervical canalbelow the level of the internal cervicalos.6,9 The cause of such implantations is

nknown but predisposing factors in-lude prior uterine curettage, inducedbortion, Asherman’s syndrome, leio-yomata, presence of an IUD, in vitro

ertilization, and prior in utero exposureo diethylstilbesterol.10-13

Raskin suggested that the diagnosis by

Ectopic pregnancy is a very common diaglocation varies. Although 97% of ectopicsciated with commonly recognized risk facpelvic and abdominal locations that may noextensive review of the literature, along wittion frequency, etiologic possibilities, and tlocation are presented. When ectopic preggardless of location, conservative, fertility-sterminating the pregnancy. Predisposing rican be ectopic-location specific.

Key words: abdominal pregnancy, cesarea

ultrasound examination of cervical preg-

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nancy required 4 criteria: enlargement ofthe cervix, uterine enlargement, diffuseamorphous intrauterine echoes, and ab-sence of an intrauterine pregnancy.14

Timor-Tritsch et al, refined the criteriato include the placenta and entire chori-onic sac containing the pregnancy mustbe below the internal cervical os and thecervical canal must be dilated and barrelshaped.15 If necessary to exclude the di-agnosis of a spontaneous abortion inprogress, the presence of embryonic car-diac activity, and/or Doppler ultrasoundindicating vascular attachment confirma living pregnancy.

Before the now common use of earlypregnancy transvaginal ultrasound, cer-vical pregnancies were frequently diag-nosed at the time of spontaneous abor-tion or reached the second trimester,both associated with life-threateninghemorrhage frequently requiring hys-terectomy as treatment. Usually, thefirst complaint is painless vaginalbleeding and speculum examinationmay reveal an open external cervical oswith a fleshy type endocervical masspresenting. With early transvaginal ul-trasound, these implantations are eas-ily identified (Figure 2) and can, thus,be treated with conservative fertilitysparing options. Although there areneither large published series nor con-

is (2% of pregnancies), and implantationimplanted within the fallopian tube, asso-, ectopic implantation can occur in otherve such predisposing risk factors. After ane author’s personal experience, implanta-tment options for each ectopic pregnancycy is diagnosed early, before rupture, re-ing treatment options can be successful inactors and treatment options can vary and

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Expert Reviews General Gynecology www.AJOG.org

cervical pregnancy, and no standardrecommendations are available, sev-eral conservative treatment optionshave been reported.

Administration of systemic methotrex-ate alone has been successful.16,17 How-ver, pretreatment levels of human chori-nic gonadotrophins greater than 5000IU/mL, and/or the presence of embry-

nic cardiac activity, very commonlyound with cervical pregnancies, are rela-ive contraindications to the use of sys-emic methotrexate for the treatment ofny ectopic pregnancy.7 Methotrexate ad-inistration, followed by curettage has

een proven effective.18 Uterine artery em-bolization alone,19 and uterine artery em-

olization, followed by curettage20 haveterminated cervical pregnancies withoutsignificant hemorrhage, preserving theuterus.

Infiltration of the cervix around thecervical pregnancy with a hemostatic va-soconstricting agent, followed by theplacement of cervical sutures to tempo-rarily occlude the descending cervicalbranches of the uterine arteries, includ-ing cerclage, followed by suction curet-tage and postcurettage cervical canal bal-loon tamponade13,21-25 has proven verysuccessful in treating early first trimestercervical pregnancies. A key point withthis technique is to not attempt cervicaldilation before initiation of the passageof an appropriately sized suction can-

FIGURE 1Left ampullary fallopian tube ectop

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A, Laparoscopic appearance of an unrupturedLinear salpingostomy with enucleation of ectopicFylstra. Ectopics not within the fallopian tube. Am J Obstet G

ula.24 Dilation can disrupt implantation

290 American Journal of Obstetrics & Gynecology

and immediately lead to heavy vaginalbleeding. It is this author’s opinion thatthis is the simplest treatment, with 100%success in his hands, and the preferredtreatment for first trimester cervicalpregnancy. Given the rarity of cervicalimplantation, the success rate for the va-riety of reported treatments cannot bestated.

