types of ectopic pregnancy?

Ectopic pregnancy in uncommon implantation sites
Author links open overlay panelSanaaBadraAbdel-NaserGhareepb
Lamya M.AbdullabRabeiHassaneinc
https://doi.org/10.1016/j.ejrnm.2012.10.006
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Abstract

The majority of ectopic pregnancies are located within the fallopian tube. Nevertheless, pregnancies have been reported to implant in the cervix, ovary, interstitial tubal segment, and at various intra-abdominal sites. The diagnosis and treatment of these unusual implantation sites presents a challenge for clinical as well as radiological diagnosis and there is a tendency to overlook its possibility. In this study, we attempt to summarize the current data regarding diagnosis and optimal treatment of these unusual ectopic pregnancies from our experience with six unusual types of ectopic pregnancies from the Women Hospital, Doha, Qatar.

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Keywords
Ectopic pregnancy
Uncommon implantation sites
1. Introduction

Ectopic pregnancy is among the leading causes of mortality among pregnant women (1). Although the incidence of ectopic pregnancy is estimated to be between 1% and 2%, the majority (95%) of these pregnancies are located in isthmic/ampullary/fimbrial (extracornual) portion of the fallopian tube 2, 3. However, about 5% pregnancies also occur implanted in the cervix, ovary, previous cesarean scar, interstitial portion of the fallopian tube and abdomen as well as angular ectopic pregnancy and heterotopic pregnancy (intrauterine pregnancy (IUP) + ectopic) (4) (Fig. 1). The relative infrequency of these implantation sites makes the study of treatment efficacy difficult (5). Advances in ultrasound technology and operator expertise have provided the capability to visualize ectopic pregnancy at an unusual location at its earliest stage (6). Although routine two-dimensional ultrasound can be suggestive, 3D ultrasound is highly accurate in diagnosis. From the Women Hospital, Doha, Qatar, we illustrate and discuss six unusual types of ectopic pregnancies, heterotopic pregnancy, scar pregnancy, interstitial pregnancy, cervical pregnancy, abdominal pregnancy and ovarian pregnancy.

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Fig. 1. Diagrams showing the usual and unusual sites of ectopic pregnancy.
1.1. Case No. 1

The patient was 39 years old, gravida 3 para 1 + 1. The patient was admitted through the emergency department with a missed period and moderate abdominal pain. Patient was examined, her vitals were stable, and ultrasound was requested. There is an intrauterine pregnancy with extra uterine left sided tubal pregnancy, so decision was taken for admission. In the ward, the patient was stable with sudden left sided pain. Abdominal examination shows abdomen is soft and lax with mild tenderness. On the 2nd day patient is well, ambulating, no abdominal pain. No vaginal bleeding. Ultrasound is confirmed, she has a viable heterotopic pregnancy of 7 weeks (Fig. 2) and she posted to laparoscopy.

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Fig. 2. US showing heterotopic pregnancy, intra and extra uterine viable fetus ±7 weeks, with laparoscopic picture of the patient.

Laparoscopy confirmed a left sided viable tubal pregnancy involving the whole left tube and impending rupture. The left tube (almost all) was cauterized and cut. The pregnancy was taken out through an endo-bag and sent for histopathology.

The patient was discharged on the 3rd day with stable vital signs and ultrasound was done to confirmed intrauterine pulsating pregnancy.
1.2. Case No. 2

A 25 year old patient, G2P1. She has previous CS. She is 5 weeks amenorrhea. Patient was admitted from the emergency department as referred from a private hospital, where she was diagnosed as ectopic pregnancy in the CS scar and was given methotrexate injection. By examination, she was stable; abdomen was soft, lax, no tenderness and pelvic examination not done. BHCG (beta human chorionic gonadotropin) done in private hospital was usually normal. Patient was admitted in the ward, at night BHCG → 7929 IU, high liver function tests and normal CBC, Hb and PLT count.

Plan: observation, vital sign chart and repeat ultrasound in the next day.

Ultrasound shows: gestational sac seen eccentrically located in the lower uterine segment in the site of the previous LSCS (Fig. 3). GSD = 1.1 cm showing a yolk sac and tiny fetal node (CRL: 2.0 mm). No fetal cardiac activity seen or recorded.

