Unusual ectopic pregnancies

Unusual ectopic pregnancies: A retrospective analysis of65 cases

Nan Shan1, Dan Dong1, Weiguo Deng2 and Yan Fu1

1Department of Obstetrics and Gynecology, First Hospital of Jilin University, and 2Department of Nutrition and FoodHygiene, School of Public Health, Jilin University, Changchun, China

Abstract

Aim: The aim of this study was to retrospectively investigate unusual ectopic pregnancies (EP) and comparethem with fallopian ones.Material and Methods: A total of 1000 cases of ectopic pregnancies were analyzed, including 65 unusual cases.We discussed distribution, incidence, risk factors, examinations, treatments and prognoses.Results: Ovarian pregnancy was associated with placement of intrauterine device and pelvic inflammatorydiseases. Extratubal EP have a high rate of misdiagnosis and presented more serious manifestations. Someunusual EP could be diagnosed by ultrasonography. Ovarian pregnancy was usually manifested as positiveculdocentesis. Most of the unusual EP underwent surgery, except some early cervical and corneal pregnancies.Conclusion: Although extratubal pregnancies are difficult to diagnose, some histories and auxiliary examina-tions could make diagnosis easier for clinical physicians. Surgery is still the most effective approach fortreatment of unusual EP, while conservative treatment of mifepristone combined with methotrexate or curet-tage could be used for early diagnosis and treatment of cervical pregnancy.Key words: cervical pregnancy, cornual pregnancy, methotrexate conservative treatment, ovarian pregnancy,unusual ectopic pregnancies.

Introduction

Nearly 95% of ectopic pregnancies (EP) are implantedin the various segments of the fallopian tubes. Theremaining 5% implant in the ovary, peritoneal cavity, orwithin the cervix.1 When the blastocyst implants ordevelops in pelvic areas other than the tubes, the preg-nancy is considered an unusual EP. Compared withtubal ones, extratubal EP are atypical in history orsymptoms, appear belatedly and might be more dan-gerous. Early diagnosis of extratubal EP is extremelydifficult. We analyzed a 10-year series of consecutivecases in order to evaluate unusual EP retrospectively as

a whole, and thus to make a forward investigation forfuture therapy.

Methods

From January 2000 to January 2010, 1000 cases of EP(935 tubal pregnancies, 65 extratubal pregnancies)were diagnosed and treated in our center. Diagnosiswas essentially clinical and based on history, clinicalsigns and symptoms, physical examination, humanchorionic gonadotrophin (hCG) assessment eitherin urine or in serum, and transvaginal ultrasound. Insome cases, a diagnostic curettage was performed to

Received: November 7 2012.Accepted: April 4 2013.Reprint request to: Dr Yan Fu, Department of Obstetrics and Gynecology, First Hospital of Jilin University, Changchun 130021, China.Email: [email protected]

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doi:10.1111/jog.12146 J. Obstet. Gynaecol. Res. Vol. 40, No. 1: 147–154, January 2014

© 2013 The Authors 147Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology

mailto:[email protected]

remove intrauterine trophoblastic tissues. The majortreatments included surgeries and conservative thera-pies, such as mifepristone combined with methotrexate(MTX) or curettage.

c2-test was used to examine the correlation betweencategorical factors, including the distribution, inci-dence, risk factors, examinations, treatments and prog-noses. Statistical analysis was performed on spss 13.5.P < 0.05 was considered statistically significant.

ResultsIncidence

The sites of implantation are listed in Table 1. Meanmaternal age upon diagnosis was 30.9 years (20–47),and in 31 cases (47.7%), it was less than 30 years.

Risk factors

Of the 1000 EP, 44.6% of women were primigravid,and others reported previous pregnancies, of which17.6% had a history of cesarean sections. Based on theirhistories, most patients had fertility-reducing riskfactors, such as usage of intrauterine devices (IUD,

16.3%), pelvic inflammatory diseases (19.6%), curettage(56.8%) and previous ectopic pregnancy (5.4%). Onlyone patient underwent in vitro fertilization (IVF).

As shown in Table 2, patients with a history of pelvicinflammatory diseases showed particularly significantdifferences among ovarian (c2 = 13.5, P < 0.01), cornual(c2 = 10.2, P < 0.01) and tubal pregnancies. Placementof IUD was significantly associated with ovarian preg-nancy (c2 = 25.2, P < 0.01) in comparison with otherunusual EP.

