ECTOPIC PREGNANCY

EPIDEMIOLOGY
• 6% of pregnancy-associated mortality (1, 2).
• fourth most common cause of maternal death in the most recent
Confidential Enquiry into Maternal Deaths (CEMD) in the United
Kingdom 2000–2002, accounting for 73% of early pregnancy deaths.
[3] Furthermore, it is still the most common cause of maternal deaths
in the first trimester.[4]
• Two thirds of women who died from ectopic pregnancy were
misdiagnosed in primary care or Accident and Emergency.[3]
SITES
• The most common site for implantation is the fallopian tube; however,
the conceptus may implant in the ovaries, the cervix, or the abdomen.
[1,2] 
DEFINITION
• definite ectopic pregnancy: extrauterine gestational sac with yolk sac
and/or embryo
• probable ectopic pregnancy: heterogeneous mass in the adnexal area
• pregnancy of unknown location: no evidence of either an intrauterine
or an extrauterine pregnancy
• probable intrauterine pregnancy: visualization of an intrauterine ring
structure
• definite intrauterine pregnancy: intrauterine gestational sac with yolk
sac and/or embryo.
RISK FACTOR OF ECTOPIC
PREGNANCY
Factors
High risk Moderately elevated risk Mildly elevated risk
(OR >4.0) (OR >2.0) (OR <2.0)<
•prior tubal surgery •sterility •age over 40 years
•adjusted OR: 4.0 (2.6–6.1); OR: 4.7– •adjusted OR: 2.1–2.7; OR: 2.5–21.0 •(OR: 1.4–6.1)
21.0

•prior extrauterine pregnancy •current or prior ascending infection

•(OR: 6.0–11.5) •adjusted OR: 3.4 (2.4–5.0); OR: 2.5–
3.7

•sterilization •cigarette smoking

•(OR: 4.9–18.0) •adjusted OR: 1.5 (1.1–2.2); OR: 2.3–
2.5

•use of intrauterine device •more than one sexual partner (OR:

•adjusted OR: 2.4 (1.2–4.9); OR: 4.2– 2.1–2.5)
45.0

•intrauterine exposure to •tubal pathology

diethylstilbestrol •adjusted OR: 3.7 (1.2–4.8); OR:
•(OR: 2.4–13.0) 2.5–3.5
DIAGNOSTIC ALGORITHM
TVUS FINDINGS: EMPTY UTERUS

Transvaginal gray-scale image of the empty uterus in the sagittal plane.

TVUS FINDINGS

• Transvaginal ultrasound scan

showing a pseudosac in the
uterus (black arrow) with a
live ectopic pregnancy in the
adnexa (white arrow).
TVUS FINDINGS (2)