A heterotopic ectopic cervical preg-nancy has been successfully terminatedwith ultrasound-guided suction curet-tage, leaving the intrauterine pregnancyundisturbed.26

When treating all cervical ectopic preg-nancies, anticipation of significant bleed-ing and a management plan to preventand/or control hemorrhage can avoid hys-terectomy. This may require interven-tional radiology personnel experienced inarteriography and embolization of the pel-vic vessels.

Ovarian pregnancyOne half of 1% to almost 3% of ectopicsare implanted within the ovary.6,27,28

Ovarian pregnancy, like other nontubalectopic pregnancies, may occur withoutthe usual expected antecedent risk fac-tors for ectopic pregnancy. The present-ing signs and symptoms are similar toother ectopic pregnancies: positive preg-nancy test, abdominal pain, and vaginalbleeding.

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ultrasound finding suggesting ovarianimplantation is a walled cystic masswithin or adjacent to an ovary, but thisdoes not exclude a corpus luteum and atubal implantation. Doppler ultrasoundcannot always distinguish between a cor-pus luteum and an ovarian pregnancyimplantation. This diagnosis is usually apathologic diagnosis (Figure 3): made bymicroscopic examination of a surgicallyremoved adnexal mass, based on Spei-gelberg’s criteria: the tube must be intactand distinctly separate from the ovary,the gestational sac must occupy the nor-mal anatomical location of the ovary, thegestational sac must be connected to theuterus by the utero-ovarian ligament,and unquestioned ovarian tissue must bedemonstrated in the wall of the gesta-tional sac.29 Speigelberg’s criteria cannot

e established with ultrasound.28

It is important for the laparoscopicsurgeon to understand that an ovarianpregnancy may look like a hemorrhagiccorpus luteum ovarian cyst on direct in-spection, and only the pathology fromcystectomy, if possible, or oophorec-tomy will reveal the true diagnosis. How-ever, when an adnexal ectopic is diag-nosed with a nonsurgical algorithm,conservative medical therapy can besuccessful without a true diagnosis oflocation.7,30

Abdominal pregnancyLess than 1% of ectopic pregnancies areimplanted within the abdominal cav-ity.6,31 The pathogenesis of abdominalmplantation is controversial. Many arehe result of secondary nidation withinhe peritoneal cavity after tubal abortion,ubal rupture, or uterine rupture.32 Truerimary abdominal implantation mustatisfy the criteria of Studdiford.33 Stud-iford,33 reporting a primary peritoneal

implantation in 1942, established 3 crite-ria for such a primary abdominal preg-nancy: normal fallopian tubes with noevidence of recent or remote trauma, theabsence of any uteroperitoneal fistula,and the presence of a pregnancy relatedexclusively to the peritoneal surface andearly enough to eliminate the possibilityof secondary implantation after a pri-

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The most common abdominal im-plantation site is the posterior cul-de-sac, followed by the mesosalpinx, theomentum, the bowel and its mesentery,and the peritoneum of the pelvic and ab-dominal walls, including the anteriorcul-de-sac31 (Figure 4). Treating pri-mary abdominal pregnancies over a 12-year period, Shaw et al31 found 55% inthe posterior cul-de-sac, 27% in the me-sosalpinx, 9% in the omentum, and 9%between the anterior uterine wall and thebladder. However, pregnancy implanta-tion can occur anywhere in the abdo-men, even elsewhere in the body, includ-ing the retroperitoneal space, the liver,the spleen, the appendix, and even thelung.34-40 The diagnosis of these very un-usually ectopic locations is frequentlymade at the time of surgical interven-tion. The evaluation of otherwise unex-plained masses or hemorrhage shouldinclude measurement of human chori-onic gonadotropin (hCG). Because thereare only individual case reports of suchunusual pregnancy implantations, noincidence forecast nor treatment guid-ance can be offered.