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Fig. 3. Showing non-viable ectopic pregnancy in lower cesarean section scar (LSCS).

On the next day, patient still vitally stable with a drop of high liver function. We followed her on 13/09/2009 in the emergency department: BHCG = 7870. Patient was discharged with an appointment after 1 week and she was advised if any bleeding or severe pain must come to emergency department. After 1 week, the patient was seen in the clinic with BHCG 16/9/2009 and 23/09/2009 and she was instructed for BHCG weekly till it will become negative. Last BHCG on 26/10/2009 = 0.61 IU which is negative and the patient was discharged from the clinic.
1.3. Case No. 3

A 32 year old female G3P1 + 1 in ±8 weeks of amenorrhea with previous CS admitted through the emergency department with a mild brownish discharge and patient admitted to ward planned for observation. O/E, she is vitally stable, abdomen is soft, lax, no mass or tenderness.

Ultrasound (2D & 3D) was done and shows a non-viable fetal pole within the gestational sac that is eccentrically located in the right fundal side with the rim of myometrial tissue surrounding the pregnancy sac → right interstitial pregnancy (Fig. 4).

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Fig. 4. Showing eccentrically located GS in the right fundal side separated from endometrial cavity by myometrial tissue consistent with right interstitial pregnancy.

Methotrexate was given with serial BHCG for follow up. Serial BHCG: 23/05/2011 → 9325 IU – 25/05/2011 → 4756 IU

So decision was taken to discharge her and she was instructed about all complications which can happen. The patient came for follow up in the outpatient clinic on 15/06/2011. She was well, no pain or bleeding and BHCG → 914 IU. So the patient was instructed to do BHCG weekly till it will become negative. BHCG in 18/07/2011 → 0.16 IU negative.
1.4. Case No. 4

A 26 year old lady, Primigravida, IVF pregnancy. ET = 4/2/2008, so she is 9 weeks on 5/3/2008. She was admitted through the emergency department, complaining of backache with no bleeding. Routine investigation requested including blood tests and ultrasound was done.

Ultrasound shows a well formed GS with surrounding echogenic rim centrally located in the cervical canal with yolk sac and embryo without cardiac pulsation and the endometrial cavity is empty and diagnosed as cervical pregnancy. The GSD = 1.99 cm and CRL = 0.28 cm corresponding to ±6 weeks GA (Fig. 5). Patient was admitted to the ward, decision was taken for methotrexate therapy.

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Fig. 5. Abdominal and TV US with Doppler showing non-viable ±6 weeks ectopic cervical pregnancy.

O/E: she is vitally stable, mild abdominal; abdomen was soft, lax and not tender. Pelvic examination was not done with slight bleeding since 1 h.

Patient receives methotrexate on 6/3/2008 with dropping of BHCG level.

Plan will be for observation, CBC and BHCG.

The patient was re-admitted on 27/03/2008 complaining from lower abdominal pain. O/E: she is vitally stable, abdomen is soft, lax and not tender and PV was not done. The patient was kept under observation until 1/4/2008 then was discharged with BHCG weekly until it will be negative with ultrasound and Doppler follow up. BHCG came down and became negative on 14/6/2008.

Serial follow up US shows a gradual decrease in the size of the sac and CRL until the last follow up study after three months showing the GS is markedly collapsed and only a small remnant about 11 × 5 mm is detected (Fig. 6).

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Fig. 6. The last follow up US and Doppler study (3 month) after methotrexate therapy showing only small remnant.
1.5. Case No. 5

A 36 year patient, G1P0, IVF twin pregnancy (Dichorionic Diamniotic)

○

Embryo transfer (ET): 02/07/08.
○

EDD: 24/03/09.
○

Known to be gestational diabetic on diet.

Current pregnancy:

○

The patient had her 2nd successful trial of IVF pregnancy which is twin’s pregnancy (Di–Di).
○

She started to follow in Women Hospital out patient clinic from 22 weeks where she had 3 visits to clinic at 22–34–35 weeks.
○

Apart from gestational diabetes on diet, her other investigations were normal including US.

First US scan done at 23 weeks: compatible with date with no anomalies. Then that scan was followed by four other scans, all were found to be with normal growth and normal Doppler.

