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Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 519–527

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Surgical treatment of ectopic pregnancy Mohammed Agdi, MD, Fellow of Reproductive Endocrinology and Infertility and Past-fellow of Advanced Gynecologic Endoscopy, Togas Tulandi, MD, MHCM, Professor of Obstetrics and Gynecology and Milton Leong Chair in Reproductive Medicine * Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada

Keywords: ectopic pregnancy tubal pregnancy interstitial pregnancy cornual pregnancy cervical pregnancy caesarean scar pregnancy ovarian pregnancy abdominal pregnancy laparoscopy laparotomy

Ectopic pregnancy remains the leading cause of death in the first trimester of pregnancy. Today, serial serum hCG measurements and transvaginal ultrasound examination can provide early detection of most ectopic pregnancies allowing medical treatment with methotrexate. In those who require surgery, the type of procedure depends on the clinical situation and the location of the pregnancy. Most of the cases can and should be performed by laparoscopy. Compared with laparotomy, the laparoscopic approach is associated with many advantages including short hospital stay, low cost and less adhesion formation. In addition, hemoperitoneum is not a contraindication for performing laparoscopy. Linear salpingostomy is the procedure of choice when unruptured tubal pregnancy is found in women who want to preserve their fertility; otherwise, salpingectomy is performed. Fertility performance after salpingostomy and salpingectomy is comparable. Similar to the case with tubal ectopic pregnancy in general, women with non-tubal ectopic pregnancy such as cervical, interstitial, or Caesarean scar pregnancy should be first treated medically with methotrexate. These types of ectopic pregnancies may be associated with massive bleeding during surgery. Precautionary procedures should be considered and these include the placement of an angiographic catheter for possible uterine artery embolization. These pregnancies can also be treated laparoscopically. Ó 2009 Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Obstetrics and Gynecology, McGill University, Women’s Pavilion, 687 Pine Avenue West, Montreal, H3A 1A1, Quebec, Canada. Tel.: +1 514 340 8222x4920; Fax: þ1 514 843 1448. E-mail address: (T. Tulandi). 1521-6934/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.bpobgyn.2008.12.009


M. Agdi, T. Tulandi / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 519–527

The estimated incidence of ectopic pregnancy is 1–2%1, and the traditional treatment is surgery by laparotomy. With early diagnosis, treatment may be carried out using laparoscopy, or by medical treatment. In fact, most ectopic pregnancies in our institution are first managed medically; however, some cases still need surgical treatment, and today the majority of these are laparoscopic. Site of ectopic pregnancies Besides the hemodynamic status of the patient, the site of the ectopic pregnancy determines the type of surgery. Table 1 demonstrates the location of ectopic pregnancy.2 The most common site is in the ampulla of the tube, and the least is in the cervix or in the abdominal cavity.2,3 Very rarely, it is found retroperitoneally or after a hysterectomy.4–6 It is important to establish the diagnosis as early as possible. This may be accomplished by having a high index of suspicion, the use of serum human chorionic gonadotropin (hCG) levels, and transvaginal ultrasound examination.7 The risk factors of ectopic pregnancy are depicted in Table 2. Management of ectopic pregnancy The management of ectopic pregnancy can be expectant, medical, or surgical. The choice depends on the clinical circumstances, site of ectopic pregnancy, and serum hCG levels. We use expectant management only in those with low and declining serum hCG levels. Spontaneous resolution of ectopic pregnancy has been reported in 47.7–69.2% of cases.8,9 Discussion on medical management of ectopic is beyond the scope of our review. However, in appropriately selected patients, the success rate of medical treatment with methotrexate is up to 90%.9–11 Surgical treatment and approaches In 1955, Jeffcoate suggested that salpingo-oophrectomy for the treatment of ectopic pregnancy prevented future recurrence.12 Improvements in the diagnosis and treatment has made this dogma obsolete. Three randomized studies have demonstrated the advantages of laparoscopy over laparotomy for the treatment of ectopic pregnancy.13–15 Compared with laparotomy, laparoscopy is associated with less blood loss, shorter hospital stay, lower cost, and less adhesion formation. Laparoscopy in the presence of hemoperitoneum Ectopic pregnancy is still the most common cause of mortality in the first trimester of pregnancy. Indeed, with massive bleeding in a relatively short time, hemorrhagic shock may occur. However, with gradual bleeding most patients remain hemodynamically stable despite a hemoperitoneum of 1000 to 1500 ml.16 Regardless of the surgical approach, a patient who is hemodynamically unstable has to be stabilized first. This includes intravenous infusion of crystalloid solution or blood if necessary, and close monitoring of input and output. Concerns regarding performing laparoscopy in bleeding patients relate to the creation of the pneumoperitoneum and possible delay in controlling the bleeding. Pneumoperitoneum exerts Table 1 Incidence of different types of ectopic pregnancy. Type

