Ectopic and Heterotopic Pregnancies

  • Mehmet Cihat Unlu
  • Gazi Yildirim


Ectopic pregnancy is a common and serious problem, with a significant morbidity rate and the potential for maternal death. The incidence of extrauterine pregnancy (EUP) is listed at 10–20 per 1000 pregnancies. In 95–97% of cases, this will be a tubal pregnancy. Ectopic pregnancy is the leading cause of pregnancy-related death in the first trimester. If a woman of reproductive age presents with abdominal pain, vaginal bleeding, syncope, or hypotension, the physician should have ectopic pregnancy in mind. Many patients have no documented risk factors and no physical indications of ectopic pregnancy. A combination of β-hCG titers with transvaginal ultrasonography (USG) is recommended whenever ectopic pregnancy is suspected. Earlier diagnosis, together with laparoscopy, led to the current standard of minimally invasive and tube-sparing diagnosis and treatment. In a symptomatic patient, the following applies: there is a suspicion of an EUP if the serum β-hCG value is above 1500 IU/L and the uterine cavity is seen as empty in vaginal sonography, without previous severe bleeding. Management is dictated by the clinical presentation, serum β-hCG levels, and transvaginal USG findings. MTX, as a single intramuscular injection, can be given to women who are hemodynamically stable and treatment adherent and have an initial serum β-hCG concentration of less than 5000 IU/L and no USG evidence of fetal cardiac activity. Patients who do not meet these criteria should be treated surgically, in most cases, by laparoscopy. Laparoscopic surgery is the cornerstone of treatment in the majority of women with tubal pregnancy. Surgical treatment is particularly appropriate for women who are hemodynamically unstable or unlikely to be adherent to posttreatment monitoring and those who do not have immediate access to medical care. The choice of treatment should be guided by the patient’s preference after a detailed discussion about monitoring, outcomes, and the risks and benefits of both approaches.


Ectopic pregnancy Tubal ectopic Nontubal ectopic Heterotopic pregnancy 

Supplementary material

Video 26.1

Linear salpingotomy for tubal ampullary ectopic pregnancy (MPG 106880 kb)

Video 26.2

Partial salpingectomy for tubal interstitial ectopic pregnancy (MPG 63596 kb)

Video 26.3

Partial salpingectomy for tubal ampullary ectopic pregnancy. Patient had an ectopic pregnancy in the same tuba, and 1 year ago partial salpingectomy was performed. Ectopic mass can be seen at the distal blind end of the same tuba uterina (MPG 39392 kb)