Abdominal pregnancies frequentlyprogress until late diagnosis, defined asgreater than 20 weeks’ gestation, leading toa high maternal mortality rate, 0.5-18%,a rate 8 times greater than that of otherectopic pregnancies.41,42 As pregnancy ad-ances the placental support for the fetussually becomes compromised and the fe-

us can die. Placental separation with mas-ive intraabdominal bleeding is unpredict-ble. Because of the high fetal and maternalortality rates, such pregnancies should

e terminated as soon as the diagnosisn confirmed, regardless of gestationalge.31,43 There are reports of individual-zed management. Given the advances ineonatology and preterm infant survival,eighing the risk of the sudden onset of

ife-threatening maternal hemorrhage vseonatal death must be considered wheniagnosing abdominal pregnancy at or neareonatal survivability. Expectant manage-ent of abdominal pregnancy reaching near

erm has been reported.44,45 Such expec-antly management patients need to be ad-

itted to a hospital where there is 24-hoururgical, anesthesia, and neonatal expertise
nd adequate blood bank services. m
The diagnosis of abdominal preg-ancy can be frequently expected withbdominal imaging, but is commonly

FIGURE 2Cervical ectopic pregnancy

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A, Midline sagittal transvaginal ultrasound appearan(open arrow). B, Three-dimensional transvaginal ulFylstra. Ectopics not within the fallopian tube. Am J Obstet G

ade at the operating table, because of t

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cute abdominal pain and suspected ec-opic pregnancy, with an abdominal im-lantation never suspected preopera-

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be suspected when finding fetal malpre-sentation, oligohydramnios, malforma-tions including compression defects andpulmonary hypoplasia, palpation of fetalparts just below the abdominal wall, andan abnormally high alpha fetoproteinlevel.46-49 The diagnosis has also been

ade at the time of planned cesarean de-ivery for failure of cervical dilation.50

With normal deliveries, myometrialcontractions control blood loss from theplacental implantation site. However,with abdominal implantation the pla-centa is located over tissues that cannotcontract, and partial removal of the pla-centa can lead to significant hemor-rhage.51 In general, unless the placentacan be delivered completely and withoutdifficulty, with identifying its blood sup-ply with adequate ligation, it is preferableto cut the umbilical cord in close prox-imity to the placenta and leave the pla-centa in situ and await spontaneous nat-ural resorption.43,51-54 Leaving placentaltissue in situ frequently leads to a stormypostoperative course with ileus and in-fection.55,56 Postoperative methotrexate

gnancy implanted in the anterior cul-de-sac.ol 2012.

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dministration plus feeding vessel em-olization by interventional radiologyas been used to assist in recovery.53,57

With the universal use of early preg-nancy imaging, the diagnosis can be con-firmed at an early gestational age, butthis requires imaging demonstrating acontinuity of the cervix and uterus with-out pregnancy contents. Failure to fol-low basic ultrasound principles can missthe diagnosis.58 Such early diagnosis canspare maternal mortality at the expenseof fetal mortality, with a perinatal mor-tality rate of 40-95%.52 Removal of earlybdominal pregnancies has be success-ully completed laparoscopically.59-63

Cesarean scar ectopic pregnancyAlthough previously rare, the incidenceof pregnancy implantation within thescar of a prior cesarean is increasing.When this author first reviewed the Eng-lish literature on published cases of ce-sarean scar pregnancies from 1966 until2002, only 19 cases were found.64 Manymore cases have been reported since, in-cluding a series from China including 96cases.65 This increase is presumably dueo increased recognition and the increas-ng number of cesarean deliveries. Theatural history of such a condition is un-nown, but uterine scar rupture andemorrhage, even in the first trimester,eems likely if the pregnancy is allowedo continue, with possible serious mater-al morbidity and the possible need forysterectomy and loss of subsequent fer-ility. Early diagnosis of such implanta-ion is made only with a high level of sus-icion: early ultrasound in a woman withprior cesarean delivery (Figure 5).Endometrial and myometrial disrup-

ion or scarring can predispose to abnor-al pregnancy implantation. Tropho-

last adherence or invasion is enhancedhen the scant decidualization of the

ower uterine segment is impaired fur-her by previous myometrial disruption.mplantation of a pregnancy within theterine scar of a prior cesarean delivery isifferent from an intrauterine pregnancyith placenta accreta. Cesarean scar im-lantation is a gestation completely sur-ounded by myometrium and the fi-rous tissue of the scar and separated

FIGURE 3Ovarian ectopic pregnancy

Microscopic appearance of chorionic villi (arrow)within ovarian tissue.Fylstra. Ectopics not within the fallopian tube. Am J ObstetGynecol 2012.

