Management of Unusual Not Scar Ectopic Pregnancy: A Multicentre Retrospective
Case Series
Authors: Ferrari Federico , Ficarelli Silvia , Cornelli Benedetta , Ferrari Filippo Alberto , Farulla Antonino , Alboni Carlo , Fontana Enrico , Roccio Marianna , Boschi Anna Chiara , Buca Danilo , Leombroni Martina , Peterlunger Isabel , Moruzzi Maria Cristina , Beneduce Giuliana , Bolomini Giulia , Laganà Antonio Simone , Malorgio Piero , Ricci Giuseppe , Franchi Massimo , Scambia Giovanni , Sartori Enrico , Odicino Franco 
Published: February 2021

Background:
Management of unusual not scar ectopic pregnancies (UNSEPs) is an unexplored clinical
field because of their low incidence and lack of guidelines.

Objective:
To report the clinical presentation, the first- and second-line treatment and outcomes of UNSEPs.

Methods:
We retrospectively collected patients treated for UNSEP (namely cervical, interstitial, ovarian, angular, abdominal,
cornual and intramural), their baseline characteristics, risk factors, symptoms, diagnostic pathway and the
type of first-line treatment (medical, surgical or combined). We further collected treatment failures and the type of second-
line treatment. We assessed treatment outcomes, time to serum beta human chorionic gonadotropin (β-hCG) level
negativity, length of recovery, follow up and return to a normal menstrual cycle.

Results:
From 2009 to 2019, we collected 79 cases. Of them, 27 (34%), 23 (29%), 12 (15%), 8 (10%), 6 (8%) and 3
(4%) were cervical, interstitial, ovarian, angular, abdominal and cornual, respectively. Forty women (50.6%) were submitted
to medical treatment, mostly methotrexate based; conversely, 36 patients (45.6%) underwent surgery and only 3
women (3.8%) received a combined treatment. The success of first-line treatment rate, regardless of UNSEP location,
was 53% and 89% for medical and surgical treatment, respectively. Treatment failures (21 patients) were submitted to
second-line treatment, respectively 47.6% and 52.4% to medical and surgical approach. Of interest, cervical pregnancies
achieved the lowest rate of first-line medical treatment success (22%) and received more frequently (69%) a subsequent
surgical approach with no hysterectomy. Interstitial pregnancies were submitted to surgery mostly for a matter of
urgency (71%), otherwise, they were treated with a medical approach both at first- and second-line treatment. Ovarian
pregnancies were treated with ovariectomy in 44% of the cases submitted to surgery. Angular pregnancies underwent
surgery more often, while all the abdominal pregnancies underwent endoscopic or open surgery. Cornual pregnancies
received cornuostomy in 75% of the cases. Overall, the need for blood transfusion was 23.1% among the patients submitted
to surgery. The median length of hospitalisation was shorter for women submitted to surgical first-line treatment
(5 vs. 10 days; p = 0.002). In case of first-line medical treatment and in case of failure, we found an increase of 3
days (CI95% 0.6-5.5; p = 0.01) and of 3.6 days (CI95% 0.89-6.30; p = 0.01) in the length of hospitalisation, respectively.
Negative β-HCG levels were obtained earlier in the surgical group (median 25 vs. 51 days; p = 0.001), as well as
the return to normal menstrual cycle (median 31 vs. 67 days; p < 0.000). Post-treatment follow-up, regardless of the
failure of first-line treatment was shorter in the surgical group (median 32 versus 68 days; p= 0.003).

Conclusion:
Cervical pregnancies were successfully managed with a surgical approach without hysterectomy, and
hence, we suggest avoiding medical treatment. No consensus emerged for other UNSEPs. Ovarian, angular and interstitial
pregnancies are burdened by a non-conservative approach on the utero-ovarian structures. The surgical approach
led to shorter recovery, earlier β-hCG negativity and shorter follow-up, even though there is an increased risk for blood
transfusion.