Last scan was on 15/02/09, (Di–Di), normal growth, normal liquor and Doppler for both fetuses, 1st cephalic (2.1) kg and 2nd transverse (2.2) kg.

On 05/03/09 the patient came to emergency complaining of watery vaginal discharge with lower abdominal pain and leaking confirmed in emergency by speculum Ex. PV: 3 cm, 80% effaced, cephalic, -3 stations, so patient admitted to labor room (LR).

In LR: bed side US showed both fetuses cephalic and over 3.5 h the patient progressed nicely to fully dilated cervix under epidural analgesia and remained fully dilated for 2 h. The 1st twin delivered was female, cephalic with APGAR 9–10 weighing 2295 gm then the cervix reformed where the 2nd twin lie transversely. So, decision taken for emergency CS.

On laparotomy;
○

There was gestational sac outside the intact uterus.
○

The sac opened through a thin area where no placenta is.
○

Baby boy delivered with APGAR score 9–10, 2265 gm.

After delivery of baby, the placenta was found attached to cecum, sigmoid colon, back of uterus till fundus & Rt. broad ligament (Fig. 7).

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Fig. 7. Laparotomy of the patient showing (a) Intact posterior wall with membranous adhesion to rectum, (b) membranous attachment to the sigmoid colon, (c) main feeding from broad ligament with intact anterior uterine wall.

The sac has a vascular pedicle which clamped, divided and removed completely with placenta.

Both maternal and fetal conditions were clinically and hemodynamically stable in the ward. The patient had remarkable recovery.

1.6. Case No. 6

A 28-year-old lady, nullipara presented to the emergency department with vaginal spotting and severe abdominal pain. Qualitative pregnancy test was positive, so quantitative test (BHCG) taken and it was 15531 IU.

Ultrasound revealed, normal size RVF empty uterus with a large heterogeneous left adnexial mass around 10.6 × 6.8 cm seen with turbid fluid in the Douglas pouch (Fig. 8).

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Fig. 8. Left adnexial mass with pelvic hemorrhage seen by US and laparoscopy.

The patient is generally stable with abdominal tenderness with re-bound tenderness, maximum on the left iliac fossa with no rigidity.

Pelvic exam: RVF uterus, normal size, positive cervical excision, so decision was taken for urgent laparoscopy.

During the procedure: There is moderate internal hemorrhage. Blood was evacuated using suction with inspection of pelvis. There is a brown soft tissue material measuring 10 × 7 cm with a small area of oozing. Mass excised was taken out using the endo-bag and sent for histopathology. Suction irrigation of the pelvis and homeostasis were done. The patient was discharged in the next day with good general condition. BHCG = 6008 IU. She had an appointment in the clinic after 2 weeks to check histopathology and BHCG (become729 IU after 2 weeks).

Histopathology report:

1.

Left ovary excision consistent with ectopic pregnancy (chronic villi seen).
2.

Left fallopian tube cystectomy consistent with para-tubal cyst (hydatid of morgagni).

2. Discussion

Ectopic pregnancy at any location is a serious problem due to significant maternal morbidity and mortality. Although the unusual implantation sites are much less frequent, these must also be considered (7).
2.1. Heterotopic pregnancy

A rare type of multiple pregnancies involving one viable pregnancy in the uterus and the other implanted elsewhere as an ectopic pregnancy (our illustrated case No. 1 both are viable). Heterotopic pregnancies occur with rates less than one in 30,000 naturally occurring pregnancies (as in our case No. 1), and one in 100 couples who conceive through assisted reproduction (8).

The risk of both ectopic and heterotopic gestations increased in: (a) assisted reproduction techniques due to super ovulation, (b) patients with previous tubal surgeries, (c) persistent or rising BHCG levels after an induced/spontaneous abortion, (d) when the uterine fundus is larger than for menstrual dates, (e) when more than one corpus luteum is present in a natural conception 9, 10. Most commonly, the location of ectopic gestation in a heterotopic pregnancy is the fallopian tube (as our case No. 1). However, cervical and ovarian heterotopic pregnancies have also been reported 11, 12. Intrauterine gestation with hemorrhagic corpus luteum can simulate heterotopic/ectopic gestation both clinically and on ultrasound (13). A high resolution transvaginal ultrasound with color Doppler will be helpful as the trophoblastic tissue in the adnexa in a case of heterotopic pregnancy shows increased flow with significantly reduced RI (9). As in our illustrated case and according to patient presentation and condition, the treatment of a heterotopic pregnancy is laparoscopy/laparotomy for the tubal pregnancy (10).
2.2. Cesarean scar pregnancy

