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Chapter: Obstetrics and Gynecology: Ectopic Pregnancy and Abortion

Nonfallopian-Tube Ectopic Pregnancy

Ectopic implantation of the fertilized egg in the ovary is rare.

Nonfallopian-Tube Ectopic Pregnancy




Ectopic implantation of the fertilized egg in the ovary is rare. The recent increased incidence is likely due to im-proved imaging modalities. Risk factors are similar to those for tubal pregnancies. Diagnosis is based on the classical sonographic description of a cyst with a wide echogenic outer ring on or within the ovary.




Also termed cornual pregnancy, interstitial pregnancies implant in the proximal tubal segment that lies within the muscular uterine wall. Swelling lateral to the insertion of the round ligament is the characteristic anatomic finding. A pregnancy that implants in the cornual segment of the tube tends to present several weeks later in pregnancy, be-cause the muscular cornu of the uterus is better able to expand and accommodate an enlarging pregnancy. As a result, rupture of a cornual (isthmic) pregnancy typically occurs between the eighth and sixteenth gestational weeks, and is often associated with massive hemorrhage, frequently requiring hysterectomy. Mortality rates are quoted as high as 2.5%. 




Cervical pregnancy occurs in 1 in 9000 to 12,000 preg-nancies, when the ovum implants in the cervical mucosa below the level of the histologic cervical internal os. A risk factor unique to cervical pregnancy is a history of dilation and curettage, seen in nearly 70% of cases. Two diagnos-tic criteria are necessary for confirmation of cervical preg-nancy: (1) the presence of cervical glands opposite the placental attachment site, and (2) a portion of or the en-tire placenta must be located below either the entrance of the uterine vessels or the peritoneal reflection on the ante-rior and posterior uterine surface. Medical management can be used if the previously described criteria are met.




Heterotopic pregnancy (coincident or combined preg-nancy) is the coexistence of an ectopic and intrauterine pregnancy. The incidence was previously estimated to be 1 in 30,000 pregnancies figuring incidences of dizygotic twinning and ectopic pregnancy of 1% each. As a result of assisted reproduction, however, the rate of heterotopic pregnancies has increased to 1 in 100 pregnancies. Mech-anisms that have been proposed to explain this include: (1) hydrostatic forces delivering the embryo into the cor-nual or tubal area; (2) the tip of the catheter directing trans-fer towards the tubal ostia; or (3) reflux of uterine secretions leading to retrograde tubal implantation. In addition to the option of surgical management of the ectopic pregnancy while attempting to not disturb the intrauterine pregnancy, medical therapy in which potassium chloride can be in-jected into the pregnancy sac is a consideration.


Methotrexate is contraindicated due to potential detrimental effects on the normal pregnancy.




The estimated incidence of abdominal pregnancy ranges from 1 in 10,000 to 1 in 25,000 live births. Abdominal pregnancies may result from primary implantation onto the peritoneal surface or secondary implantation via tubal rupture or tubal abortion. Physical findings and symptoms are widely variable, depending on gestational age and site of implantation. Diagnosis is confirmed primarily by ultra-sonography.


Abdominal pregnancy is usually discovered long be-fore fetal viability and removal of the pregnancy is the mainstay of therapy. Survival of the fetus occurs in only 10% to 20% of cases; up to one-half of those surviving have significant deformity. The patient is given the option of continuing the pregnancy to fetal viability with opera-tive delivery, or operative termination of the pregnancy at the time of diagnosis. In either case, removal of the pla-centa is usually not attempted because of the risk of un-controllable hemorrhage.


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