  1. 1.
    King L, Nezhat C, Nezhat F, et al. Laparoscopic access. In: Nezhat C, Nezhat F, Nezhat C, editors. Nezhat’s video-assisted and robotic-assisted laparoscopy and hysteroscopy, 4th ed. New York, NY: Cambridge University Press; 2013.Google Scholar
  2. 2.
    Alalade AO, Smith FJE, Kendall CE, Odejinmi F. Evidence-based management of non-tubal ectopic pregnancies. J Obstet Gynaecol. 2017;37(8):982–91.CrossRefGoogle Scholar
  3. 3.
    Ramkrishna J, Kan GR, Reidy KL, Ang WC, Palma-Dias R. Comparison of management regimens following ultrasound diagnosis of nontubal ectopic pregnancies: a retrospective cohort study. BJOG. 2017. [Epub ahead of print]CrossRefGoogle Scholar
  4. 4.
    Riaz RM, Williams TR, Craig BM, Myers DT. Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes. Abdom Imaging. 2015;40:2589–99.CrossRefGoogle Scholar
  5. 5.
    Tenore JL. Ectopic pregnancy. Am Fam Physician. 2000;61:1080–8.PubMedGoogle Scholar
  6. 6.
    Dart RG, Kaplan B, Varaklis K. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Ann Emerg Med. 1999;33:283–90.CrossRefGoogle Scholar
  7. 7.
    Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007;(1):CD000324.Google Scholar
  8. 8.
    Spandorfer SD, Barnhart KT. Role of previous ectopic pregnancy in altering the presentation of suspected ectopic pregnancy. J Reprod Med. 2003;48:133–6.PubMedGoogle Scholar
  9. 9.
    Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005;173(8):905–12.CrossRefGoogle Scholar
  10. 10.
    Condous G, Okaro E, Khalid A, Lu C, Van Huffel S, Timmerman D, et al. The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery. Hum Reprod. 2005;20:1404–9.CrossRefGoogle Scholar
  11. 11.
    Preisler J, Kopeika J, Ismail L, Vathanan V, Farren J, Abdallah Y, et al. Defining safe criteria to diagnose miscarriage: prospective observational multicentre study. BMJ. 2015;h4579:351.Google Scholar
  12. 12.
    Srisajjakul S, Prapaisilp P, Bangchokdee S. Magnetic resonance imaging in tubal and non-tubal ectopic pregnancy. Eur J Radiol. 2017;93:76–89.CrossRefGoogle Scholar
  13. 13.
    Elson J, Tailor A, Banerjee S, Salim R, Hillaby K, Jurkovic D. Expectant management of tubal ectopic pregnancy: prediction of successful outcome using decision tree analysis. Ultrasound Obstet Gynecol. 2004;23:552–6.CrossRefGoogle Scholar
  14. 14.
    National Institute for Health and Care Excellence. Ectopic pregnancy and miscarriage: diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage. NICE clinical guideline 154. Manchester: NICE; 2012.Google Scholar
  15. 15.
    Kirk E, van Calster B, Condous G, Papageorghiou AT, Gevaert O, van Huffel S, et al. Ectopic pregnancy: using the b-hCG ratio to select women for expectant or medical management. Acta Obstet Gynecol Scand. 2011;90:264–72.PubMedGoogle Scholar
  16. 16.
    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.PubMedGoogle Scholar
  17. 17.
    Pansky M, Bukovsky I, Golan A, et al. Local methotrexate injection: a nonsurgical treatment of ectopic pregnancy. Obstet Gynecol. 1989;161:393–6.Google Scholar
  18. 18.
    Fernandez H, Baton C, Beniflan JL, Frydman R, Lelaidier C. Methotrexate treatment of ectopic pregnancy: 100 cases treated by primary transvaginal injection under sonographic control. Fertility & Sterility. 1993;59:773–7.CrossRefGoogle Scholar
  19. 19.
    Egarter C, Husslein P. Treatment of tubal pregnancy by prostaglandins. Lancet. 1988;14:1104–5.CrossRefGoogle Scholar
  20. 20.
    Lang P, Weiss PAM, Mayer HO. Local application of hyperosmolar glucose solution in tubal pregnancy. Lancet. 1989;2(8668):922–3.CrossRefGoogle Scholar
  21. 21.
    Tzafettas J, Anapliotis S, Zournatzi V, Boucklis A, Oxouzoglou N, Bondis J. Transvaginal intra amniotic injection of methotrexate in early ectopic pregnancy. Advantages over the laparoscopic approach. Early Hum Dev. 1994;39:101–7.CrossRefGoogle Scholar