CS scar pregnancy is a rare form of ectopic pregnancy with an incidence of 1:1800 pregnancies (14). It is associated with complications such as uterine rupture and massive hemorrhage requiring emergency hysterectomy (15). A report describes a successful pregnancy till term after previous cesarean ectopic pregnancy (16). Diagnosis of cesarean ectopic pregnancy can be made easily if the sonologist is familiarized with the case (17). In our case No. 2, the cesarean scar ectopic pregnancy was diagnosed early by ultrasound. Presentation of the patient often dictates the mode of treatment of this case. Systemic methotrexate followed by dilatation and evacuation have been described (18). Treatment by suction curettage has been described in selected cases (19). Other treatment options include uterine artery embolization (20), laparoscopic ligation of bilateral uterine arteries followed by excision of ectopic mass (21). As used in our illustrated case, asymptomatic and hemodynamically stable patients are candidates for medical management by methotrexate.
2.3. Interstitial ectopic pregnancy

Interstitial pregnancy occur in interstitial segment of the fallopian tube that lies within the muscular wall of the uterus (22) and accounts for up to 1–3% of all ectopic pregnancies (23). Correct diagnosis of ectopic pregnancy can be quite difficult. It requires accurate ultrasound interpretation. The diagnosis relies heavily on ultrasound and potentially on laparoscopic evaluation (24). Ultrasound frequently shows a thin rim of myometrial tissue surrounding the ectopic pregnancy sac (25). The interstitial line has been described as an echogenic line extending into the corneal region and abutting the gestational sac, and is highly specific for interstitial pregnancy (3). In our case No. 3, the diagnosis was suggested on a 3D transvaginal ultrasonography prior to development of any complication, resulting in early management. The traditional treatment of interstitial pregnancy has been cornual resection or hysterectomy in cases with severely damaged uterus (26). However, there are successful case reports of laparoscopic resection of cornual pregnancies (27). Although the surgical management of interstitial pregnancy has remained most common, methotrexate has been used as the first-line treatment, we use this line in our case No. 3. In an analysis of 13 case series of a total of 47 total cases treated with methotrexate, Fisch et al. concluded that methotrexate is a safe option. However, there are reports of high failure rates, and there is a need for proper patient selection and extended monitoring (28).
2.4. Cervical ectopic pregnancy

Cervical ectopic pregnancies account for less than 1% of all pregnancies, with an estimated incidence of one in 2500 to one in 18,000 29, 30. In the past, cervical ectopic pregnancy was associated with significant hemorrhage and was treated presumptively with hysterectomy. Improved ultrasound resolution and earlier detection of these pregnancies have led to the development of more conservative treatments that attempt to limit morbidity and preserve fertility.

Cervical pregnancy is diagnosed by US according to the following criteria described by Hofmann and Timor-Tritsch (31).

1.

Presence of gestational sac or placental texture dominantly within the cervix.
2.

No evidence of intrauterine pregnancy.
3.

Visualization of an endometrial stripe (except in case of heterotopic pregnancy).
4.

Hourglass uterine shape with ballooned cervical canal.
5.

Sac with active cardiac motion below the internal Os for viable pregnancy.

Color Doppler scanning is useful in differentiating between inevitable miscarriage of a gestational sac in the cervix and true cervical pregnancy. In true cervical pregnancy, Doppler studies show characteristic patterns of trophoblast with high flow velocity and low impedance, while in miscarriage the sac will be mobile, with no Doppler evidence of blood flow 32, 33. Cervical pregnancies before 12 weeks, without fetal cardiac activity and with lower serum BHCG levels seem more amenable to conservative treatment 34, 35. Most reports of successful conservative therapy involve the use of systemic chemotherapy in combination with cervical evacuation and the use of hemostatic techniques 36, 37. Spitzer et al. (34) reported using curettage followed by the injection of prostaglandin F2α to increase uterine contractions, promote vasoconstriction, and therefore, reduce hemorrhage. In our case No. 4 we use the conservative measures with systemic methotrexate and follow up as it become the standard first-line approach to treatment of women who desire fertility preservation and the treatment was successful and reached the full resolution.
2.5. Abdominal ectopic pregnancy