Comparison of misdiagnosis rates

In our investigation, the 10-year rate of tubal preg-nancy misdiagnosis was 1.4%, which was much lowerthan that of extratubal ones (c2 = 440.7, P < 0.01).Among extratubal EP, cornual (c2 = 20.5, P < 0.01) andcervical (c2 = 4.0, P < 0.05) pregnancies had lowerrates of misdiagnosis due to the help of ultrasoundexamination.

Comparison of clinical manifestations

As shown in Tables 3 and 4, EP patients showedclinical manifestations, such as a definitely delayed

Table 1 Sites of implantation in EP

Site Case Age Parity(above 2) (%)

Ratio(%)

Ratio (%)of unusual EP

Tube 935 32.4 � 4.9 515 (51.5%) 93.5 —Ovarian 29 29.1 � 5.9 16 (55.2%) 2.90 44.6Cornual 21 32.4 � 5.4 13 (61.9%) 2.10 32.3Cervical 8 32 � 7.5 6 (75%) 0.80 12.3Rudimentary horn 1 20 0 0.10 4.6Abdominal 3 29.6 � 4.9 1 (33.3%) 0.30 3.1Tubal stump 2 26 � 5 1 (50%) 0.20 1.5Cesarean scar 1 30 1 (100%) 0.10 1.5Total 1000 32.3 � 6.8 553 100 100

EP, ectopic pregnancy.

Table 2 Risk factors

Site (n) Pelvicinflammatorydiseases (%)

Cesareansection

IUD Pregnancy(above 2)(%)

Curettage(%)

Ectopicpregnancy(%)

Ovarian (29) 13 (44.8%)** 2 8 (27.5%) 16 (55.2%) 16 (55.2%) 1 (3.4%)Cornual (21) 10 (47.6%)** 3 1 (4.7%) 13 (61.9%) 12 (57.1%) 0Cervical (8) 4 (50%) 1 1 6 (75%) 5 (62.5%) 0Abdominal (3) 1 (33.3%) 1 0 1 (33.3%) 1 (33.3%) 0Tubal stump (2) 1 (50%) 0 0 1 (50%) 1 (50%) 1Cesarean scar (1) 0 1 0 1 (100%) 1 (100%) 0Tube (935) 167 (17.9%**) 167 153 (16.4%) 515 (55.1%) 532 (56.9%) 53 (5.7%)

*P < 0.05; **P < 0.01. IUD, intrauterine device.

N. Shan et al.

148 © 2013 The AuthorsJournal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology

menstruation over a month (85.5%), abdominal pain(62.8%), vaginal bleeding (83.3%), cervical motion pain(51.7%), abdominal bleeding (39.4%) and shock (13%).Unusual EP showed more severe abdominal bleeding(P < 0.05), abdominal muscle tension (P < 0.01), sec-ondary anemia (P < 0.01) or shock (P < 0.01) than tubalpregnancies.

According to the implantation sites, EP showed spe-cific signs and symptoms: patients with ovarian preg-nancy were observed with more abdominal bleedingthan cornual (c2 = 10.7, P < 0.01) or cervical (c2 = 13.6,P < 0.01) pregnancies. Ovarian EP also presentedmore serious secondary anemia (c2 = 9.5, P < 0.01) andobvious cervical motion pain compared with cornealones. Abdominal pain was significantly differentbetween cervical and tubal pregnancies (c2 = 8.0,P < 0.01).

Auxiliary examinations

In our study, women were observed with positive hCGboth in urine (94.5%) and serum (91.4%). Some patientswere admitted to hospital as an emergency so theyprovided urine hCG instead of serum hCG as a diag-nostic method of pregnancy before treatment. About

46.9% of the patients showed positive culdocen-tesis, and 94.1% of the patients were diagnosed byultrasonography.

Culdocentesis was more meaningful for ovarianpregnancy than for corneal pregnancy (c2 = 14.7,P < 0.01). Ultrasound examinations were significantlymeaningful for tubal (c2 = 526.9, P < 0.01), cervical(c2 = 10.5, P < 0.01) and cornual (c2 = 30.0, P < 0.01)pregnancies (Table 5).

Treatments

As shown in Table 6, most women with unusual EPunderwent surgery, except those with cervical andcorneal pregnancies, which were treated with conser-vative approaches, including methotrexate therapy andcurettage. During operations, we found 82.8% (24/29)of ovarian pregnancies had active hemorrhage, whichcould prove its hazard.