• Transvaginal ultrasound scan showing

an empty uterus (short white arrow,
pointing toward the thin white
horizontal linear shadow, the
endometrium) and a mass in the
pouch of Douglas (black arrow) with
some free fluid (long white arrow).
TVUS FINDINGS (3)
• A. In this 20-year-old woman with a positive pregnancy test presenting to the emergency department with
pelvic pain and vaginal spotting, there is an adnexal mass with echogenic ring (arrow). B. A color Doppler
image of the right adnexa shows increased vascularity in the echogenic ring. The patient was diagnosed with
ectopic pregnancy based on a clinical and sonographic assessment and was treated successfully with
methotrexate.
TVUS FINDINGS (4)
• In a 21-year-old woman
presenting to the emergency
department with pelvic pain
and a positive pregnancy test,
simple free fluid was found in
the pelvic cul-de-sac. The
patient also had an echogenic
left adnexal mass (not
included in this figure), which
was confirmed to be an
ectopic pregnancy
intraoperatively.
TVUS FINDINGS (5)
• In this 22-year-old woman with a
prior history of ectopic pregnancy
presenting to the emergency
department with pelvic pain and a
positive pregnancy test, a large
volume of complex free fluid with
internal echogenicity was found in
the pelvic cul-de-sac, most likely
representing hemoperitoneum. A
ruptured tubal ectopic pregnancy
was confirmed intraoperatively.
TVUS FINDINGS (6)
• Pseudogestational sac in an ectopic pregnancy.A 28-year-old woman with a positive pregnancy test
presented to the emergency department with right lower quadrant pain. A. A small amount of free fluid is seen
within the endometrial cavity, without evidence of a yolk sac or embryo (arrow). It is irregularly-shaped and
centrally located, rather than in the eccentric location often seen with a normal gestational sac. However, it
should be noted that in a woman with a positive β-human chorionic gonadotropin (β-hCG) test, any intrauterine
sac-like fluid collection seen on ultrasound is highly likely to be a gestational sac. B. There is a right adnexal
mass with an echogenic ring (open arrow), suspicious for ectopic pregnancy. This patient was followed
clinically with serial β-hCG testing, and she was later diagnosed with ectopic pregnancy and treated medically.
OVARIAN ECTOPIC
PREGNANCY (OEP)
EPIDEMIOLOGY
• Ovarian ectopic pregnancy (OEP) is an uncommon type of
ectopic gestation that is difficult to diagnose, may even present
as a complex adnexal mass mimicking an ovarian tumor [1,2]
and is often discovered during surgery.
• OEP constitutes approximately 3% of all ectopic cases
• OEP occurs naturally, but its incidence following in
vitro fertilization and embryo transfer (IVF-ET) increases.
Marcus and Brinsden [3] reported an incidence of 6% of OEP
conceived after IVF-ET.
PATHOPHYSIOLOGY
• OEP occurs when a fertilized ovum implants on the surface of the ovary. It can be categorized
into primary and secondary classifications wherein primary OEP usually occurs due to ovulatory
dysfunction and the ovum is fertilized while still within the follicle, before the follicle being expelled
from the ovary.3
•  Secondary OEP occurs when fertilization takes place within the fallopian tube and the conceptus
is regurgitated and implanted in the ovarian stroma.3
• OEP can also be further characterized into intrafollicular and extrafollicular.3
•  Intrafollicular OEP, also called failure of follicular expulsion, occurs when the ovum is fertilized
within the follicle inside of the ovary and is very rare.8
•  Extrafollicular OEP occurs when the ovum is fertilized and subsequently migrates to and implants
on the ovary.8
•  Intrafollicular OEP occurs as mostly primary, whereas extrafollicular can be primary or secondary.
3

•  Classification of OEP into primary or secondary does not affect the overall management of the
patient because both are managed in a similar manner.9
CAUSES
• 1.Embryo migration related to the presence of certain conditions
that cause fallopian tube epithelial damage that alters tubal
motility6
• 2.A hindrance in the release of the ovum from the ruptured
follicle2
• 3.Inflammatory thickening of the tunica albuginea. 5
RISK FACTOR OF OEP
History of intrauterine contraceptive device use

Pelvic inflammatory disease

• An IUCD is the
Sexually transmitted infections most significant
Use of assisted reproductive technologies risk factor,
Prior pelvic surgery accounting for up
Endometriosis to 57% to 90% of
Previous ectopic pregnancy patients with
Salpingitis primary OEP.
Advanced maternal age

Multiparity

Infertility (rare)
RISK FACTOR: PID, IUD
• Pelvic inflammatory disease does not have an effect on ovarian
ectopic pregnancy like it does on tubal pregnancy [9, 14].
• IUDs are thought to be a main factor in ovarian ectopic
pregnancy cases according to the majority of studies. It is
believed that IUDs trigger mild inflammation that disturbs the
ciliary activity of the endosalpinx and leads to ovum transport
delay and ectopic implantation [15, 16].
RISK FACTOR: IUD
• The theory behind this is that although the IUCD provides protection from intrauterine
implantation, it does not prevent ovarian implantation.11
•  Specifically, it is thought that the IUCD may potentiate ovarian implantation due to
changes in prostaglandin synthesis that subsequently increases tubal peristalsis.11
• Although there is a known correlation between a history of PID and prior pelvic surgery
in tubal ectopic pregnancies, these risk factors may not play a significant role in OEP. 2
•  PID can lead to a reduction of tubal motility or thickening of the ovarian albuginea
caused by the natural inflammatory response. Theoretically, this thickening can result in
a reduction of follicular dehiscence subsequently leading to an increased risk of OEP.10
•  It is also suggested that scarring of the fallopian tube from PID can prevent the
fertilized ovum from migrating into the uterus and lead to tubal implantation. However,
this scarring-impaired migration is less likely to result in ovarian implantation.
CLINICAL MANIFESTATION
Mild to moderate pelvic or lower abdominal pain