Abdominal pregnancy is an extremely rare event (1.4% of ectopic pregnancies) that may be difficult to diagnose and awareness of this condition is very important in reducing the associated morbidity and mortality. Abdominal pregnancies refer to those with extra uterine implantations in omentum, vital organs, or large vessels. These pregnancies can go undetected until an advanced gestational age and often result in severe hemorrhage, disseminated intravascular coagulation, bowel obstruction, and fistulae 38, 39, 40. Frequently, these pregnancies are encountered with a viable fetus, which complicates their management.

The diagnosis is often made using ultrasound and X-ray. Sonographic features suggestive of abdominal pregnancy include empty uterus, absence of myometrium around the fetus, oligohydramnios, abnormal fetal lie and poorly defined placenta (41). Elevated serum alpha-fetoprotein has also been associated with abdominal pregnancy. Diagnostic laparoscopy may also be of value when there is a doubt about pregnancy location (42). In some cases, the diagnosis is not made until laparotomy (43), this occurs in our case No. 5 that diagnosed by mistake as intrauterine twins. MRI holds promise as a diagnostic tool 43, 44.

The optimal treatment of abdominal pregnancy is unknown. It has been reported that management of the placenta correlates well with maternal morbidity. When possible, ligation of placental blood supply and removal should be attempted to reduce maternal complications (45). Alternatively, the umbilical cord may be ligated and expectant management, arterial embolization, or methotrexate used to facilitate involution (42). However, leaving the placenta in situ may lead to further complications such as infection, secondary hemorrhage, or intestinal obstruction (46). Olsen et al. (47) reported laparoscopic management of a broad ligament pregnancy without complication. Primary methotrexate has been attempted for early gestations with minimal success (48).
2.6. Ovarian pregnancy

Ovarian pregnancy is one of the rarest varieties of ectopic pregnancies accounting for 0.15–3% of all ectopic gestations. Patients frequently present with abdominal pain and menstrual irregularities. Preoperative diagnosis is challenging but transvaginal sonography has often been helpful. A diagnostic delay may lead to rupture, secondary implantation or operative difficulties. Therefore, awareness of this rare condition is important in reducing the associated risks (49). The diagnosis routinely is made by ultrasound appearance of a wide echogenic ring on the ovary, frequently with a yolk sac or fetal parts. Ovarian pregnancies are often confused with corpus luteum cysts (50). 3D ultrasound imaging has been used to distinguish ovarian pregnancy from corpus luteum cysts. It may be useful to perform intraoperative ultrasound to distinguish an ovarian pregnancy from an ovarian cyst (51). Our illustrated case No. 6 diagnosed by US as tubal pregnancy and suspected on laparoscopy and finally diagnosed by histopathology. Ovarian pregnancy can be treated conservatively with single-dose methotrexate. However, the preferred mode of treatment is oophorectomy by laparotomy or laparoscopy, currently, laparoscopic surgery is the treatment of choice.
3. Conclusion

Six unusual types of ectopic pregnancy were illustrated and discussed in this article. These are heterotopic pregnancy (combined intra- and extra uterine pregnancies), scar pregnancy, interstitial pregnancy, cervical pregnancy, abdominal pregnancy and ovarian pregnancy. Ectopic pregnancies of unusual location are encountered much less frequently, but are perhaps more morbid. The use of advanced ultrasonography in combination with ultrasensitive serum β-hCG assays should lead to early diagnosis. Early diagnosis and use of multiple modalities can reduce morbidity and mortality in cases of ectopic pregnancy at unusual location.