  22. 22.
    Ugur M, Yesilyurt H, Soysal S, Gokmen O. Prophylactic vasopressin during laparoscopic salpingotomy for ectopic pregnancy. J Am Assoc Gynecol Laparosc. 1996;3:365–8.CrossRefGoogle Scholar
  23. 23.
    Yao M, Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril. 1997;67:421–33.CrossRefGoogle Scholar
  24. 24.
    Elson CJ, Salim R, Potdar N, Chetty M, Ross JA, Kirk EJ. Diagnosis and Management of Ectopic Pregnancy: green-top guideline no. 21. BJOG. 2016;123(13):e15-e55.Google Scholar
  25. 25.
    Laparoscopic removal of an ectopic pregnancy. In: Wallwiener D, Becker S. Atlas of gynecologic surgery. 4th ed. Stuttgart: Thieme; 2009.Google Scholar
  26. 26.
    Timor-Tritsch IE, Monteagudo A, Matera C, Veit CR. Sonographic evolution of cornual pregnancies treated without surgery. Obstet Gynecol. 1992;79:1044–9.PubMedGoogle Scholar
  27. 27.
    Faraj R, Steel M. Management of cornual (interstitial) pregnancy. Obstet Gynaecol. 2007;9:249–55.Google Scholar
  28. 28.
    Monteagudo A, Minior VK, Stephenson C, Monda S, Timor-Tritsch IE. Non-surgical management of live ectopic pregnancy with ultrasound- guided local injection: a case series. Ultrasound Obstet Gynecol. 2005;25:282–8.CrossRefGoogle Scholar
  29. 29.
    Damario M, Rock J. Chapter 34: ectopic pregnancy. In: Rock JJ, Jones HI, editors. TeLInde's operative gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2011. p. 798–824.Google Scholar
  30. 30.
    Cucinella G, Calagna G, Rotolo S, Granese R, Saitta S, Tonni G, et al. Interstitial pregnancy: a road map of surgical treatment based on a systematic review of the literature. Gynecol Obstet Investig. 2014;78:141–9.CrossRefGoogle Scholar
  31. 31.
    Nezhat CH, Dun EC. Laparoscopically-assisted, hysteroscopic removal of an interstitial pregnancy with a fertility-preserving technique. J Minim Invasive Gynecol. 2014;21(6):1091–4.CrossRefGoogle Scholar
  32. 32.
    Spiegelberg O. The casuistry of ovarian pregnancy. Archiv Fur Gynaekologie. 1878;13:73–6.CrossRefGoogle Scholar
  33. 33.
    Poole A, Haas D, Magann EF. 2012. Early abdominal ectopic pregnancies: a systematic review of the literature. Gynecol Obstet Investig. 2012;74:249–60.CrossRefGoogle Scholar
  34. 34.
    Hailu FG, Yihunie GT, Essa AA, Tsega WK. Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case report. BMC Pregnancy Childbirth. 2017;17(1):243.CrossRefGoogle Scholar
  35. 35.
    Gerli S, Rossetti D, Baiocchi G, Clerici G, Unfer V, Di Renzo GC. Early ultrasonographic diagnosis and laparoscopic treatment of abdominal pregnancy. Eur J Obstet Gynecol Reprod Biol. 2004;113:103–5.CrossRefGoogle Scholar
  36. 36.
    Lockhat F, Corr P, Ramphal S, Moodley J. The value of magnetic resonance imaging in the diagnosis and management of extra-uterine abdominal pregnancy. Clin Radiol. 2006;61:264–9.CrossRefGoogle Scholar
  37. 37.
    Agarwal N, Odejinmi F. Early abdominal ectopic pregnancy: challenges, update and review of current management. Obstet Gynaecol. 2014;16:193–8.Google Scholar
  38. 38.
    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.CrossRefGoogle Scholar
  39. 39.
    Ying X, Zheng W, Zhao L, Zhou M, Chen Z. Clinical characteristics and salvage management of persistent cesarean scar pregnancy. J Obstet Gynaecol Res. 2017;43(8):1293–8.CrossRefGoogle Scholar
  40. 40.
    Gonzalez N, Tulandi T. Cesarean scar pregnancy: a systematic review. J Minim Invasive Gynecol. 2017;24(5):731–8.CrossRefGoogle Scholar
  41. 41.
    Rheinboldt M, Osborn D, Delproposto Z. Cesarean section scar ectopic pregnancy: a clinical case series. J Ultrasound. 2015;18:191–5.CrossRefGoogle Scholar
  42. 42.
    Huanxiao Z, Shuqin C, Hongye J, Hongzhe X, Gang N, Chenkag X, et al. Transvaginal hysterotomy for cesarean scar pregnancy in 40 consecutive cases. Gynecol Surg. 2015;12:45–51.CrossRefGoogle Scholar