Vaginal bleeding

Amenorrhea/menstrual irregularities

Nausea

Vomiting

Constipation

Hypovolemic shock (if ruptured)

EXAMINATION FINDINGS
• Clinical examination and laboratory findings include lower
abdominal tenderness with or without rigidity or guarding,
vaginal bleeding, adnexal tenderness, palpable adnexal mass,
positive pregnancy test, and elevated beta-human chorionic
gonadotropin (β-hCG) level.12
•  A positive qualitative pregnancy test and single measurement
of the quantitative β-hCG level alone cannot differentiate an
intrauterine pregnancy from an ectopic pregnancy.
PATHOGNOMONIC SIGN
• A true ovarian pregnancy cannot be separated from the ovarian
tissue (a negative “sliding organ sign”). This can be evaluated
by applying gentle pressure to the mass by means of the
endovaginal probe from within or with manual compression of
the patient’s abdomen by hand. Most extrauterine pregnancies
will be clearly separated from the ovary using this technique,
although there can be some overlap in appearance, as a tubal
pregnancy can become adherent to the ovary.11
DIAGNOSTIC APPROACH
• In all sexually active women of reproductive age who present with lower abdominal
pain, with or without vaginal bleeding, an ectopic pregnancy must be excluded. A
qualitative urine dipstick test for beta-hCG (urinary pregnancy test) must be carried
out.[4,5] This is a quick, easy, and sensitive test. It has a sensitivity of 99% at a urine
beta-hCG level greater than 25 IU/L.[4] If a woman has a negative urinary
pregnancy test, this almost invariably means that she does not have an ectopic
pregnancy.[4] However, if it is positive the woman should have a USS.[4,5]
• Gracia and Barnhart[6] compared different methods of diagnosing ectopic
pregnancy using combinations of transvaginal ultrasound plus biochemistry (serum
progesterone and serum beta-hCG), ultrasound only, and clinical examination
without ultrasound. The study found that the most accurate method of diagnosing
ectopic pregnancy was using a combination of ultrasound followed by beta-hCG.
DIAGNOSTIC APPROACH
• A recently published review by Sawyer and Jurkovic[2] found that the most accurate way to
diagnose an ectopic pregnancy is the use of a combination of ultrasonography, serum beta-hCG, and
histology, either following laparoscopy or dilatation and curettage (D&C). However, unlike
ultrasonography, neither biochemistry nor histology are available immediately, and when presented
with a pregnant woman with pain and/or vaginal bleeding, clinicians must urgently exclude an
ectopic pregnancy. As such, the initial investigation should be ultrasonography.
• In addition to having a transabdominal ultrasound scan, a symptomatic woman with a positive
urinary pregnancy test should also have a transvaginal ultrasound scan (TVS) performed. The use of
TVS in the diagnosis of ectopic pregnancy has become widely accepted and practiced. Transvaginal
ultrasonography has transformed the assessment of problems in early pregnancy.[5] It is suggested
that transvaginal ultrasonography is the “ultimate diagnostic tool” in the diagnosis of ectopic
pregnancy.[7] In fact, Condous upholds that “transabdominal ultrasonography is an outdated
modality which is not diagnostic of ectopic pregnancy and should no longer be used.[4]” However,
transabdominal scans are still very informative because TVS can miss some suprapubic pathology.
Comparing the 2 ultrasonographic modalities, it has been said that the diagnostic reliability of
transabdominal ultrasonography is around 70%, whereas that of TVS, under ideal conditions, is
more than 90%.[8]
DIAGNOSIS
• The diagnosis of OEP includes medical history, physical
examination, transvaginal ultrasonography (TUS) with color