FIGURE 4Early abdominal ectopic pregnancy

Laparoscopic appearance of an early abdominal preFylstra. Ectopics not within the fallopian tube. Am J Obstet Gynec

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tube. The mechanism that most proba-bly explains scar implantation, like intra-mural implantation, is invasion of themyometrium through a microscopictract. Like intramural pregnancy, such atract is believed to develop from thetrauma of previous uterine surgery, such ascurettage, cesarean delivery, myomec-tomy, metroplasty, hysteroscopy, and evenmanual removal of the placenta.66-68 Thetime interval between such trauma and asubsequent pregnancy may impact onimplantation events. Some of the re-ported cases were diagnosed and treatedwithin a few months of a prior cesareandelivery suggesting that incomplete heal-ing of the uterine scar may contribute toscar implantation.69,70

Early diagnosis with ultrasound can of-fer treatment options capable of avoidinguterine rupture and hemorrhage and,thereby, preserve the uterus. The differen-tial diagnosis between spontaneous abor-tion in progress, cervicoisthmic preg-nancy, and implantation within a cesareanscar can be difficult. Strict ultrasound im-aging criteria must be used to assess the di-agnosis of cesarean scar pregnancy. Ultra-sound should reveal an empty uterinecavity, an empty cervical canal, develop-ment of the gestational sac in the anteriorpart of the uterine isthmus, and an absenceof healthy myometrium between the blad-der and the gestational sac, this last crite-rion allowing differentiation from cervi-coisthmic implantation.71

Because of the rarity of this ectopic im-plantation, there are no universal treat-ment guidelines nor preferred treatmentconcensus for cesarean scar pregnancy.A variety of uterine and fertility-sparingtreatment successes have been reported:laparotomy hysterotomy with resectionand uterine scar dehiscence repair;72-77

laparoscopic resection and uterine scardehiscence repair;78,79 hysteroscopic re-ection alone;80,81 hysteroscopic resec-

tion after treatment with methotrexateor uterine artery embolization;82 curet-tage after uterine artery embolizationand methotrexate;83 systemic metho-rexate as primary treatment;84-85 directnjection of methotrexate or hyperosmolarlucose into the cesarean scar pregnancy;71

uterine artery embolization alone;86 and

terine artery embolization combinedith local methotrexate.86

Slow drug absorption into the cesareanscar pregnancy after systemic methotrex-ate is expected because the pregnancy issurrounded by fibrous scar rather than anormally vascularized myometrium, po-tentially limiting systemic access. There-fore, direct intragestational sac injectionmay be more effective when methotrexatetreatment is chosen.87-90

Evacuationbycurettagealonehasbeenat-tempted, but secondary salvage treatmentshave been necessary.69,73-75,78,82,83,90 Curet-tage alone seems to be contraindicatedbecause the trophoblastic tissue is out-side the uterine cavity unreachable bythe curette, and curettage can poten-tially rupture the uterine scar implan-tation and disrupt the myometriumleading to severe hemorrhage.

Surgical resection seems to offers theopportunity to remove the pregnancyand simultaneously repair the defect.Such treatment has resulted in successful

FIGURE 5Cesarean scar ectopic pregnancy

Midline sagittal transvaginal ultrasound appeara(arrow).Fylstra. Ectopics not within the fallopian tube. Am J Obstet G

subsequent pregnancies.77,80,91 Primary

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urgical treatment by laparotomy or lap-roscopy, with repair, as soon as the di-gnosis is confirmed may be the pre-erred treatment option.

One expectantly managed woman withcesarean scar pregnancy had severe ab-ominal pain develop at 35 weeks’ gesta-ion necessitating an urgent laparotomynd delivery. Although a healthy infantas delivered, a hysterectomy was re-uired with massive blood loss, a coagu-

opathy, and a 16-unit blood transfusion.nasmuch as maternal well being is the firstriority, despite the delivery of a healthyewborn infant, the authors of this reportuestioned the prudence of allowing suchpregnancy to continue.92

Although cesarean scar pregnancy is anuncommon occurrence, only with a highindex of suspicion and the use of endovagi-nal sonography can the diagnosis be madeearly enough to prevent rupture leading tosignificant maternal morbidity and loss offuture fertility. Clinical history and endo-vaginal ultrasound can aid in differentiating

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FIGURE 6Right interstitial ectopic pregnancy

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Fylstra. Ectopics not within the fallopian tube. Am J Obstet G

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tional pathology. A sagittal ultrasound viewalong the long axis of the uterus, through thegestational sac, can localize precisely a cesar-

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Interstitial ectopic pregnancyTwo to 3% of ectopics are implantedwithin the interstitial portion of the fal-lopian tube, that portion of the tube thattransitions from the endometrial cavityto the isthmus through a wall of myome-trium.6 This ectopic location is includedin this discussion because its diagnosisand treatment can differ from other fal-lopian tube implantations. The intersti-tial, or cornual, portion of the fallopiantube is tortuous, 0.7 mm in diameter and1-2 cm in length.93 This is a relativelyhick segment of fallopian tube with areater capacity to expand before rup-ure than more distal portions of the fal-opian tube.94 Because implantation

within this portion of the fallopian is still“within the tube,” it is associated with thesame commonly recognized risk factorsfor tubal ectopic pregnancy. No single fac-tor clearly differentiates women with aninterstitial pregnancy from those with isth-mic or ampullary ectopic pregnancies.95

Transvaginal ultrasound is the pri-mary method for diagnosing interstitialimplantation (Figure 6). However, manyearly ultrasounds show that these preg-nancies are surrounded by myometriumand can be mistaken for normally im-planted pregnancies. Ultrasound find-ings that are highly suggestive of intersti-tial implantation are the identification ofan echogenic line between the gesta-tional sac and the endometrial cavity,“the interstitial line sign,” and an emptyuterine cavity with a gestational sac ec-centrically located outside the endome-trial cavity with a thin mantle of sur-rounding myometrium less than 5 mmin thickness.96 Collectively, these ultra-ound findings are 88-93% specific, butith a sensitivity of only 40%.97,98 Cor-

onal images generated by 3-dimensional(3D) sonography are helpful in identify-ing these features97 (Figure 6, B).

Magnetic resonance imaging (MRI)ay be helpful if ultrasound imaging is

nconclusive. MRI criteria for diagno-is are identical to those of transvaginalltrasound: eccentricity of the gesta-

ional sac, presence of myometrial tis-ue that surrounds the entire gesta-ional sac with a thickness of less than 5

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Interstitial ectopic pregnancies are fre-quently mislabeled as “cornual ectop-ics.” Cornual pregnancy refers to a preg-nancy within the horn of a bicornuateuterus, communicating or noncommu-nicating, and the clinical outcome of thisimplantation varies greatly and dependson the size and expansile capacity of theaffected horn.96

Angular pregnancies are implanted inone of the lateral angles of the uterinecavity, medial to the uterotubal junction,and lead to asymmetric enlargement ofthe uterus.100 What distinguishes an in-terstitial ectopic pregnancy from an an-gular pregnancy is that the laparoscopicappearance of the bulge of an interstitialpregnancy is lateral to the round ligament,whereas the bulge of an angular pregnancyismedial to theroundligament,displacingthe round ligament laterally. Over onethird of angular pregnancies end in earlyabortion, but for those that continue pel-vic pain, persistent vaginal bleeding, pla-cental retention during the third stage oflabor, and rarely uterine rupture can beexpected complications.100

Although interstitial ectopic pregnan-cies can rupture later in gestation, in theearly second trimester, many ruptureless than 12 weeks and many as early as 7to 9 weeks gestation.93,101-103 Interstitialectopics are associated with a higher rateof hemoperitoneum, hypovolemia, andcatastrophic hemorrhage and a 2-2.5%maternal mortality rate.104

Diagnosis after rupture most com-monly requires laparotomy and fre-quently hysterectomy. However, with ahigh index of suspicion, such ectopicscan be diagnosed early and successfullytreated conservatively. Minimally inva-sive laparoscopic surgery has revolution-ized the treatment options.

Transcervical hysteroscopic suctionevacuation with laparoscopic or ultra-sonographic guidance as been reportedwith success.105,106 Laparoscopic corn-uotomy with salpingostomy and laparo-scopic cornual excision or cornualwedge resection for small ectopics canalso be successful but with the requiredlaparoscopic skills to do so.107-115 Suc-
cess with selective uterine artery emboli-
zation has been reported but requiredthe expertise of experienced interven-tional radiology.116-119

Systemic methotrexate administra-tion success following the guidelines es-tablished for the medical management ofectopic pregnancy can yield up to 94%success rate without surgery.7,120 Local

ethotrexate injection appears to be asffective as systemic administration butequires the expertise of ultrasounduided needle placement.121

Long-term, the greatest risk for sub-sequent pregnancies is uterine rupture,this depending on the nature of the in-terstitial ectopic treatment and the de-gree of myometrial disruption. Carefulantepartum surveillance with a plannednear term cesarean delivery seemsprudent.

Isthmic tubal ectopic pregnancyUp to 12% percent of ectopics are im-planted within the isthmic, or proximalportion of the fallopian tube (Figure 7).6

Because an implantation within this por-

FIGURE 7Left isthmic fallopian tube ectopic

Laparoscopic appearance of an unruptured ectofallopian tube.Fylstra. Ectopics not within the fallopian tube. Am J Obstet G

tion of the fallopian is still “within the

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tube,” it is associated with the same com-monly recognized risk factors for tubalectopic pregnancy. No single factorclearly differentiates women with anisthmic pregnancy from those with in-terstitial or ampullary ectopic pregnan-cies. Implantation in this portion of thefallopian tube is included in this discus-sion, because the surgical managementof isthmic implantations differs fromdistal fallopian tube implantations. Theisthmic portion of the tube is narrowwith a compact, well-defined muscularislayer.122 Ectopics implanted within this

ortion of the fallopian tube quickly in-ade the muscularis layer and usuallyupture early.122 Although linear salpin-

gostomy has been reported to be success-ful, because of this muscularis invasionsuch ectopics treated with surgical sal-pingostomy are at higher risk of leavingchorionic villi behind, and, therefore, apersistent ectopic pregnancy, requiringadditional rescue therapy. Optimal sur-gical success requires resection of that

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without immediate tubal reanastomo-sis.123 When diagnosed early and unrup-ured, medical therapy can be successful,lthough consideration should be giveno gestational age, hCG levels, and theresence of cardiac activity.7

Ectopic after hysterectomyOnly 56 cases of ectopic pregnancy afterhysterectomy have been reported in theworld’s literature, and this is rarely sus-pected before surgical intervention (Fig-ure 8).124 Over half of such pregnancies

ave been “early presentations,” this oc-urring because an unrecognized, pre-linical pregnancy existed at the time ofysterectomy: a preimplanted fertilizedvum was in transit and confined to theallopian tube, or sperm was presentithin the fallopian when the hysterec-

omy was performed during a periovula-ory period, allowing postoperative fer-ilization and tubal implantation. Anmmediate prehysterectomy pregnancyest would not be expected to be positivender such circumstances.“Late presentation” ectopics have oc-

urred after all types of hysterectomy,nd as remote as 12 years after the hys-erectomy. These posthysterectomy ec-opic pregnancies occur with retentionf one or both ovaries with the presencef a vaginal-tubal or vaginal-peritoneal

FIGURE 8Posthysterectomy ovarianectopic pregnancy

Laparoscopic appearance of an ovarian preg-nancy (arrow) after prior subtotal cesarean hys-terectomy. Posthysterectomy vaginal cuff (openarrow).Fylstra. Ectopics not within the fallopian tube. Am J ObstetGynecol 2012.

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ccess to ovulated ova. Although this hasccurred after all types of hysterectomy,2% follow vaginal hysterectomy.124 Al-hough the operative narrative for the hys-erectomy was seldom available to the phy-icians treating these women with ectopicregnancy, observations thought to in-rease the chance for vaginal-to-peritonealstula formation include an open vaginaluff closure technique, vaginal cuff infec-ion or hematoma formation, vaginal cuffranulation tissue, and a prolapsed fallo-ian tube.125-132

With this disproportionate number ofectopic pregnancies after vaginal hyster-ectomy, a causal relationship is sug-gested.126 The usual method of vaginalcuff closure differs between vaginal hys-terectomy and abdominal hysterectomy.The adnexal structures can be broughtinto closer proximity of the vaginal cuffwith vaginal hysterectomy cuff closure,and can even be incorporated into theperitoneal closure, increasing the chancefor a prolapsed fallopian tube into thevaginal cuff or the development of a vag-inal-to-peritoneal or vaginal-to-tubalfistula.124,125 Ectopic pregnancies afterotal abdominal hysterectomy have beeneported, indicating that vaginal-to-eritoneal fistula can even develop afterhis procedure. However, the smallumber of such cases would suggest that

t is less likely to occur, presumably be-ause the residual fallopian tubes andvaries are more distant from the vaginaluff during abdominal hysterectomyuff closure, and the commonly usedechnique of closure of the pelvic floorarietal peritoneum over the vaginal cuff

solates the vagina from the peritonealavity.124

Subtotal hysterectomy has increasedin the United States in the past decade,estimated to now make up 7.5% of allhysterectomies performed.133 Ectopicpregnancy after supracervical hysterec-tomy has been reported127,130,134 raisingthe concern that sperm can access theperitoneal cavity through a patent cervi-cal canal. Pathologic identification ofsuch a communication through a resid-ual cervix has been documented. Cau-tery of the cervical canal and cervicalstump to prevent cyclic vaginal bleeding
after laparoscopic supracervical hyster- t
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ectomy, now a more commonly per-formed operation, has also failed to pre-vent a patent cervical canal and anectopic pregnancy after hysterectomy.131

With the current popularity of laparo-scopic supracervical hysterectomy, manyinvestigators, including this author, areconcerned about a potential increase in theincidence of ectopic pregnancy afterhysterectomy.127,130,134

Two cases of “late presentation” ecto-pic pregnancy have followed supracervi-cal cesarean hysterectomy.127,133 Leaving

remnant of cervix or the epithializationf a much larger vaginal cuff closure areaecause of cervical dilation at the time ofesarean hysterectomy may increase fis-ulous tract formation.

Because the symptoms of ectopic preg-ancy can be mimicked by common im-ediate complications after hysterectomy,

uch as protracted abdominal pain, pelvicematoma formation, vaginal cuff infec-ion, and vaginal bleeding, ectopic preg-ancy is rarely expected in most posthyster-ctomy cases until additional imaging orepeat operation confirms the diagnosis.

The prevention of “early presentation”ctopic pregnancy after hysterectomy ishe prevention of pregnancy before hyster-ctomy. Hysterectomy, like tubal steriliza-ion, if possible, should be avoided in theuteal phase of the menstrual cycle in thoseomen not previously sterilized or not us-

ng reliable contraception, unless no vagi-al intercourse has occurred during thereoperative period. Women should bereoperatively counseled as such. Anyoman who has undergone hysterectomy

nd had not previously undergone tubalterilization or had a partner vasectomy, oras not using reliable contemporaneous

ontraception, should be considered atisk for this diagnosis should otherwise un-xplained postoperative pain or bleedingccur.It may not be possible to prevent all

late presentation” ectopic pregnanciesfter hysterectomy, but its prevention ishe prevention of vaginal-to-peritonealavity communication. Vaginal cuff clo-ure, regardless of operative technique,hould be sure not to incorporate the fal-opian tube into the vaginal cuff, andostoperative vaginal cuff granulation
issue, a very common finding, must be


differentiated from a portion of pro-lapsed fallopian tube, with biopsy, if nec-essary. When the cervix is left in situ,techniques should be used to obliterateor isolate the residual cervical canal, thuspreventing a patent cervical canal allow-ing sperm access to the peritoneal cavity.

The incidence of ectopic pregnancy afterhysterectomy is infinitesimal, despite anestimated 600,000 hysterectomies eachyear in the United States, and that one-third of all US women have had a hysterec-tomy by age 60 years.135 However, it wouldbe prudent for any woman, even afterhysterectomy with ovaries in situ, whopresents with an acute abdomen or ab-dominal-pelvic pain to be screened forpregnancy, and only with a high index ofsuspicion will the diagnosis be made.

SummaryEctopic pregnancy occurs in 1 of every 50pregnancies. Early transvaginal ultrasoundcan locate most, if not all early pregnancies.The late diagnosis of an ectopic pregnancyincreases the risk for loss of fertility and ofmaternal mortality. Many nontubal ecto-pic locations are diagnosed in the operat-ing room or are never known because of asuccessful response to medical manage-ment for a pregnancy of unknown loca-tion. Although medical management withmethotrexate has been successfully used,nontubal ectopic pregnancies frequentlymay require surgical intervention. f

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