The treatment of these unusual ectopic gestations may not be as commonplace as treatment of tubal pregnancies, but with early diagnosis and effective planning, their treatment can be equally as effective.
References

1
Centers for disease control
Pregnancy-related mortality ratios: United States 1991–1999
MMWR Surveill Summ, 52 (2003), p. ss-2
Google Scholar
2
L. Speroff, M. Frtitz
Clinical gynecologic endocrinology and infertility
(7th ed.), Lippincott Williams & Wilkins, New York (2004)
Google Scholar
3
S. Lau, T. Tulandi
Conservative medical and surgical management of interstitial ectopic pregnancy
Fertil Steril, 72 (1999), pp. 207-215
Article

Download PDFView Record in ScopusGoogle Scholar
4
J. Bouyer, J. Coste, H. Fernandez, J.L. Pouly, N. Job-Spira
Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases
J Hum Reprod Sci, 17 (12) (2002), pp. 3224-3230
View Record in ScopusGoogle Scholar
5
D.V. Vaesky, S. Yagel
Ectopic pregnancies of unusual location: management dilemmas
Ultrasound Obstet Gynecol, 31 (2008), pp. 245-251
Google Scholar
6
E. Araujo jr, F.S.M. Zanforlin, C.R. Pires, F.H.A. Guimaraes, A.A. Massaguer, L.M. Nardozza, et al.
Three dimensional transvaginal sonography of early and asymptomatic interstitial pregnancy
Arch Gynecol Obstet, 275 (2007), pp. 207-210
Google Scholar
7
N. Shah, N.H. Khan
Third delay of maternal mortality in a tertiary hospital
Rawal Med J, 32 (2007), pp. 163-167
View Record in ScopusGoogle Scholar
8
Ludwig M. Heterotopic pregnancy in a spontaneous cycle: do not forget about it! Eur J Obstet Gynecol Reprod Biol, 1999 [accessed 05.06.08].
Google Scholar
9
M.J. Glassner, E. Aron, B.A. Eskin
Ovulation induction with clomiphene and the rise in heterotopic pregnancies: A report of two cases
J Reprod Med, 35 (1990), pp. 175-178
View Record in ScopusGoogle Scholar
10
Ectopic pregnancy, text book of Williams obstetrics. 21st ed. Multifetal ectopic pregnancy. p. 888–9 [chapter 34].
Google Scholar
11
M. Hirose, T. Nomura, K. Wakuda, T. Ishguro, Y. Yoshida
Combined intrauterine and ovary pregnancy: a case report
Asia Ocaena J Obstet Gynaecol, 20 (1994), p. 25
View Record in ScopusGoogle Scholar
12
D. Peleg, I. Bar-Hava, M. Neaman-Leavin, Ashkena, I.J. Ben-Rafaelz
Early diagnosis and successful non surgical treatment of viable combined intrauterine and cervical pregnancy
Fertil Steril, 62 (1994), p. 405
Article
Download PDFView Record in ScopusGoogle Scholar
13
S. Sohail
Haemorrhagic corpus luteum mimicking heterotopic pregnancy
J Coll Physicians Surg Pak, 15 (2005), pp. 180-181
View Record in ScopusGoogle Scholar
14
K. Seow, L. Hang, Y. Lin
Cesarean scar pregnancy: issues in management
Ultrasound Obstet Gynecol, 23 (2004), pp. 247-253
View Record in ScopusGoogle Scholar
15
N.J. Ben, Y.D. Ofili, M. Marash
First trimester cesarean scar pregnancy evolving into placenta previa/acreta at term
J Ultrasound Med, 24 (2005), pp. 1569-1573
Google Scholar
16
Pregnancy followed by vaginal delivery: in a woman with a previous history cesarean scar ectopic pregnancy
Med Channel, 16 (2010), pp. 94-96
Google Scholar
17
Y.D. Ofili, N.J. Ben, E. Sawyer, J. Yazbek, C. Lee, J. Gon-zalez, et al.
Deficient lower segment cesarean section scars: prevalence and risk factors
Ultrasound Obstet Gynecol, 31 (2008), pp. 72-77
Google Scholar
18
O. Graesslin, F. Dedecker, C. Quereux, R. Gabriel
Conservative treatment of ectopic pregnancy in a cesarean scar