and/or power Doppler and serum quantitative β-hCG levels.
• The gold standard for definitive diagnosis and management of
OEP is surgical laparoscopy or laparotomy with histopathologic
confirmation.
• Advantages of laparoscopic surgery versus laparotomy include
shorter operating times, less intraoperative blood loss, shorter
hospital stay, and decreased need for postoperative analgesia
• In the hemodynamically stable patient, further diagnostic evaluation should include
transvaginal ultrasound (TV-US).13
• If the patient appears clinically stable at the time of the diagnostic evaluation and
early OEP versus corpus luteum cyst is suspected, close follow-up with serial β-
hCG measurements and TV-US in 2 to 3 days can be considered after
consultation with obstetrics-gynecology.
•  Correlation of serial quantitative β-hCG level measurements with TV-US findings
can aid in accurate interpretation in regards to an ectopic pregnancy. Usually, an
intrauterine gestational sac can be visualized on TV-US when the quantitative β-
hCG level is greater than 2,000 to 3,000 IU/L.14
•  An empty uterine cavity with a β-hCG level less than 2,000 to 3,000 IU/L can
signify an intrauterine pregnancy too early to visualize. Therefore, serial
quantitative β-hCG levels correlated with serial TV-US findings are recommended
to determine an early intrauterine pregnancy from ectopic pregnancy.
DEFINITIVE DIAGNOSTIC CRITERIA
(Spiegelberg)
• 1) The Fallopian tube with its fimbria should be intact and
separate from the ovary.
• 2) The gestational sac should occupy the normal position of the
ovary.
• 3) The gestational sac should be connected to the uterus by the
ovary ligament.
• 4) Ovarian tissue must be present in the specimen attached to the
gestational sac.
these are surgical criteria; none of these criteria can be established
by ultrasonography
SUGGESTED SONOGRAPHIC
DIAGNOSTIC CRITERIA
• 1.an empty endometrial cavity;
• 2.a gestational sac that is inseparable from adjacent ovarian
parenchyma;
• 3.a yolk sac and fetal pole, with or without cardiac motion,
depending on gestational age;
• 4.a wide echogenic ring with an internal echolucent area on the
ovarian surface (“ring of fire” sign);
• 5.the presence of an ovarian cortex, including corpus luteum or
follicles near the mass; and
• 6.echogenicity of the ring that is usually larger than the ovary itself.
SUGGESTED SONOGRAPHIC
DIAGNOSTIC CRITERIA (2)
• empty uterine cavity
• the thickened endometrium
• free fluid
SUGGESTED SONOGRAPHIC
DIAGNOSTIC CRITERIA (3)
• a wide echogenic ring with an internal hypoechoic central area
on the ovarian surface
• the presence of ovarian cortex, including corpus luteum or
follicles around the mass
• the echogenicity of the ring usually greater than that of the
ovary itself [14].
SUGGESTED COMBINED DIAGNOSTIC
CRITERIA
• (1) β-hCG level > 1,000 IU/L
• (2) no gestational sac is seen on TV-US
• (3) ovarian involvement is confirmed on laparoscopy, and with
bleeding, visualization of chorionic villi, or presence of atypical
cysts on the ovary
• (4) normal fallopian tubes; and
• (5) absence of serum β-hCG level after treatment.11
DIAGNOSTIC RELIABILITY
•  The sensitivity of diagnosing ectopic pregnancy using
quantitative β-hCG in combination with TUS detection of an
adnexal mass can be as high as 96% and the specificity 100%
DD
• corpus luteum cyst
• hemorrhagic ovarian cyst
• endometriotic ovarian cyst/chocolate cyst
• tubal ectopic pregnancy
• early or failed intrauterine pregnancy
• in the presence of a negative pregnancy test, appendicitis
DD: CORPUS LUTEUM
• Corpus luteum.This figure represents a 32-year-old woman who
presented to the emergency department with lower abdominal pain. A.
There is an intraovarian cystic structure with echogenic ring and internal
debris (indicated with cross-hair markings). This ovarian structure most
likely represents a corpus luteum. B. A color Doppler ultrasonography of
the same structure shows significant peripheral vascularity, which is often
seen in a corpus luteum.
DD: PARAOVARIAN CYST
• Paraovarian cyst.In a 47-year-old woman, there is an anechoic cyst
with a thin wall and posterior acoustic enhancement inferior to the
right ovary, which is compatible with a paraovarian cyst (arrow
Intraovarian vs extraovarian mass
• free movement between the ovary and an adnexal mass on
palpation during ultrasound (sliding organs sign) can assist in
differentiating intraovarian from extraovarian masses. 13
•  However, this is not useful when attempting to distinguish
between OEP, corpus luteum cyst, and hemorrhagic ovarian
cyst. The use of 3-dimensional ultrasound has been suggested
to make a difference in differentiating OEP from a corpus
luteum cyst or hemorrhagic cyst; however, use of this
technology is limited.15
CORPUS LUTEUM CYSTS, TUBAL
ECTOPIC PREGNANCY, AND OEP
• Although corpus luteum cysts, tubal ectopic pregnancies, and OEPs all
have a ring-like appearance, differences on ultrasound are usually
evident. A corpus luteum cyst appears less echogenic than the ovary, the
OEP has a ring-like structure that appears more echogenic than the ovary
itself,10
•  and a tubal ectopic pregnancy ring has a much thinner wall by
comparison.9
•  Ultrasonographic differences in the appearance of an endometriotic
ovarian cyst, or chocolate cyst, versus an OEP include the appearance of
homogenous low-level echoes with some area of increased echogenicity
(which signifies clot), without demonstrating any evidence of internal blood
flow.16
USG USAGE TO DIFFERENTIATE OEP
AND CORPUS LUTEUM
• Ultrasound diagnosis of OEP shows the empty uterine cavity, the thickened
endometrium and free fluid. It is difficult to make the differential diagnosis
with a corpus luteum as both structures are located in the ovary.
• Some studies have showed that in stimulated ovaries, despite large size and
vascularization, it is also possible to diagnose OEP with TUS and with serum
quantitative β-hCG [26,27]. Comstock et al. [4] described the ultrasonic
appearances suggestive of OEP as a wide echogenic ring surrounding a
central hypoechoic structure; these findings have been documented in
other case report [28,29].
• In evaluation of the walls of the corpus luteum and the ectopics, Stein et al. [14]
found that tubal ectopic rings were more echogenic than the corpus
luteum. With respect to color Doppler, the results are controversial because
there is an overlap distinguishing a corpus luteum from OEP. If a yolk sac or
embryo can be seen, the diagnosis is established, but this is infrequent
USG USAGE TO DIFFERENTIATE OEP
AND CORPUS LUTEUM
• The use of duplex Doppler to distinguish between an ovarian
ectopic pregnancy and a corpus luteum cyst is unreliable. They
can each display the so-called “ring of fire” sign, as both the
ectopic ring and the walls of a corpus luteum can have
significant vascularity.12,13 In addition to the use of color Doppler,
pulsed wave Doppler is likewise of limited value. Studies have
shown that there is no significant difference between the peak
systolic velocities (PSV) of an ectopic pregnancy compared to
that of a corpus luteum. The same study also concluded that
although a very high resistive index (RI > 0.7) or a very low one
(RI < 0.39) can be useful in differentiating an EP from a CLC,
there is a significant overlap between the two. 14,15
• Follow-up ultrasound findings should demonstrate that a corpus
luteum cyst shows progressive involution with increasing
crenulation of its margins, whereas an OEP will grow, with
marked thickening of the circumferential echogenic margins and
development of a yolk sac and fetal pole within the gestational
sac.13
TX
• The therapy of early ovarian pregnancy is surgical in the first line, and in the
event that the patient desires a future pregnancy, ovarian wedge resection is
preferred; the conservation of ovarian tissue is the clinical goal of the
treatment. Medical management is rarely used; only a few case reports
describe the successful medical management of OEP with methotrexate,
either intramuscular [30,31] or by local injection into the sac [32].
• On the other hand, laparoscopic treatment with systemic methotrexate was
reported as a good result [33,34]. Considering the great improvements in
laparoscopic techniques, medical treatment with methotrexate would be
relegated to a secondary option for incomplete resection or trophoblast
persistence [26,33]. In our case continuous monitoring of the patient with
serum values of β-hCG levels, and the detailed and thorough description of
ultrasound findings of the right ovary allowed for a conservative therapeutic
strategy and proper postoperative course.
TX: SURGERY
• The advantages of laparoscopy over laparotomy are more rapid access
to the abdomen, shorter surgery, less blood loss, less extensive
postoperative adhesions, faster recovery, and lower costs of
hospitalization and rehabilitation (30). Organ-preserving surgery is
associated with higher rates of retention of trophoblastic tissue (4–15
%) (1).
• Laparoscopy is the gold standard of surgical treatment for extrauterine
pregnancy. Laparotomy is performed only if laparoscopy is not
possible for technical, logistic, or medical reasons.
TX: MEDICAL MANAGEMENT
(METHOTREXATE)
• Medical management using a single dose of intramuscular
methotrexate or etoposide has been reported but is uncommon
and remains controversial. Little evidence is available regarding
medical management of OEP using methotrexate; however,
some case reports have described successful treatment. 5
•  Although a methotrexate injection is less invasive than surgery,
higher treatment failure rates and risk for ovarian bleeding have
been seen with the use of methotrexate.8
METHOTREXATE
• Methotrexate is a folic acid antagonist whose activity manifests itself chiefly in rapidly proliferating
cells at the implantation site, particularly trophoblasts (36)
• The success rate of methotrexate treatment is variably reported in the literature, with rates ranging
from 63% to 97%; this is presumably due to the heterogeneity of patient groups and inclusion criteria,
differences in methotrexate treatment protocols, and varying definitions of treatment response (32).
The two most common protocols are the single-dose and the multi-dose protocol (Table 4) (37).
• A meta-analysis of non-randomized studies revealed an 89% overall success rate of pharmacotherapy
(1181 of 1327 patients treated); the multi-dose protocol was successful significantly more often than
the single-dose protocol (93% versus 88%) but caused more side effects (37).
• The most common ones (nausea, vomiting, stomatitis, diarrhea, elevated liver enzymes) were usually
mild (38). The rarer serious side effects included renal and hepatic damage, pneumonia, dermatitis,
and pleuritis; these can be managed by adjusting the dose and duration of methotrexate treatment (36
).
METHOTREXATE TX PROTOCOLS
Protocol Dosage, mode of Timing of hCG measurement Additional
administration administration administration
Single-dose •MTX 50 mg/m² BSA •Day 1 •before treatment •MTX 50 mg/m²
IM •Day 1 BSA, IM on Day 7:
•Day 4 if hCG drops by
•Day 7 <15% from day 4 to
day 7

Multi-dose •MTX 1 mg/kg IM •Day 1 MTX •before treatment •2nd, 3rd, or 4th
•LEU 0.1 mg/kg IM •Day 2 LEU •Day 1 dose of MTX
•possiblyDay 3 MTX •Day 3 1mg/kg IM followed
•Day 4 LEU •Day 5 by LEU 0.1 mg/kg
•possiblyDay 5 MTX •Day 7 IM:if hCG drops by <
•Day 6 LEU 15% of prior hcg
•possiblyDay 7 MTX value
•Day 8 LEU
METHOTREXATE USAGE CRITERIA
(1) no signs of hemodynamic compromise
(2) no evidence of blood in the pelvis
(3) pregnancy size must be < 3.5 cm with no fetal heart activity; and
(4) β-hCG level should be < 3,500 IU/L.12

•  If used, a single dose of methotrexate by laparoscopic-assisted injection

into the ectopic site is recommended.9
•  Higher failure rates have been reported if the gestational sac is > 3.5 mm
or if the serum β-hCG level is < 5,000 IU/L.9
•  There are few recommendations for medical management to be
appropriate when the risks of surgery are high.8
•  The American Society for Reproductive Medicine does not recommend
methotrexate as the first-line treatment of OEP.14
TX: SURGICAL VS MEDICAL
Surgical treatment
•Indications
rupture
•hemodynamic instability
•symptoms (eg., pain)
•diagnostic laparoscopy
•suspected heterotopic pregnancy
Medical treatment (methotrexate)*
•Indications
hCG <5000 iu/l
•rising hCG level in 48 hours
•normal: hemoglobin, leukocytes, platelets, liver
enzymes
•diameter of gestational sac <4 cm
•Absolute contraindications
trauterine pregnancy
•imune suppression
•hypersensitivity to methotrexate
•active lung disease
•active peptic ulcer disease
•clinically significant renal or hepatic dysfunction
•breastfeeding
•ruptured extrauterine pregnancy
•hemodynamic instability
•Relative contraindications
hCG>5000 IU/L
•objection to blood transfusions
•follow-up not possible
TX: SURGICAL VS MEDICAL
Surgical treatment Medical treatment (methotrexate)*
•Surgical procedure
organ- (tube-) preserving surgery
salpingotomy
•segmental resection (partial
salpingectomy)
•transampullary expression (“milk-
out”)
•Indications for an ablative
procedure (salpingectomy)
uncontrollable bleeding
•marked tubal destruction
•ipsilateral recurrence
•prior ipsilateral sterilization

•Follow-up
weekly hCG measurement until
normalization
•persistent extrauterine
pregnancy/trophoblastic tissue:
• re-laparoscopy
• drug therapy (methotrexate)
when indicated
•Follow-up
weekly hCG measurement until
normalization
•persistent extrauterine
pregnancy/trophoblastic tissue:
• repeat methotrexate
administration
• surgery when indicated
• Operative organ-preserving treatment versus pharmacotherapy
• A Cochrane analysis and three underpowered prospective randomized
trials did not provide an adequate data base for a reliable comparison
of fertility rates after tube-preserving surgery and drug treatment with
methotrexate (29, 39). The most recent evaluation of the Auvergne
registry revealed no significant difference in fertility rates (34). Only
recently, in the context of the prospective, randomized DEMETER
trial, Fernandez et al. reported no significant difference in 2-year
fertility rates between women who had undergone these two types of
treatment, with intrauterine pregnancy rates of 71% versus 67% (32) (
Table 2)
COMPLICATION
• OEP occurs when a fertilized ovum implants on the surface of the ovary and
usually terminates with rupture in the first trimester, which can lead to internal
hemorrhage and hypovolemic shock.5
•  Although the ovary should be able to accommodate more freely than the
fallopian tube to the size of the expanding pregnancy, rupture at an early
stage is common.1
•  Overall, 91% of OEPs end in rupture during the first trimester, 5.3% end in
the second trimester, and 3.7% end in the third trimester. 6
•  Only 1 case of an OEP that advanced to full-term delivery has been reported.
7

•  High levels of maternal morbidity and mortality exist due to the infrequency of
OEP presentation and its diagnostic challenges
CASE REPORT
CASE REPORT

• Ovarian gestational sac (right: with doppler US) before methotrexate

CASE REPORT
• Sonographic findings after methotrexate treatment.This is a 31-year-old
woman who has positive but declining serial β-human chorionic gonadotropin
levels. A. There is a heterogeneous echogenic mass (arrow) in the left adnexa
adjacent to the left ovary (open arrow). The patient was diagnosed with left tubal
ectopic pregnancy and was started on medical treatment with methotrexate. B. On
a follow-up pelvic ultrasound 10 days after initiation of methotrexate treatment,
there is interval enlargement of the left tubal ectopic pregnancy (arrow) due to
surrounding hemorrhage and edema.