Incidence (%)

Ampullary Isthmic Fimbrial Interstitial Ovarian Intra-abdominal Cervical

70 12 11.1 2.4 3.2 1.3 <1

M. Agdi, T. Tulandi / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 519–527


Table 2 Risk factors for ectopic pregnancy. (Reproduced with permission from UpToDate). High risk Previous ectopic pregnancy Previous tubal surgery/pathology Tubal ligation History of in utero exposure to diethylstilbestrol Current IUD use Moderate risk Infertility and infertility treatments Pelvic inflammatory disease Previous cervicitis (gonorrhea, chlamydia) Cigarette smoking Low risk Previous pelvic surgery Vaginal douching

pressure against the diaphragm and blood vessels decreasing the cardiac output. However, this effect is counteracted by the Trendelenburg position. Further, the increase in intra-abdominal pressure provides tamponade to the bleeding vessels and decreases the bleeding. Depending on the expertise of the operator, most skilled laparoscopists will be able to obtain hemostasis in a short time. Following trocar insertion, the laparoscope is inserted gradually. Without touching the blood in the peritoneal cavity, the tip of the scope will remain clean and it allows immediate visualization of the pelvic organs. Otherwise, it has to be cleaned repeatedly and it will delay hemostasis. The pelvic organs may be completely covered by blood. By anteflexing the uterus with the uterine manipulator, the Fallopian tube can be identified and the bleeding immediately secured.17 Once the bleeding is controlled, evacuation of the blood can be performed. Not uncommonly, bleeding is due to tubal abortion only. Tubal pregnancy The most common form of ectopic pregnancy is tubal pregnancy. Depending on the patient’s condition and fertility status, site and condition of the Fallopian tube, there are several surgical techniques. Linear salpingostomy Linear salpingostomy is the procedure of choice when unruptured tubal pregnancy is found in women who want to preserve their fertility. One starts by immobilizing the tube with an atraumatic grasper. We inject diluted vasopressin (0.2 IU/ml of normal saline) into the area of tube with maximal distention. Linear salpingostomy is performed by making a longitudinal 1 cm incision on the antemesosalpinx part of the tube using monopolar needle cautery, or laser. Using a suction irrigator, the gestational product is flushed out of the tube (Figs. 1, 2). Bleeding can be controlled either by mechanical pressure or by coagulation using fine tip microbipolar forceps. If bleeding persists, we ligate the blood vessels in the mesosalpinx. The tubal stoma is left open to heal by secondary intention.18 Fimbrial expression Fimbrial pregnancy is located in the fimbria, the most distal part of the Fallopian tube. As the pregnancy usually results in tubal abortion, gentle fimbrial expression of the pregnancy from the tube may be all that is required. This is achieved by applying pressure on the fimbrial end with atraumatic grasping forceps. If unsuccessful, linear salpingostomy is performed. Recurrent ectopic pregnancy after fimbrial expression is atypical. In one case series involving 31 women treated by fimbrial expression no recurrence was reported.19 The overall rate of recurrent ectopic pregnancy after linear salpingostomy is 15.4%.9


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Fig. 1. A longitudinal incision on the antemesosalpinx of the tube. (Reproduced with permission from Atlas of Laparoscopy and Hysteroscopy Technique, 3rd edition (Ed. T. Tulandi), Informa, London, 2007).

