Skip to main content
SpringerLink
Log in

Pregnancy of Unknown Location and Ectopic Pregnancy

  • Chapter
  • First Online:
Handbook of Consult and Inpatient Gynecology

  • 1003 Accesses

Abstract

Pregnancies of unknown location are diagnosed in patients with positive serum human chorionic gonadotropin (hCG) levels and pelvic ultrasounds without evidence of ectopic or intrauterine pregnancies. These may develop into ongoing intrauterine pregnancies, miscarriages, or ectopic pregnancies. This chapter discusses diagnostic approaches to pregnancies of unknown location, as well as the diagnosis and management of ectopic pregnancies.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Kirk E, Condous G, Bourne T. Pregnancies of unknown location. Best Pract Res Clin Obstet Gynaecol. 2009;23:493–9.

    Article  PubMed  Google Scholar 

  2. Mehta TS, Levine D, Beckwith B. Treatment of ectopic pregnancy: is a human chorionic gonadotropin level of 2000 mIU/mL a reasonable threshold? Radiology. 1997;205:569–73.

    Article  CAS  PubMed  Google Scholar 

  3. Doubilet PM, Benson CB. Further evidence against the reliability of the human chorionic gonadotropin discriminatory level. J Ultrasound Med. 2011;30:1637–42.

    PubMed  Google Scholar 

  4. Morse CB, Sammel MD, Shaunik A, Allen-Taylor L, Oberfoell NL, Takacs P, et al. Performance of human chorionic gonadotropin curves in women at risk for ectopic pregnancy: exceptions to the rules. Fertil Steril. 2012;97:101–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Barnhart K. Clinical practice. Ectopic pregnancy. N Engl J Med. 2009;361:379–87.

    Article  CAS  PubMed  Google Scholar 

  6. Verhaegen J, Gallos ID, van Mello NM, Abdel-Aziz M, Takwoingi Y, Harb H, et al. Accuracy of single progesterone test to predict early pregnancy outcome in women with pain or bleeding: meta-analysis of cohort studies. BMJ. 2012;345:e6077.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Fernandez H, Gervaise A. Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy. Hum Reprod Update. 2004;10:503–13.

    Article  PubMed  Google Scholar 

  8. Rubal L, Chung K. Do you need to definitively diagnose the location of a pregnancy of unknown location? The case for “yes.”. Fertil Steril. 2012;98:1078–84.

    Article  PubMed  Google Scholar 

  9. Brady P, Imudia AN, Awonuga AO, Wright DL, Styer AK, Toth TL. Pregnancies of unknown location after in vitro fertilization: minimally invasive management with Karman cannula aspiration. Fertil Steril. 2014;101:420–6.

    Article  CAS  PubMed  Google Scholar 

  10. Shaunik A, Kulp J, Appleby DH, Sammel MD, Barnhart KT. Utility of dilation and curettage in the diagnosis of pregnancy of unknown location. Am J Obstet Gynecol. 2011;204:130 e1–6.

    Article  PubMed  Google Scholar 

  11. Practice Committee of the American Society for Reproductive Medicine. Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013;100:638–44.

    Article  Google Scholar 

  12. Job-Spira N, Fernandez H, Bouyer J, Pouly JL, Germain E, Coste J. Ruptured tubal ectopic pregnancy: risk factors and reproductive outcome: results of a population-based study in France. Am J Obstet Gynecol. 1999;180:938–44.

    Article  CAS  PubMed  Google Scholar 

  13. Barrenetxea G, Barinaga-Rementeria L, Lopez de Larruzea A, Agirregoikoa JA, Mandiola M, Carbonero K. Heterotopic pregnancy: two cases and a comparative review. Fertil Steril. 2007;82:9–15.

    Google Scholar 

  14. Johansen K. Pregnancy in a rudimentary horn. Obstet Gynecol. 1983;61:565–7.

    Google Scholar 

  15. Nahum GG. Rudimentary uterine horn pregnancy. The 20th-century worldwide experience of 588 cases. J Reprod Med. 2002;47:151–63.

    PubMed  Google Scholar 

  16. Li C, Meng CX, Zhao WH, Lu HQ, Shi W, Zhang J. Risk factors for ectopic pregnancy in women with planned pregnancy: a case-control study. Eur J Obstet Gynecol Reprod Biol. 2014;181:176–82.