Obstet Gynecol, 105 (2005), pp. 869-871
View Record in ScopusGoogle Scholar
19
M. Arsalan, O. Pata, T.U. Dilek, A. Aktas, M. Abas, S. Dilek
Treatment of viable cesarean scar ectopic pregnancy with suction curettage
Int J Gynecol Obstet, 89 (2005), pp. 163-166
Google Scholar
20
P. Marchiole, F. Gorlero, G. Decaro
Intramural pregnancy embedded in a previous cesarean section scar treated conservatively
Ultrasound Obstet Gynecol, 23 (2004), pp. 305-309
Google Scholar
21
C.J. Wang, L.T. Yuen, C.F. Yen, C.L. Lee, Y.K. Soong
Three dimensional power Doppler ultrasound diagnosis and laparoscopic management of a pregnancy in a previous cesarean scar
J Laparoendosc Adv Surg Tech A, 14 (2004), pp. 399-402
View Record in ScopusGoogle Scholar
22
T. Tulandi, D. Al-Jaroudi
Interstitial pregnancy: results generated from The Society of Reproductive Surgeons Registry
Obstet Gynecol, 103 (2004), pp. 47-50
View Record in ScopusGoogle Scholar
23
S. Dilbaz, B. Katas, B. Demir, B. Dilbaz
Treating cornual ectopic pregnancy with a single methotrexate injection
J Reprod Med, 50 (2) (2005), pp. 141-143
View Record in ScopusGoogle Scholar
24
D.L. Katz, J.P. Barrett, J.S. Sanfilippo, D.M. Badway
Combined hysteroscopy and laparoscopy in the treatment of interstitial pregnancy
Am J Obstet Gynecol, 188 (2003), pp. 1113-1114
Article
Download PDFView Record in ScopusGoogle Scholar
25
A.P. Advincula, S. Senapati
Interstitial pregnancy
Fertil Steril, 82 (6) (2004), pp. 1660-1662
View Record in ScopusGoogle Scholar
26
D.L. Katz, J.P. Barrelt, J.S. San Fillipo, D.M. Badway
Combined hysteroscopy and laparoscopy in the treatment of insterstitial pregnancy
Am J Obstet Gynecol, 188 (2003), pp. 1113-1114
Article
Download PDFView Record in ScopusGoogle Scholar
27
H.S. Moon, Y.J. Choi, V.H. Park, S.G. Kim
New simple endoscopic operations for interstitial pregnancies
Am J Obstet Gynecol, 152 (2000), pp. 114-121
Article
Download PDFView Record in ScopusGoogle Scholar
28
J.D. Fisch, B. Ortiz, S. Tazuke, U. Chitkara, L. Giudice
Medical management of interstitial ectopic pregnancy: a case report and literature review
J Hum Reprod Sci, 13 (7) (1998), pp. 1981-1986
View Record in ScopusGoogle Scholar
29
I. Cepni, P. Ocal, S. Erkan, B. Erzik
Conservative treatment of cervical ectopic pregnancy with transvaginal ultrasound guided aspiration and single-dose methotrexate
Fertil Steril, 81 (4) (2004), pp. 1130-1132
Article
Download PDFView Record in ScopusGoogle Scholar
30
F.B. Ushakov, U. Elchalal, P.J. Aceman, J.G. Schenker
Cervical pregnancy: past and future
Obstet Gynecol Surv, 52 (1997), pp. 45-59
View Record in ScopusGoogle Scholar
31
Sarwat. Ara, Nadia. Awais
Abdominal pregnancy: a diagnostic dilemma
Prof Med J, 18 (3) (2011), pp. 479-484
CrossRefGoogle Scholar
32
D. Jurkovic, D. Mavrelos
Catch me if you scan: ultrasound diagnosis of ectopic pregnancy
Ultrasound Obstet Gynecol, 30 (2007), pp. 1-7
CrossRefView Record in ScopusGoogle Scholar
33
J.F. Lemus
Ectopic pregnancy: an update
Curr Opin Obstet Gynecol, 12 (2000), pp. 369-375
View Record in ScopusGoogle Scholar
34
D. Spitzer, H. Steiner, A. Graf, M. Zajc, A. Staudach
Conservative treatment of cervical pregnancy by curettage and local prostaglandin injection
J Hum Reprod Sci, 12 (4) (1997), pp. 860-866
View Record in ScopusGoogle Scholar
35
J.A. Cosin, M. Bean, D. Grow, H. Wiczyk
The use of methotrexate and arterial embolization to avoid surgery in a case of cervical pregnancy
Fertil Steril, 67 (6) (1997), pp. 1169-1171
Article
Download PDFView Record in ScopusGoogle Scholar
36
A. Monteagudo, N. Tarricone, I. Timor-Tritsch, J. Lenner
Successful transvaginal ultrasound-guided puncture and injection of a cervical pregnancy in a patient with simultaneous intrauterine pregnancy and history of a previous cervical pregnancy
Ultrasound Obstet Gynecol, 8 (1996), pp. 381-386
CrossRefView Record in ScopusGoogle Scholar
37
D. Jurkovic, E. Hacket, S. Campbell
Diagnosis and treatment of early cervical pregnancy: a review and report of 2 cases treated conservatively
Ultrasound Obstet Gynecol, 8 (1996), pp. 373-380
CrossRefView Record in ScopusGoogle Scholar
38
H.K. Atrash, A. Friede, C. Hogue
Abdominal pregnancy in the United States: frequency and maternal mortality
Obstet Gynecol, 69 (1987), pp. 333-337
View Record in ScopusGoogle Scholar
39
B. Fisch, Y. Peled, B. Kaplan, S. Zehavi, A. Neri
Abdominal pregnancy following in vitro fertilization in a patient with previous bilateral salpingectomy
Obstet Gynecol, 88 (4) (1996), pp. 642-643
Article
Download PDFView Record in ScopusGoogle Scholar
40
M.S. Rahman, S. Al-Suleiman, J. Rahman, M.H. Al-Sibai
Advanced abdominal pregnancy—observations in 10 cases
Obstet Gynecol, 59 (1982), pp. 366-372
View Record in ScopusGoogle Scholar
41
Xu. Bing, et al.
The use of ultrasonography in conservative management of cervical pregnancy
Sonography, 7 (2012), pp. 131-140
View Record in ScopusGoogle Scholar
42
Y. Morita, O. Tutsumi, K. Kuramochi, M. Momoeda, H. Yoshikawa, Y. Taketani
Successful laparoscopic management of primary abdominal pregnancy
J Hum Reprod Sci, 11 (11) (1996), pp. 2546-2547
CrossRefView Record in ScopusGoogle Scholar
43
M.A. Onan, A.B. Turp, A. Saltik, N. Akyurek, C. Taskiran, O. Himmetoglu
Primary omental pregnancy: case report
J Hum Reprod Sci, 20 (3) (2005), pp. 807-809
CrossRefView Record in ScopusGoogle Scholar
44
A. Jazayeri, T.A. Davis, D.N. Contreras
Diagnosis and management of abdominal pregnancy: a case report
J Reprod Med, 47 (12) (2002), pp. 1047-1049
View Record in ScopusGoogle Scholar
45
J. Rahaman, R. Berkowitz, H. Mitty, S. Gaddipati, B. Brown, F. Nezhat
Minimally invasive management of an advanced abdominal pregnancy
Obstet Gynecol, 103 (2004), pp. 1064-1068
View Record in ScopusGoogle Scholar
46
M. Ludwig, M. Kaisi, O. Bauer, K. Diedrich
The forgotten child—a case of heterotopic, intraabdominal and intrauterine pregnancy carried to term
J Hum Reprod Sci, 14 (5) (1999), pp. 1372-1374
View Record in ScopusGoogle Scholar
47
M.E. Olsen
Laparoscopic treatment of intraligamentous pregnancy
Obstet Gynecol, 89 (1997), p. 862
Article

Download PDFView Record in ScopusGoogle Scholar
48
M. Zinger, D. Rosenfeld
Failed treatment of abdominal pregnancy with methotrexate
J Reprod Med, 46 (4) (2001), pp. 392-394
View Record in ScopusGoogle Scholar
49
Sonia Gon
Two cases of primary ectopic ovarian pregnancy
OJHAS, 10 (1) (2011)
Google Scholar
50
C. Comstock, K. Huston, W. Lee
The ultrasonographic appearance of ovarian ectopic pregnancies
Obstet Gynecol, 105 (1) (2005), pp. 42-46
View Record in ScopusGoogle Scholar
51
S. Panda, L.M. Darlong, S. Singh, T. Borah
Case report of a primary ovarian pregnancy in a primigravida
J Hum Reprod Sci, 2 (2009), pp. 90-92
CrossRefView Record in ScopusGoogle Scholar

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Available online 27 November 2012