Salpingectomy Salpingectomy is removing a segment of the Fallopian tube that contains the ectopic gestation (partial salpingectomy) or the entire Fallopian tube (total salpingectomy). Salpingectomy vs. salpingostomy Pregnancy rates after linear salpingostomy and salpingectomy are comparable if the contralateral Fallopian tube is normal.20 Langer et al. reported that the rate of recurrent ectopic pregnancy is 7% if the contralateral tube is normal and 18 and 25% if the opposite tube is abnormal or absent.21 In a prospective study, Olofsson et al. reported that the pregnancy rates after salpingostomy, salpingectomy or methotrexate treatment were not signiďŹ cantly different.22 In a retrospective cohort

Fig. 2. Flushing out the products of conception. (Reproduced with permission from Atlas of Laparoscopy and Hysteroscopy Technique, 3rd edition (Ed. T. Tulandi), Informa, London, 2007).

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study, 88 patients underwent either linear salpingostomies or salpingectomies were followed up until 12 years.23 The authors could not find any difference in the pregnancy rate between the two groups. Fertility performance after surgery appears to be related to reproductive performance before the ectopic pregnancy. In 1997, Yao and Tulandi reviewed the literature of different treatments for tubal pregnancy including 1514 patients treated with salpingostomy, 3584 patients with total salpingectomy and 540 patients with methotrexate. Among patients who attempted to conceive, the subsequent intrauterine pregnancy rate was 61.4% after salpingostomy, 38.1% after partial or total salpingectomy, and 54% after methotrexate treatment. The recurrent ectopic pregnancy rates after salpingostomy, salpingectomy and methotrexate treatment were 15.4, 9.8 and 8%, respectively.9,53 The criteria of methotrexate treatment is shown in Table 3. Persistent ectopic pregnancy A meta-analysis of randomized controlled trials demonstrated that laparoscopic salpingostomy is associated with a higher persistent trophoblastic rates but is more cost effective than open laparotomy.24 In another report, the rates of persistent ectopic pregnancy after laparoscopic salpingostomy and laparotomy were 16 and 2% respectively.25 Perhaps, this difference is related to the surgeon’s experience and expertise in laparoscopy. In any event, if there is a possibility that some trophoblastic tissue is left in situ, a single dose of methotrexate can be administered. Tubal patency The tubal patency rate after salpingostomy by laparoscopy or laparotomy is similar, but the incidence of adhesion formation is significantly higher when laparotomy is used.26 Non-tubal ectopic pregnancy Management of non-tubal ectopic pregnancy depends a great deal on its location. Interstitial ectopic pregnancy Interstitial or cornual pregnancy is located in the intra-myometrial portion of the Fallopian tube. It is atypical and can occur even after salpingectomy. For patients who fulfill the criteria for medical management, the current first line of treatment is systemic methotrexate. In those requiring surgery, cornual resection or salpingostomy can be performed. Depending on the surgeon’s preference and expertise, the procedure may be carried out laparoscopicaly.27 The overall success rates of surgical treatment approaches 100%, and of methotrexate treatment 83%.28 Owing to the difficulty in obtaining hemostasis during cornual resection29, several authors have described techniques to minimize the bleeding.30,31 These include the use of monopolar electrocautery or harmonic scalpel, and the administration of diluted vasopressin into the uterus. Osuga et al32 advocated clamping the adjacent uterine wall proximal to the cornual pregnancy with long-jaw forceps before incising the cornua. Similar to the closure of a myomectomy incision, the myometrial defect should be sutured thoroughly. Table 3 Clinical criteria for Methotrexate administration for ectopic pregnancy (Reproduced with permission from UpToDate). Hemodynamic clinical stability Unruptured ectopic pregnancy Size of ectopic < 4 cm Initial ß-hCG < 10,000 mUI/ml Patient’s compliance with subsequent follow-up No medical conditions contraindicating methotrexate therapy