    Article  PubMed  Google Scholar 

  17. Cooper MD, Rapp J, Jeffery-Wiseman C, Barnes RC, Stephens DS. Chlamydia trachomatis infection of human fallopian tube organ cultures. J Gen Microbiol. 1990;136:1109–15.

    Article  CAS  PubMed  Google Scholar 

  18. Bouyer J, Coste J, Shojaei T, Pouly JL, Fernandez H, Gerbaud L, et al. Risk factors for ectopic pregnancy: a comprehensive analysis based on a large case-control, population-based study in France. Am J Epidemiol. 2003;157:185–94.

    Article  PubMed  Google Scholar 

  19. Farquhar CM. Ectopic pregnancy. Lancet. 2005;366:583–91.

    Article  PubMed  Google Scholar 

  20. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996;174:1161–8.

    Article  CAS  PubMed  Google Scholar 

  21. Furlong LA. Ectopic pregnancy risk when contraception fails. A review. J Reprod Med. 2002;47:881–5.

    CAS  PubMed  Google Scholar 

  22. Committee on Trauma. Advanced trauma life support 1 student manual. 8th ed. Chicago: American College of Surgeons; 2008.

    Google Scholar 

  23. Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon Jr WF, Kato K, et al. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma. 1999;46:466–72.

    Article  CAS  PubMed  Google Scholar 

  24. Benacerraf B, Parker-Jones K, Schiff I. Decidual cast mimicking an intrauterine gestational sac and fetal pole in a patient with ectopic pregnancy. A case report. J Reprod Med. 1984;29:498–500.

    CAS  PubMed  Google Scholar 

  25. Doubilet PM. Ultrasound evaluation of the first trimester. Radiol Clin North Am. 2014;52:1191–9.

    Article  PubMed  Google Scholar 

  26. Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, et al. Association between first-trimester vaginal bleeding and miscarriage. Obstet Gynecol. 2009;114:860–7.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Doubilet PM, Benson CB, Bourne T, Blaivas M, Society of Radiologists in Ultrasound Multispecialty Panel on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy, Barnhart KT, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013;369:1443–51.

    Google Scholar 

  28. Frates MC, Visweswaran A, Laing FC. Comparison of tubal ring and corpus luteum echogenicities: a useful differentiating characteristic. J Ultrasound Med. 2001;20:27–31.

    CAS  PubMed  Google Scholar 

  29. Hofmann HM, Urdl W, Höfler H, Hönigl W, Tamussino K. Cervical pregnancy: case reports and current concepts in diagnosis and treatment. Arch Gynecol Obstet. 1987;241:63–9.

    Article  CAS  PubMed  Google Scholar 

  30. Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol. 2000;16:592–3.

    Article  CAS  PubMed  Google Scholar 

  31. Timor-Tritch IE, Monteagudo A, Matera C, Veit CR. Sonographic evolution of cornual pregnancies treated without surgery. Obstet Gynecol. 1992;79:1044–9.

    Google Scholar 

  32. Molinaro TA, Barnhart KT. Ectopic pregnancies in unusual locations. Semin Reprod Med. 2007;25:123–30.

    Article  PubMed  Google Scholar 

  33. Comstock C, Huston K, Lee W. The ultrasonographic appearance of ovarian ectopic pregnancies. Obstet Gynecol. 2005;105:42–5.

    Article  PubMed  Google Scholar 

  34. Allibone GW, Fagan CJ, Porter SC. The sonographic features of intra-abdominal pregnancy. J Clin Ultrasound. 1981;9:383–7.

    Article  CAS  PubMed  Google Scholar 

  35. Arslan T, Bilgiç E, Sentürk MB, Yücel N. Rudimentary uterine horn pregnancy: a mystery diagnosis. Fertil Steril. 2009;2037(92):e1–3.

    Google Scholar 

  36. Tsafrir A, Rojansky N, Sela HY, Gomori JM, Nadjari M. Rudimentary horn pregnancy: first-trimester prerupture sonographic diagnosis and confirmation by magnetic resonance imaging. J Ultrasound Med. 2005;24:219–23.

    PubMed  Google Scholar 

  37. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006;107:1373–81.

    Article  PubMed  Google Scholar 

  38. Zakaria MA, Abdallah ME, Shavell VI, Berman JM, Diamond MP, Kmak DC. Conservative management of cervical ectopic pregnancy: utility of uterine artery embolization. Fertil Steril. 2011;95:872–6.

    Article  PubMed  Google Scholar 

  39. Sand PK, Stubblefield PA, Ory SJ. Methotrexate inhibition of normal trophoblasts in vitro. Am J Obstet Gynecol. 1986;155:324–9.

    Article  CAS  PubMed  Google Scholar 

  40. Barhart KT, Hummel AC, Sammel MD, Menon S, Jain J, Chakhtoura N. Use of “2 dose” regimen of methotrexate to treat ectopic pregnancy. Fertil Steril. 2007;87:250–6.

    Article  Google Scholar 

  41. Alleyassin A, Khademia A, Aghahosseini M, Safdarian L, Badenoosh B, Hamed EA. Comparison of success rates in the medical management of ectopic pregnancy with single dose and multi dose administration of methotrexate: a prospective, randomized clinical trial. Fertil Steril. 2006;85:1661–6.

    Article  CAS  PubMed  Google Scholar 

  42. Stovall TG, Ling FW, Gray LA. Single-dose methotrexate for treatment of ectopic pregnancy. Obstet Gynecol. 1991;77:754–7.

    CAS  PubMed  Google Scholar 

  43. Menon S, Colins J, Barnhart KT. Establishing a human chorionic gonadotropin cutoff to guide methotrexate treatment of ectopic pregnancy: a systematic review. Fertil Steril. 2007;87:481–4.

    Article  CAS  PubMed  Google Scholar 

  44. Ory SJ, Villanueva AL, Sand PK, Tamura RK. Conservative treatment of ectopic pregnancy with methotrexate. Am J Obstet Gynecol. 1986;154:1299–306.

    Article  CAS  PubMed  Google Scholar 

  45. Goldstein DP, Goldstein PR, Bottomly P, Osathanondh R, Marean AR. Methotrexate with citrovorum factor rescue for nonmetastatic gestational trophoblastic neoplasms. Obstet Gynecol. 1976;46:321–3.

    Google Scholar 

  46. Guvendag Guven ES, Dilbaz S, Dilbaz B, Aykan Yildirim B, Akdag D, Haberal A. Comparison of single and multiple dose methotrexate therapy for unruptured tubal ectopic pregnancy: a prospective randomized study. Acta Obstet Gynecol Scand. 2010;89:889–95.

    Article  PubMed  Google Scholar 

  47. Gungorduk K, Asicioglu O, Yildirim G, Gungorduk OC, Besimoglu B, Ark C. Comparison of single dose and two dose methotrexate protocols for the treatment of unruptured ectopic pregnancy. J Obstet Gynaecol. 2011;31:330–4.

    Article  CAS  PubMed  Google Scholar 

  48. Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing “single dose and multidose” regimens. Obstet Gynecol. 2003;101:778–84.

    PubMed  Google Scholar 

  49. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 94: medical management of ectopic pregnancy. Obstet Gynecol. 2008;111:1479–85.

    Article  Google Scholar 

  50. Hung TH, Shau WY, Hsieh TT, Hsu JJ, Soong YK, Jeng CJ. Prognostic factors for an unsatisfactory primary methotrexate treatment of cervical pregnancy: a quantitative review. Hum Reprod. 1998;13:2636–42.

    Article  CAS  PubMed  Google Scholar 

  51. Wang Y, Xu B, Dai S, Zhang Y, Duan Y, Sun C. An efficient conservative treatment modality for cervical pregnancy: angiographic uterine artery embolization followed by immediate curettage. Am J Obstet Gynecol. 2011;204:31e1–7.

    Google Scholar 

  52. Timor-Trisch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol. 2012;207:44e1–13.

    Google Scholar 

  53. Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril. 1999;72:207–15.

    Article  CAS  PubMed  Google Scholar 

  54. Bannon K, Fernandez C, Rojas D, Levine EM, Locher S. Diagnosis and management of intramural ectopic pregnancy. J Minim Invasive Gynecol. 2013;20:697–700.

    Article  PubMed  Google Scholar 

  55. Wang S, Dong Y, Meng X. Intramural ectopic pregnancy: treatment using uterine artery embolization. J Minim Invasive Gynecol. 2013;20:241–3.

    Article  PubMed  Google Scholar 

  56. Di Luigi G, Patacchiola F, La Posta V, Bonitatibus A, Ruggeri G, Carta G. Early ovarian pregnancy diagnosed by ultrasound and successfully treated with multidose methotrexate. A case report. Clin Exp Obstet Gynecol. 2012;39:390–3.