DiscussionIncidence and related factors

The incidence of unusual EP ranges from 4.9% to10.1%,2 and in our study, it was 6.5% and consistent

Table 3 Clinical manifestation (1)

Site (n) Amenorrhea(n)

Period (day) Vaginal bleeding(n) (%)

Abdominalpain (n) (%)

Shock (n)

Ovarian (29) 28 42.6 � 9.8 21 (72.4%) 29 (100%) 9 (32.1%)Cornual (21) 19 66.2 � 15 13 (68.4%) 18 (94.7%) 7 (36.8%)Rudimentary horn (1) 1 65 0 1 (100%) 0Abdominal (3) 3 50 � 18.7 2 (66.7%) 3 (100%) 0Tubal stump (2) 2 55.7 � 13.8 1 (50%) 2 (100%) 1Cesarean scar (1) 1 54 1 (100%) 1 (100%) 0Cervical (8) 7 83.9 � 28.1 7 (87.5%) 1 (12.5%) 1Tubal (935) 794 50.9 � 11.9 788 (84.2%) 573 (61.3%**) 112 (1.2%)

*P < 0.05; **P < 0.01.

Table 4 Clinical manifestation (2)

Site (n) Abdominalbleeding (n)(%)

Analinflation(n)

Abdominalmuscletension (n)

Cervicalmotion pain(n) (%)

Secondaryanemia (n)(%)

Ovarian (29) 23 (79.3%)** 11 6 18 (62.1%)** 21 (72.4%)*Cornual (21) 7 (33.3%) 3 2 2 (9.5%) 8 (38%)Rudimentary horn (1) 0 0 0 0 0Abdominal (3) 3 (100%) 1 2 1 (33.3%) 3 (100%)Tubal stump (2) 1 (50%) 2 0 0 2 (100%)Cesarean scar (1) 1 (100%) 1 0 1 (100%) 1 (100%)Cervical (8) 0** 0 0 0 7 (87.5%)Tubal (935) 359 (3.8%**) 203 (21.7%) 540 (57.8%**) 495 (52.9%) 357 (38.2%)

*P < 0.05; **P < 0.01.

Unussual ectopic pregnancies


with the reports. Although this incidence is low, thedanger and mobility from an extratubal pregnancy ishigher than normal pregnancy. Moreover, the successrate for a subsequent pregnancy will be reduced afterEP.

In our series, the most common site of implantationin EP is the tube, followed by the ovary, corn, cervixand abdomen. The rarest site is the cesarean scar.

Ovarian pregnancy is very rare, accounting for 0.3%–3.0% of EP,3 and its incidence in our investigation was3.1%. Ovarian pregnancy is generally believed to beassociated with pelvic inflammatory diseases and pre-vious surgery in the pelvic cavity. We found 44.8% ofthe cases (13/29) had a history of pelvic inflammatorydiseases, and 55.2% (16/29) had a history of delivery orcurettage. Patients with a history of pelvic inflamma-tory diseases showed a significant difference in ovarianthan corneal and tubal pregnancies. Furthermore, evenwithout inflammatory history, pelvic surgeries mayalso cause ovarian inflammation and thicken the albug-inea, which could lead to a relative lack of follicularfluid pressure. Finally, it would generate ovulation dis-order. Ovum might be detained in the broken folliclesand fertilized just in the ovary.

Reportedly, the use of IUD seems to be dispropor-tionately associated with ovarian pregnancy.4,5 In ourseries, 10 out of 29 patients had a history of IUD place-ment (27.6%), which indicated statistical relevancebetween IUD and ovarian pregnancy, and suggestedthat IUD placement may change some manners in thepathophysiological environment of the ovary. IUD washypothesized to successfully prevent all pregnancies,except ovarian ones.6 Therefore, the history of IUDplacement is useful if a patient is suspected of ovarianpregnancy. However, it was reported that the incidencerate of PID among IUD users as reported from different

studies depends heavily on the definition used and themeans available for diagnosing PID. It varies from 1 per100 to 1 per 1000 woman-years – a tenfold difference –in different studies. PID risk has been found to besixfold higher in the first month after IUD insertionthan it is thereafter. Beyond the first month or so afterinsertion, the incidence of PID is low among womenusing IUD and at a level that appears similar to that forwomen in general.7

The incidence of cervical pregnancy is less than 1%of all EP,8,9 varying from 1/10003 to 1/18 000.4 the causemay be associated with the following factors: (i) cesar-ean section and usage of IUD might interfere with theimplantation of blastocyst; (ii) repeated endometrialcurettages might damage the endometrium or form ascar, and thus retard the pass and implantation of blas-tocyst at cervix (in our series, 75% of the cases [6/8]reported a history of induced abortion or cesareansection and placement of IUD, which suggested thatintrauterine surgeries could be an important cause forcervical pregnancy); and (iii) with the development ofreproductive technology, embryo transfer as in vitrofertilization is also a substantial cause.