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Hysteroscopic removal of interstitial ectopic pregnancy has also been described33,34, however, the efficacy and long-term results of this technique are unknown. Due to the risks of uterine rupture after an interstitial pregnancy, any subsequent pregnancy should be monitored carefully, and we suggest a Caesarean delivery at term to avoid the risk of uterine rupture during labor. Cervical pregnancy Cervical pregnancy is a pregnancy located in the endocervix. It is often mistaken as an incomplete miscarriage, cervical or prolapsed fibroid, a low-implanted placenta, cervical cancer or trophoblastic tumor. The diagnosis is established principally using transvaginal ultrasonography, or occasionally MRI. The typical clinical findings are of a closed internal os with or without dilated external os. Similar to other types of ectopic pregnancy, the initial treatment is methotrexate administration. Several case series and retrospective studies have demonstrated over 90% success rate with local or systemic methotrexate.3,35–37 These approaches are discussed in more detail elsewhere. Some cases still require surgery, however, cervical pregnancies are vascular, and surgery might be associated with severe hemorrhage. In the worst case scenario, women with uncontrolled bleeding might need a hysterectomy. Preoperative preparation is therefore very important. The patient should be informed about the possibility of life-threatening hemorrhage that may require blood transfusion or hysterectomy. She should have an intravenous line with a large bore needle, 4 units of blood for possible transfusion, and the patient should have a Foley catheter for accurate monitoring of intake and output. In women who wish to preserve their fertility, insertion of an angiographic catheter to the uterine arteries should be considered. In the presence of uncontrolled bleeding, arterial embolization could be carried out in order to preserve the uterus. Surgical attempts to reduce the bleeding include the application of cervical cerclage before evacuation of the pregnancy. The cerclage is applied close the level of the internal os to occlude the blood vessels supplying the cervix. These vessels are usually engorged in the pregnant state. Alternatively, one could ligate the descending branch of the uterine vessels vaginally. Ovarian pregnancy Ovarian pregnancy is the most common type of non-tubal pregnancy. The diagnosis is usually made at the time of surgery and preoperatively the diagnosis is correct in only 26% of cases.38 Ultrasonographically, ovarian pregnancy can be mistaken as a corpus luteum or hemorrhagic cyst, and a rightsided ovarian pregnancy can be confused with appendicitis or appendiceal mass. Surgical treatment consists of simple evacuation of the gestational products or ovarian wedge resection in the presence of a large ectopic mass; occasionally, oophorectomy is required. Abdominal pregnancy Abdominal pregnancy is extremely rare, and early diagnosis is difficult. It can be found anywhere in the peritoneal cavity including on the bowel, appendix, or broad ligaments. Rarely, it occurs after a hysterectomy.39–41 Findings of early abdominal pregnancy at laparoscopy or laparotomy should be followed by its removal. Occasionally, abdominal pregnancy is diagnosed early by ultrasound. The patient can be treated with systemic methotrexate and feticide under ultrasound guidance. Undiagnosed abdominal pregnancy can progress until an advanced stage with a viable gestation. However, in most cases fetal demise occur with symptoms of intra-abdominal bleeding. Late abdominal pregnancy should be managed by laparotomy. Due to the risks of severe bleeding from the placental attachment, one should ligate the umbilical cord closed to the placenta, and the placenta is left in situ. Postoperatively, serial measurements of serum hCG levels are performed. It might take 3–4 months before the serum hCG is undetectable, and the placental mass regresses.42 The process could be shortened by systemic administration of methotrexate. In women who are lactating, embolization of the placental blood vessels is an alternative.

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Caesarean scar ectopic pregnancy With the increasing number of caesarean deliveries over the past decade, a few authors have reported ectopic pregnancy in the uterine scar. It usually appears as a ballooning in the anterior low uterine wall.43,44 Caesarean scar pregnancy can rupture leading to intraperitoneal bleeding. Treatment consists of medical treatment with methotrexate, uterine artery embolization or surgery.45–47 In those who need surgery, excision of the uterine scar containing the ectopic pregnancy is performed. Surgical management allows repair of the defected Caesarean scar which may decrease the risk of recurrence. Surgery may be carried out by laparoscopy or laparotomy. Entry into the uterine cavity might be required if the ectopic gestation is located deep in the myometrium; hysterectomy is rarely needed.48–52 Other approaches to managing these pregnancies are discussed in the chapter on non-tubal ectopic pregnancies. Conclusions Ectopic pregnancy remains the leading cause of death in the first trimester of pregnancy. Today, transvaginal ultrasound examination facilitates early detection of most ectopic pregnancies allowing medical treatment with methotrexate. In those who require surgery, the surgery of choice is laparoscopy, and in women with tubal pregnancy laparoscopic salpingostomy. Other types of ectopic pregnancy including cornual, abdominal or Caesarean-scar pregnancies can also be treated laparoscopically.

Practice points  Laparoscopy is a safe and effective surgical intervention in treating ectopic pregnancy.  Depending on the surgeon’s preference, laparoscopic surgery may be safely carried out in the presence of hemoperitoneum.  Compared with laparotomy, laparoscopic surgery has many advantages including short hospital stay, and less adhesion formation.  Conservative surgery of tubal pregnancy (salpingostomy) should be performed in women who desire to preserve their fertility.  Most ectopic pregnancies can first be treated medically with methotrexate.  Non-tubal ectopic pregnancies such as cervical, interstitial, or Caesarean-scar pregnancy can be associated with massive bleeding during surgery. Precautionary procedures should be considered and these include the placement of angiographic catheter for possible uterine artery embolization.

Research agenda  Treatment of tubal pregnancy has been well established. However, the best management of non-tubal pregnancies including cervical and Caesarean scar pregnancies remains unclear. Due to their low incidence, most authors have published only case reports of small number of patients. A multicenter study or a registry of these cases will provide a better understanding of unusual ectopic pregnancies and their treatment.

References 1. Goldner TE, Lawson HW, Xia Z et al. Surveillance for ectopic pregnancy–United States, 1970–1989. MMWR CDC Surveill Summ 1993; 42: 73–85. 2. Bouyer J, Coste J, Fernandez H et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 2002; 17: 3224–3230.


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3. Marcovici I, Rosenzweig BA, Brill AI et al. Cervical pregnancy: case reports and a current literature review. Obstet Gynecol Surv 1994; 49: 49–55. 4. Iwama H, Tsutsumi S, Igarashi H et al. A case of retroperitoneal ectopic pregnancy following IVF-ET in a patient with previous bilateral salpingectomy. Am J Perinatol 2008; 25: 33–36. 5. Isaacs Jr JD, Cesare Sr CD & Cowan BD. Ectopic pregnancy following hysterectomy: an update for the 1990s. Obstet Gynecol 1996; 88: 732. 6. Alexander AR & Everidge GJ. Ectopic pregnancy following total vaginal hysterectomy. Obstet Gynecol 1979; 53: 7S–8S. 7. Cacciatore B. Can the status of tubal pregnancy be predicted with transvaginal sonography? A prospective comparison of sonographic, surgical, and serum hCG findings. Radiology 1990; 177: 481–484. 8. Shalev E, Peleg D, Tsabari A et al. Spontaneous resolution of ectopic tubal pregnancy: natural history. Fertil Steril 1995; 63: 15–19. 9. Yao M & Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril 1997; 67: 421–433. 10. Canis M, Savary D, Pouly JL et al. Ectopic pregnancy: criteria to decide between medical and conservative surgical treatment?. J Gynecol Obstet Biol Reprod (Paris) 2003; 32: S54–S63. *11. Alleyassin A, Khademi A, Aghahosseini M et al. Comparison of success rates in the medical management of ectopic pregnancy with single-dose and multiple-dose administration of methotrexate: a prospective, randomized clinical trial. Fertil Steril 2006; 85: 1661–1666. 12. Jeffcoate TN. Salpingectomy or salpingo-oophorectomy? J Obstet Gynaecol Br Emp 1955; 62: 214–215. *13. Lundorff P, Thorburn J, Hahlin M et al. Laparoscopic surgery in ectopic pregnancy. A randomized trial versus laparotomy. Acta Obstet Gynecol Scand 1991; 70: 343–348. *14. Murphy AA, Nager CW, Wujek JJ et al. Operative laparoscopy versus laparotomy for the management of ectopic pregnancy: a prospective trial. Fertil Steril 1992; 57: 1180–1185. *15. Vermesh M, Silva PD, Rosen GF et al. Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy. Obstet Gynecol 1989; 73: 400–404. 16. Mohamed H, Maiti S & Phillips G. Laparoscopic management of ectopic pregnancy: a 5-year experience. J Obstet Gynaecol 2002; 22: 411–414. *17. Tulandi T & Kabli N. Laparoscopy in patients with bleeding ectopic pregnancy. J Obstet Gynaecol Can 2006; 28: 361–365. 18. Tulandi T & Guralnick M. Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy. Fertil Steril 1991; 55: 53–55. 19. Sherman D, Langer R, Herman A et al. Reproductive outcome after fimbrial evacuation of tubal pregnancy. Fertil Steril 1987; 47: 420–424. 20. Kjellberg L, Lalos A & Lalos O. Reproductive outcome after surgical treatment of ectopic pregnancy. Gynecol Obstet Invest 2000; 49: 227–230. 21. Langer R, Bukovsky I, Herman A et al. Conservative surgery for tubal pregnancy. Fertil Steril 1982; 38: 427–430. 22. Olofsson JI, Poromaa IS, Ottander U et al. Clinical and pregnancy outcome following ectopic pregnancy; a prospective study comparing expectancy, surgery and systemic methotrexate treatment. Acta Obstet Gynecol Scand 2001; 80: 744–749. 23. Ory SJ, Nnadi E, Herrmann R et al. Fertility after ectopic pregnancy. Fertil Steril 1993; 60: 231–235. *24. Hajenius PJ, Mol F, Mol BW et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007. CD000324. 25. Pouly JL, Mahnes H, Mage G et al. Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steril 1986; 46: 1093–1097. *26. Lundorff P, Hahlin M, Kallfelt B et al. Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. Fertil Steril 1991; 55: 911–915. 27. Tulandi T & Saleh A. Surgical management of ectopic pregnancy. Clin Obstet Gynecol 1999; 42: 31–38. quiz 55–6. 28. Lau S & Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999; 72: 207–215. *29. Tang A, Baartz D & Khoo SK. A medical management of interstitial ectopic pregnancy: a 5-year clinical study. Aust N Z J Obstet Gynaecol 2006; 46: 107–111. 30. Goldberger SG, Rosen DJ, Cohen II et al. Laparoscopic resection of a cornual pregnancy: a first case report. J Am Assoc Gynecol Laparosc 1994; 1: S12–S13. 31. Ferland RJ. Resection of Left Cornual Ectopic Pregnancy by Ultrasonically Activated Scalpel. J Am Assoc Gynecol Laparosc 1994; 1: S11. 32. Osuga Y, Tsutsumi O, Fujiwara T et al. Usefulness of long-jaw forceps in laparoscopic cornual resection of interstitial pregnancies. J Am Assoc Gynecol Laparosc 2001; 8: 429–432. 33. Meyer S, Janecek P & Roenspiess U. A case of uterine rupture due to interstitial pregnancy of 22 weeks duration (author’s transl). J Gynecol Obstet Biol Reprod (Paris) 1981; 10: 235–240. 34. Budnick SG, Jacobs SL, Nulsen JC et al. Conservative management of interstitial pregnancy. Obstet Gynecol Surv 1993; 48: 694–698. 35. Vela G & Tulandi T. Cervical pregnancy: the importance of early diagnosis and treatment. J Minim Invasive Gynecol 2007; 14: 481–484. *36. Stovall TG, Ling FW, Smith WC et al. Successful nonsurgical treatment of cervical pregnancy with methotrexate. Fertil Steril 1988; 50: 672–674. 37. Oyer R, Tarakjian D, Lev-Toaff A et al. Treatment of cervical pregnancy with methotrexate. Obstet Gynecol 1988; 71: 469–471. 38. Shiau CS, Hsieh CL & Chang MY. Primary ovarian pregnancy. Int J Gynaecol Obstet 2007; 96: 127. 39. Nama V, Gyampoh B, Karoshi M et al. Secondary abdominal appendicular ectopic pregnancy. J Minim Invasive Gynecol 2007; 14: 516–517. 40. Selman AN. Ectopic pregnancy (abdominal) with a living fetus that survived. Am J Surg 1957; 93: 1036–1037. 41. Brandt AL & Tolson D. Missed abdominal ectopic pregnancy. J Emerg Med 2006; 30: 171–174. 42. Cetinkaya MB, Kokcu A & Alper T. Follow up of the regression of the placenta left in situ in an advanced abdominal pregnancy using the Cavalieri method. J Obstet Gynaecol Res 2005; 31: 22–26.

M. Agdi, T. Tulandi / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 519–527


43. Moschos E, Sreenarasimhaiah S & Twickler DM. First-trimester diagnosis of cesarean scar ectopic pregnancy. J Clin Ultrasound 2008. 44. Pascual MA, Hereter L, Graupera B et al. Three-dimensional power Doppler ultrasound diagnosis and conservative treatment of ectopic pregnancy in a cesarean section scar. Fertil Steril 2007; 88(706): e5–e7. 45. Iyibozkurt AC, Topuz S, Gungor F et al. Conservative treatment of an early ectopic pregnancy in a cesarean scar with systemic methotrexate–case report. Clin Exp Obstet Gynecol 2008; 35: 73–75. 46. Hois EL, Hibbeln JF, Alonzo MJ et al. Ectopic pregnancy in a cesarean section scar treated with intramuscular methotrexate and bilateral uterine artery embolization. J Clin Ultrasound 2008; 36: 123–127. 47. Graesslin O, Dedecker Jr F, Quereux C et al. Conservative treatment of ectopic pregnancy in a cesarean scar. Obstet Gynecol 2005; 105: 869–871. 48. Chueh HY, Cheng PJ, Wang CW et al. Ectopic twin pregnancy in cesarean scar after in vitro fertilization/embryo transfer: case report. Fertil Steril 2008. 49. Wang YL, Su TH & Chen HS. Laparoscopic management of an ectopic pregnancy in a lower segment cesarean section scar: a review and case report. J Minim Invasive Gynecol 2005; 12: 73–79. 50. Holland MG & Bienstock JL. Recurrent ectopic pregnancy in a cesarean scar. Obstet Gynecol 2008; 111: 541–545. 51. Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet Gynecol Surv 2002; 57: 537–543. 52. Ben Nagi J, Ofili-Yebovi D, Sawyer E et al. Successful treatment of a recurrent Cesarean scar ectopic pregnancy by surgical repair of the uterine defect. Ultrasound Obstet Gynecol 2006; 28: 855–856. *53. Tulandi T. Surgical treatment of ectopic pregnancy and prognosis for subsequent fertility. UpToDate. Clinical Reference Library. Available from: