Archives of Gynecology and Obstetrics

, Volume 300, Issue 3, pp 651–660 | Cite as

Chronic ectopic pregnancy: case report and systematic review of the literature

  • Clemens B. TempferEmail author
  • Askin Dogan
  • Iris Tischoff
  • Ziad Hilal
  • Günther A. RezniczekEmail author
General Gynecology



Chronic ectopic pregnancy (CEP) is a variant of ectopic pregnancy (EP) characterized by low or absent serum human chorionic gonadotropin (hCG) levels, resistance to methotrexate (MTX), and an adnexal mass with fibrosis, necrosis, and blood clots due to repeated and gradual fallopian tube wall disintegration. CEP may complicate the course of patients with EP and is difficult to diagnose.

Case presentation

The case of a 36-year-old woman with EP, low serum hCG levels, a small echogenic adnexal mass, and resistance to MTX is presented. Salpingectomy was performed and histology demonstrated CEP with fibrosis, necrosis, and a hematocele within degenerated chorionic villi.

Systematic literature review

In a database search, 19 case reports, 3 case–control studies, and 3 case series describing 399 patients with CEP were identified. Serum hCG was negative in 40/124 cases (32%) with reported levels of serum hCG. The most common presenting symptom was abdominal pain (284/399 [71%]), followed by irregular vaginal bleeding (219/399 [55%]), and fever (20/399 [5%]). 73/399 (18%) women were asymptomatic. An adnexal mass was seen in 144/298 (48%) cases with perioperative ultrasound examination and with a mean largest diameter of 6.8 cm. Data on treatment modalities and outcomes were available for 297 women. Of these, 89% underwent surgery as first-line therapy. Laparoscopy was performed in most cases. MTX was the first-line therapy in a minority of cases. Complete resolution was achieved by first-line therapy in 287/297 (97%) cases. Adverse events were reported in 218 patients with CEP. Among those, adverse events ≥ grade 3 were seen in 186/218 (85%) cases. There was no case of treatment-related mortality.


CEP is a variant of EP with low or absent trophoblast activity. A prolonged clinical course is typical and surgery is the mainstay of treatment.


Chronic ectopic pregnancy Pregnancy Methotrexate Pregnancy complication Trophoblast 



Case–control study


Chronic ectopic pregnancy


Case report


C-reactive protein


Case series


Common toxicity criteria for adverse events


Ectopic pregnancy


Human chorionic gonadotropin








White blood cell count


Author contributions

CBT, AD, and IT collected data. CBT, AD, IT, ZH, and GAR wrote the manuscript. GAR analyzed the data. All the authors participated in discussion and revision of the manuscript.



Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Consent for publication


Availability of data and material



  1. 1.
    Kouam L, Kamdom-Moyo J, Essame JL (1995) Fertility after chronic, undiagnosed, ectopic pregnancy. A case observed during a myomectomy. Contracept Fertil Sex 23:407–410Google Scholar
  2. 2.
    Abramov Y, Nadjari M, Shushan A, Prus D, Anteby SO (1997) Doppler findings in chronic ectopic pregnancy: case report. Ultrasound Obstet Gynecol 9:344–346. CrossRefGoogle Scholar
  3. 3.
    Bedi DG, Fagan CJ, Nocera RM (1984) Chronic ectopic pregnancy. J Ultrasound Med 3:347–352CrossRefGoogle Scholar
  4. 4.
    Bedi DG, Moeller D, Fagan CJ, Winsett MZ (1987) Chronic ectopic pregnancy. A comparison with acute ectopic pregnancy. Eur J Radiol 7:46–48Google Scholar
  5. 5.
    Cole T, Corlett RC (1982) Chronic ectopic pregnancy. Obstet Gynecol 59:63–68Google Scholar
  6. 6.
    Turan C, Uğur M, Dogan M, Ekici E, Vicdan K, Gökmen O (1996) Transvaginal sonographic findings of chronic ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 67:115–119CrossRefGoogle Scholar
  7. 7.
    Barnhart KT, Rinaudo P, Hummel A, Pena J, Sammel MD, Chittams J (2003) Acute and chronic presentation of ectopic pregnancy may be two clinical entities. Fertil Steril 80:1345–1351CrossRefGoogle Scholar
  8. 8.
    Drakopoulos P, Pluchino N, Yaron M, Dällenbach P (2014) Chronic tubal ectopic pregnancy: a rare but challenging diagnosis. BMJ Case Rep. Google Scholar
  9. 9.
    Fujita K, Iyoshi S, Watanabe K, Takeda A (2018) Chronic tubal pregnancy manifesting as a heterogeneous adnexal mass with prominent neovascularization in a woman with a negative serum β-human chorionic gonadotropin level. J Obstet Gynaecol Res. Google Scholar
  10. 10.
    Vukas-Radulovic N, Bullarbo M, Ekerhovd E (2017) A case of chronic ectopic pregnancy manifested by rectal bleeding. Case Rep Obstet Gynecol. (Article ID 5974590) Google Scholar
  11. 11.
    Curry NS, Blackwood GA, Tsai CC (1999) Diagnosis of chronic ectopic gestation by hysterosalpingography. Abdom Imaging 24:98–99CrossRefGoogle Scholar
  12. 12.
    Carty MJ, Barr RD, Ouna N (1976) Coagulation and fibrinolytic properties of peripheral venous blood in chronic ectopic pregnancy. S Afr Med J 50:1147–1148Google Scholar
  13. 13.
    Nacharaju M, Vellanki VS, Gillellamudi SB, Kotha VK, Alluri A (2014) A rare case of chronic ectopic pregnancy presenting as large hematosalpinx. Clin Med Insights Reprod Health 8:1–4. CrossRefGoogle Scholar
  14. 14.
    Harada M, Hiroi H, Fujiwara T, Fujimoto A, Kikuchi A, Osuga Y et al (2010) Case of chronic ectopic pregnancy diagnosed in which the complete shape of the fetus was visible by ultrasonography. J Obstet Gynaecol Res 36:462–465. CrossRefGoogle Scholar
  15. 15.
    Su C-C, Tzeng C-C, Huang K-F (2009) Chronic ovarian pregnancy mimicking an ovarian tumor diagnosed by peritoneal washing cytology: a case report. Acta Cytol 53:195–197. CrossRefGoogle Scholar
  16. 16.
    Allen W-L, Subba B, Yoong W, Fakokunde A (2007) Chronic abdominal pregnancy following rupture from a bicornuate uterus. Arch Gynecol Obstet 275:393–395. CrossRefGoogle Scholar
  17. 17.
    Di Spiezio Sardo A, Mastrogamvrakis G, Taylor A, Sharma M, Buck L, Magos A (2004) Chronic ectopic pregnancy diagnosed incidentally in an infertile woman: a case report. J Reprod Med 49:992–996Google Scholar
  18. 18.
    Walter J-E, Buckett WM (2004) Spontaneous bilateral chronic and acute tubal ectopic pregnancies following methotrexate treatment. Aust N Z J Obstet Gynaecol 44:267. CrossRefGoogle Scholar
  19. 19.
    Brennan DF, Kwatra S, Kelly M, Dunn M (2000) Chronic ectopic pregnancy—two cases of acute rupture despite negative beta hCG. J Emerg Med 19:249–254CrossRefGoogle Scholar
  20. 20.
    Porpora MG, Alò PL, Cosmi EV (1999) Unsuspected chronic ectopic pregnancy in a patient with chronic pelvic pain. Int J Gynaecol Obstet 64:187–188CrossRefGoogle Scholar
  21. 21.
    Dunn RC, Taskin O (1995) Chronic ectopic pregnancy after clinically successful methotrexate treatment of ectopic pregnancy. Int J Gynaecol Obstet 51:247–249CrossRefGoogle Scholar
  22. 22.
    Romer JH, Bluth EI (1981) An unusual case of chronic ectopic pregnancy. South Med J 74:1263–1264CrossRefGoogle Scholar
  23. 23.
    Uğur M, Turan C, Vicdan K, Ekici E, Oğuz O, Gökmen O (1996) Chronic ectopic pregnancy: a clinical analysis of 62 cases. Aust N Z J Obstet Gynaecol 36:186–189CrossRefGoogle Scholar
  24. 24.
    Kamau RK, Rogo KO (1988) Chronic ectopic pregnancy with perforation vaginal fornix: case report. East Afr Med J 65:57–59Google Scholar
  25. 25.
    Avery DM, Silverman JF, Mazur MT (1984) Retained fetal bones in chronic tubal pregnancy. Am J Obstet Gynecol 149:794–795CrossRefGoogle Scholar
  26. 26.
    Levy NB, Goldberger SB, Batchelder CS (1984) Chronic ectopic pregnancy. A survey of 54 cases. S Afr Med J 65:727–729Google Scholar
  27. 27.
    Collier CB, Birrell WR (1983) Chronic ectopic pregnancy complicated by shock and disseminated intravascular coagulation. Anaesth Intensive Care 11:246–248CrossRefGoogle Scholar
  28. 28.
    Glukhovets VI (1981) Causes for the acute and chronic course of extrauterine pregnancy. Sov Med 1981(5):112–114Google Scholar
  29. 29.
    Ohel G, Katz M (1979) Lactic dehydrogenase measurement in chronic ectopic pregnancy. Am J Obstet Gynecol 135:149–150Google Scholar
  30. 30.
    Peterek J, Horoszko B (1979) Importance of the Arias-Stella syndrome in the diagnosis of a chronic form of tubal pregnancy. Wiad Lek 32:547–549Google Scholar
  31. 31.
    Rogers WF, Shaub M, Wilson R (1977) Chronic ectopic pregnancy: ultrasonic diagnosis. J Clin Ultrasound 5:257–260CrossRefGoogle Scholar
  32. 32.
    Livnat EJ, Scommegna A (1977) Bilateral ureteral obstruction in ruptured chronic ectopic pregnancy. Am J Obstet Gynecol 127:330–332CrossRefGoogle Scholar
  33. 33.
    Menon R (1973) Chronic ectopic pregnancy—a challenge in diagnosis. Med J Malays 28:88–90Google Scholar
  34. 34.
    Hovadhanakul P, Eachempati U, Cavanagh D (1971) Ureteral obstruction in chronic ectopic pregnancy. Am J Obstet Gynecol 110:311–313CrossRefGoogle Scholar
  35. 35.
    Parker SL, Parker RT (1957) Chronic ectopic tubal pregnancy. Am J Obstet Gynecol 74:1174–1180CrossRefGoogle Scholar
  36. 36.
    Clark JF, Bryant W (1975) Chronic ectopic pregnancy. J Natl Med Assoc 67:118–121Google Scholar
  37. 37.
    Kasaven LS, Shah A, Sadoon S (2018) Chronic tubal ectopic pregnancy following clinically successful methotrexate treatment for an acute ectopic: a review of the literature. J Obstet Gynaecol. Google Scholar
  38. 38.
    O'Neill D, Pounds R, Vella J, Singh K, Yap J (2018) The diagnostic conundrum of chronic ectopic pregnancy: a case report. Case Rep Womens Health 20:e00086. CrossRefGoogle Scholar
  39. 39.
    National Cancer Institute. Common terminology criteria for adverse events (CTCAE) v5.0. (2017) Accessed 5 Jan 2019

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Obstetrics and GynecologyRuhr-Universität BochumBochumGermany
  2. 2.Department of PathologyRuhr-Universität BochumBochumGermany
  3. 3.Department of Obstetrics and GynecologyRuhr-Universität Bochum, Marien Hospital HerneHerneGermany

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