  43. 43.
    Ko JK, Li RH, Cheung VY. Caesarean scar pregnancy: a 10-year experience. Aust N Z J Obstet Gynaecol. 2015;55:64–9.CrossRefGoogle Scholar
  44. 44.
    Agarwal N, Shahid A, Odejinmi F. Caesarean scar pregnancy (CSP): a rare case of complete scar dehiscence due to scar ectopic pregnancy and its management. Arch Gynecol Obstet. 2013;288:231–2.CrossRefGoogle Scholar
  45. 45.
    Wu C, Li Y, Ye W, Ma W, Zhao D. Cook cervical ripening balloon successfully prevents excessive hemorrhage combined with ultrasound-guided suction curettage in the treatment of cesarean scar pregnancy. J Obstet Gynaecol Res. 2017;43(6):1043–7.CrossRefGoogle Scholar
  46. 46.
    Mollo A, Alviggi C, Conforti A, Insabato L, De Placido G. Intact removal of spontaneous twin ectopic cesarean scar pregnancy by office hysteroscopy: case report and literature review. Reprod Biomed Online. 2014;29:530–3.CrossRefGoogle Scholar
  47. 47.
    Litwicka K, Greco E. Cesarean scar pregnancy: a review of management options. Curr Opin Obstet Gynecol. 2013;25:456–61.CrossRefGoogle Scholar
  48. 48.
    Sönmezer M, Taskin S, Atabekoğlu C, Güngör M, Unlü C. Laparoscopic management of rudimentary uterine horn pregnancy: case report and literature review. JSLS. 2006;10(3):396–9.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Fernandez H, Gervaise A. Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy. Hum Reprod Update. 2004;10(6):503–13.CrossRefGoogle Scholar
  50. 50.
    Tal J, Haddad S, Gordon N, Timor-Tritsch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: a literature review from 1971 to 1993. Fertil Steril. 1996;66:1–12.CrossRefGoogle Scholar
  51. 51.
    Bataille P, Reynard A, Ducarme G. Spontaneous heterotopic triplets—a review of literature. J Gynecol Obstet Hum Reprod. 2017. pii: S2468-7847(17)30140-X.Google Scholar
  52. 52.
    Talbot K, Simpson R, Price N, Jackson SR. Heterotopic pregnancy. J Obstet Gynaecol. 2011;31(1):7–12.CrossRefGoogle Scholar
  53. 53.
    Habana A, Dokras A, Giraldo JL, Jones EE. Cornual heterotopic pregnancy: contemporary management options. Am J Obstet Gynecol. 2000;182(5):1264–70.CrossRefGoogle Scholar
  54. 54.
    Deffieux X, Ballester M, Collinet P, Fauconnier A. Pierre F; French National College of gynaecologists and obstetricians. Risks associated with laparoscopic entry: guidelines for clinical practice from the French college of gynaecologists and obstetricians. Eur J Obstet Gynecol Reprod Biol. 2011;158(2):159–66.CrossRefGoogle Scholar
  55. 55.
    Kårhus LL, Egerup P, Skovlund CW, Lidegaard Ø. Impact of ectopic pregnancy for reproductive prognosis in next generation. Acta Obstet Gynecol Scand. 2014;93(4):416–9.CrossRefGoogle Scholar
  56. 56.
    Hessel M, Buzink SN, Schoot D, Jakimowicz JJ. Face and construct validity of the SimSurgery SEP VR simulator for salpingectomy in case of ectopic pregnancy. J Gynecol Surg. 2012;28:411–7.CrossRefGoogle Scholar
  57. 57.
    Tong S, Skubisz MM, Horne AW. Molecular diagnostics and therapeutics for ectopic pregnancy. Mol Hum Reprod. 2015;21(2):126–35.CrossRefGoogle Scholar
  58. 58.
    Capmas P, Fernandez H. Effectiveness of gefitinib in combination with methotrexate in the treatment of ectopic pregnancy. Int J Womens Health. 2015;7:673–6.CrossRefGoogle Scholar
  59. 59.
    Lozeau AM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72(9):1707–14.PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Mehmet Cihat Unlu
    • 1
  • Gazi Yildirim
    • 2
  1. 1.Department of Obstetrics and Gynecology, Bakirkoy HospitalAcibadem UniversityIstanbulTurkey
  2. 2.Department of Obstetrics and GynecologyYeditepe University HospitalIstanbulTurkey

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