Misdiagnosis rate

The misdiagnosis rate of extratubal pregnancies isquite high (96.6%). Ovarian and tubal pregnancies aredifficult to distinguish, even by ultrasound, becausetheir clinical manifestations are similar. In our investi-gation, only one case of ovarian pregnancy was diag-nosed by ultrasound. Reportedly, all 24 cases of ovarianpregnancies in six hospitals were preoperatively mis-diagnosed.10 However, positive culdocentesis resultswere more common in patients with ovarian pregnan-cies than with cornual pregnancies, probably because a

Table 5 Auxiliary examination

Site (n) SerumhCG (n)

UrinehCG (n)

Culdocentesispositive(n)

UltrasoundDiagnosis(n)

fetal heartmovement

PersistenthCGsecretion

Cases ofmisdiagnosis

Ovarian (29) 17 (58.6%) 25 (86.2%) 20** (69%) 1 (3.4%) 1 (3.45%) 6 (20.7%) 28 (96.6%**)Cornual (21) 13 (61.9%) 13 (61.9%) 3 (14.3%) 12 (57.1%) 0 0 5 (23.8%**)Cervical (8) 6 (75%) 5 (62.5%) 0 5 (62.5%) 0 0 2 (25%*)Rudimentary horn (1) 1 (100%) 1 (100%) 0 1 (100%) 0 1 (100%) 0Abdominal (3) 2 (66.7%) 2 (66.7%) 0 0 2 (66.7%) 0 3 (100%)Tubal stump (2) 0 2 (100%) 1 (50%) 0 0 0 2 (100%)Cesarean scar (1) 1 (100%) 1 (100%) 0 0 0 0 1 (100%)Tubal (935) 874 (93.5%) 896 (95.8%) 445 (47.6%) 922 (98.6%) 38 (4.06%) 0 13 (1.4%**)Total 914 (91.4%) 945 (94.5%) 46.9 (46.9%) 941 (94.1%) 41 (4.1%) 7 (0.7%) 54 (5.4%)

*P < 0.05; **P < 0.01. hCG, human chorionic gonadotrophin.

N. Shan et al.


patient upon admission already had her ovaryruptured and suffered from severe abdominalhemorrhage.

Cornual pregnancy was often misdiagnosed as anintrauterine pregnancy because its implantation site isso close to the uterine cavity and lesions are difficult toscrape during curettage. With the improvement ofultrasound technology, cornual and cervical pregnan-cies can be more accurately diagnosed. In our investi-gation, 57.1% (12/21) of cornual pregnancies and 75%(6/8) of cervical pregnancies were diagnosed by ultra-sound, and their misdiagnosis rates (23.8% and 25%,respectively) were obviously lower than that of otherextratubal pregnancies. Ultrasound is considered asthe most important examination method as it candetect an extrauterine pregnancy with a sensitivity of89% and a specificity of 99.8%.11 Therefore, ultrasoundexamination should be encouraged during early gesta-tion in order to screen for ectopic pregnancy in a timelymanner. Ultrasound examination before abortion andvillus check after curettage are highly recommended.Uterine contents should be included in pathologicalexamination. Serum b-hCG and ultrasound should beclosely monitored without villus.

Pregnancy on a cesarean scar can be easily misdiag-nosed as inevitable abortion or cervical pregnancy dueto the low implantation site of the blastocyst. It showssimilar early manifestations as intrauterine pregnancy,threatened abortion, trophoblastic tumor or cervicalpregnancy. It could cause vaginal bleeding duringcurettage if misdiagnosed as intrauterine pregnancy.The diagnosis of pregnancy on cesarean scar is depen-dent on ultrasound, especially the uterine longitudinalsonogram. Ultrasound could reveal the correlationbetween cesarean scar and blastocyst clearly andthereby provide an objective and reliable diagnosis.

Auxiliary examination was helpless in abdominalpregnancy, and our cases were all confirmed bysurgery.

Clinical manifestations

More obvious cervical motion pain was observedbesides abdominal pain, vaginal bleeding and amenor-rhea in ovarian pregnancy. Ovarian tissues lackmuscles but are rich in vessels. When an ovary is rup-tured, severe abdominal hemorrhage, secondaryanemia (21/29, 72.4%) or even shock (9/29, 31.0%) mayoccur.

In cervical pregnancy, the endocervix is eroded bytrophoblast, and the pregnancy proceeds to develop inthe fibrous cervical wall. The higher the trophoblast is

Tab

le6

Trea

tmen

ts

Site

Con

serv

ativ

etr

eatm

ent

No

trea

tmen

tL

apar

otom

yA

dne

xect

omy

Subt

otal

rese

ctio

nof

uter

us

Hys

tere

ctom

yC

uret

tage

Lap

aros

copi

cre

sect

ion

Tube

(935

)11

3(1

2.1%

)30

(3.2

%)

531

(56.

8%)

5(0

.5%

)0

00

261

(27.

9%)

Ova

rian

(29)

00

20(6

9%)

1(3

.4%

)0

00

9(3

1%)

Cor

nual

(21)

5(2

3.8%

)1

(4.8

%)

7(3

3.3%

)1

(4.8

%)

5(2

3.8%

)1

(4.8

%)

5(2

3.8%

)0

Cer

vica

l(8

)6

(75%

)0

00

1(1

2.5%

)3

(37.

5%)

2(2

5%)

0A

bdom

inal

(3)

00

3(1

00%

)1

(33.

3%)

00

00

Rud

imen

tary

horn

(1)

00

1(1

00%

)0

00

00

Tuba

lstu

mp

(2)

00

1(5

0%)

00

00

0C

esar

ean

scar

(1)

00

00

1(1

00%

)0

00



implanted in the cervical canal, the higher capacity ithas to grow and hemorrhage. Some diagnostic criteriafor cervical pregnancy are:

1 Clinical signs and symptoms: recurring vaginalbleeding without pain was observed during earlygestation, often followed by uncontrolled hemor-rhage. In our investigation, 87.5% (7/8) of cases wereobserved with vaginal bleeding, involving threecases of emergency.

2 Gynecological examination: cervix is dilated; cervicalcanal increasingly thickens like barrel. Doctors couldsee or even touch placenta in cervix. Two cases pre-sented cervical dilation and another two casesshowed a flabby cervix. The examination may causesevere hemorrhage, so it should be deliberatedbefore examination.

3 Serum b-hCG assessment and ultrasound examina-tion. Quantitative serum hCG in cervical pregnancyis often present below the normal pregnancy due topoor blood supply. Compared with other unusualEP, cervical pregnancy showed atypical abdominalpain or bleeding. This may be the result of earlyadmission.

In abdominal pregnancy, with either tubal abortion orintraperitoneal rupture, the entire conceptus maybe extruded from the tube. If an early conceptus isexpelled essentially undamaged into the peritonealcavity, its placental attachment may persist, or it may bereimplanted almost anywhere and grow as an abdomi-nal pregnancy. This is unusual, and most small concep-tuses can be reabsorbed. They may occasionally remainin the cul-de-sac for years as an encapsulated mass, oreven become calcified to form a lithopedion.11

All our cases are secondary. The first one occurreddue to rupture of tubal pregnancy, and then the con-ceptus developed on the posterior wall of bladder. Thesecond one was from rupture of rudimentary hornpregnancy and the conceptus grew in Douglas’ spaceon the ligament of the right iliac fossa. The last onehappened due to tubal interstitial pregnancy and theconceptus dropped into the abdominal cavity. Duringthe operation, the fetus was found alive in the abdomi-nal cavity surrounded by blood. The placenta wasattached to the greater omentum.

Treatment and prognosis

Twenty-eight out of 29 women with ovarian preg-nancies underwent surgery by resection of the ovarianwedge or partial oophorectomy. Most reports advocate

preserving ovarian tissues as much as possible.Doctors cut off the affected annex only under seriousdamages.

In the past, it was suggested to cut off the uterinecorpus to avoid rupture of cornual pregnancy, andhysterectomy was recommended if necessary. In ourstudy, seven cases (33.3%) underwent lesion resectionon corpus; and five cases (23.8%) received sub-total hysterectomy due to ruptures. In recent years,many successful cases of conservative treatment werereported. We treated five patients with conservativetherapies, including mifepristone, curettage andMTX, which achieved excellent results. However,some reports also pointed out that conservative treat-ment for patients in this type of pregnancy with long-time amenorrhea and abdominal pain may notsucceed easily.

Before 12 weeks’ gestation, invasion of trophoblasticcells in the cervical wall is not deep enough, so conser-vative treatments for cervical pregnancy can be suc-cessful.12 Treatments include: (i) hysterectomy andsubtotal hysterectomy (they are operated only afterfailure of conservative treatments or uncontrolled hem-orrhage [they were used in three cases]); and (ii) con-servative treatments (the key was early diagnosis andtreatment). Recently, the use of curettage and hysterec-tomy has been reduced gradually. They are only usedas alternative therapies for MTX and uterine arteryembolization. Reportedly, MTX can be used by sys-temic or local injection. It could reach a high effect of80%.13 Usage of both mifepristone and MTX was betterthan single MTX for cervical pregnancy, as the formershowed a high success rate and lower toxicity.14 Thismethod could enhance the toxicity to trophoblast cellsand kill the embryo effectively.

In our investigation, four cases of conservative treat-ments and two cases of curettage were successful.However, vaginal bleeding may still occur after con-servative treatments. Doctors should closely monitorpatients’ conditions. One patient underwent hysterec-tomy after conservative treatment due to recurringvaginal bleeding.

Rudimentary horn in the uterus is the result of devel-opmental defects on lower segment in the duct ofMuller, which caused unequal formation on both sides.A small appendage formed next to the normal uterusand connected it through a bunch of fibrous tissues.15

Compared with the normal uterus, the rudimentaryuterus has thicker muscles (most hypoplasia) withdense vessels. Thus, severe hemorrhage often occursafter the rupture of pregnancy.

N. Shan et al.


For rudimentary horn uterine pregnancy, generalconsiderations are to excise the rudimentary horn inthe uterus.16,17 Gynecologists should excise both rudi-mentary horn and its ipsilateral tube to avoid futuretubal pregnancy.18 They should do the same in abdo-minal surgeries, once a rudimentary horn uterusis identified. One patient in our group underwentresection of rudimentary horn uterus and ipsilateralsalpingectomy.

In abdominal pregnancy, blastocyst may invade intomaternal organs or vessels, and thus cause bleeding orrupture of maternal organs. It should be immediatelytreated upon diagnosis. Three cases underwent resec-tion of lesions in the abdomen and one suffered ipsi-lateral salpingectomy.

Cesarean scar pregnancy accounted for 6.1% of theectopic pregnancies with a history of cesarean section.19

The isthmus had poor muscles due to the uterine scarbut had rich proliferations of connective tissues andvessels. If the incision site is ruptured, or the placentais separated, uncontrolled bleeding would occur.Hysterectomy is needed if necessary.20 Surgical treat-ment, including laparotomy and hysterotomy, wereattempted with success.21 Conservative treatmentsinclude systemic or direct injection of MTX.22,23 Thecombination of MTX, uterine artery embolization andlaparoscopic excision, followed by hysteroscopy toassess scar integrity, was reported.24

In conclusion, although extratubal pregnancies aredifficult to diagnose, some histories and auxiliaryexaminations could make diagnosis easier for clinicalphysicians. IUD placement and history of pelvicinflammatory disease were closely related to ovarianpregnancy. Ultrasonography is meaningful for diagno-sis of tubal, cervical and corneal pregnancies, whereasovarian pregnancy is usually manifested with positiveculdocentesis.

Surgery is still the most effective approach forunusual ectopic pregnancies, while conservative treat-ments, such as mifepristone combined with MTX orcurettage, could be used for early diagnosis and treat-ment of cervical pregnancy.

With the globally increasing incidence of sexuallytransmitted diseases, the prevalence of unusual ectopicpregnancy is anticipated to increase. Their rarity, thecomplex history and atypical clinical characteristics ofthe condition may cause them to be ignored by anunsuspecting clinician. Thus, high-level awarenessshould be maintained at all times by clinicians. This canreduce the mortality and morbidity associated withthese emergencies.

Acknowledgments

We would like to take this opportunity to thank to allauthors who have contributed to this paper.

Disclosure

None.

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N. Shan et al.


Unusual ectopic pregnancies

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