    PubMed  Google Scholar 

  57. Clayton HB, Schieve LA, Peterson HB, Jamieson DJ, Reynolds MA, Wright VC. Ectopic pregnancy risk with assisted reproductive technology procedures. Obset Gynecol. 2006;107:595–604.

    Article  Google Scholar 

  58. Goldstein JS, Ratts VS, Philpott T, Dahan MH. Risk of surgery after use of potassium chloride for treatment of tubal heterotopic pregnancy. Obstet Gynecol. 2006;107:506–8.

    Article  PubMed  Google Scholar 

  59. Hajenius PJ, Mol F, Bossuyt PMM, Ankum WM, van der Veen F. Interventions for tubal ectopic pregnancy. The Cochrane Library. 2007;(1):CD000324.

    Google Scholar 

  60. Alkatout I, Honemeyer U, Strauss A, Tinelli A, Malvasi A, Jonat W, et al. Clinical diagnosis and treatment of ectopic pregnancy. Obstet Gynecol Surv. 2013;68:571–81.

    Article  PubMed  Google Scholar 

  61. de Bennetot M, Rabischong B, Aublet-Cuvelier B, Belard F, Fernandez H, Bouyer J, et al. Fertility after tubal ectopic pregnancy: results of a population-based study. Fertil Steril. 2012;98:1271–6.e1–3.

    Article  PubMed  Google Scholar 

  62. Mol F, van Mello NM, Strandell A, Strandell K, Jurkovic D, Ross J, et al. Salpingostomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet. 2014;383:1483–9.

    Article  PubMed  Google Scholar 

  63. Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy. A review and a report of two cases treated conservatively. Ultrasound Obstet Gynecol. 1996;8:373–80.

    Article  CAS  PubMed  Google Scholar 

  64. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol. 2003;21:220–7.

    Article  CAS  PubMed  Google Scholar 

  65. Joseph RJ, Irvine LM. Ovarian ectopic pregnancy: aetiology, diagnosis, and challenges in surgical management. J Obstet Gynaecol. 2012;32:472–4.

    Article  CAS  PubMed  Google Scholar 

  66. Kraemer B, Kraemer E, Guengoer E, Juhasz-Boess I, Solomayer EF, Wallwiener D, et al. Ovarian ectopic pregnancy: diagnosis, treatment, correlation to Carnegie stage 16 and review based on a clinical case. Fertil Steril. 2009;92:392.e13–5.

    Article  PubMed  Google Scholar 

  67. Jermy K, Thomas J, Doo A, Bourne T. The conservative management of interstitial pregnancy. BJOG. 2004;111:1283–8.

    Article  PubMed  Google Scholar 

  68. Ng S, Hamontri S, Chua I, Chern B, Siow A. Laparoscopic management of 53 cases of cornual ectopic pregnancy. Fertil Steril. 2009;92:448–52.

    Article  PubMed  Google Scholar 

  69. Shaw SW, Hsu JJ, Chueh HY, Han CM, Chen FC, Chang YL, et al. Management of primary abdominal pregnancy: twelve years of experience in a medical centre. Acta Obstet Gynecol Scand. 2007;86:1058–62.

    Article  PubMed  Google Scholar 

  70. Bertrand G, Le Ray C, Simard-Emond L, Dubois J, Leduc L. Imaging in the management of abdominal pregnancy: a case report and review of the literature. J Obstet Gynaecol Can. 2009;31:57–62.

    Article  PubMed  Google Scholar 

  71. Jayasinghe Y, Rane A, Stalewski H, Grover S. The presentation and early diagnosis of the rudimentary uterine horn. Obstet Gynecol. 2005;105:1456–67.

    Article  PubMed  Google Scholar 

  72. Kadan Y, Romano S. Rudimentary horn pregnancy diagnosed by ultrasound and treated by laparoscopy–a case report and review of the literature. J Minim Invasive Gynecol. 2008;15:527–30.

    Article  PubMed  Google Scholar 

  73. Pisarska MD, Carson SA, Buster JE. Ectopic pregnancy. Lancet. 1998;351:1115–20.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Boston, MA, USA

    Paula C. Brady MD

Authors
  1. Paula C. Brady MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Paula C. Brady MD .

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Brady, P.C. (2016). Pregnancy of Unknown Location and Ectopic Pregnancy. In: Handbook of Consult and Inpatient Gynecology. Springer, Cham. https://doi.org/10.1007/978-3-319-27724-0_3

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-27724-0_3

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-27722-6

  • Online ISBN: 978-3-319-27724-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation