Management of non-tubal ectopic pregnancy
About 2-5% of EPs are located outside the fallopian tubes (8). Surgical access to the location of the implanted pregnancy and the risk of bleeding from the underlying structure determines which mode of treatment is preferred (31, 32).
EPs which have implanted on the surface of the ovary, in the abdomen, or on the omentum are usually managed surgically. The surgeon is able to see the implantation site to assess and take steps to limit any bleeding resulting from removal of the EP tissue. Serum hCG monitoring is required, as with salpingotomy, to detect residual trophoblasts and initiate methotrexate treatment as needed.
EPs can rarely implant in the interstitial portion of the fallopian tube as it passes through the myometrium. This has a characteristic appearance on ultrasonography (33). These can be managed either by surgically removing the pregnancy and surrounding myometrium with the fallopian tube, or with methotrexate. The decision will depend on the gestation and size of the EP mass at diagnosis.
Cervical EPs were traditionally managed by performing a hysterectomy as the diagnosis was previously only made after the onset of unrelenting vaginal bleeding. Caesarean section scar EPs appear to be increasing in prevalence and are located at the expected site of a previous lower segment caesarean section or at a notch visible on ultrasonography at that level. Both of these can be diagnosed by ultrasonography, and as the EP site can be accessed through the vagina, both medical and surgical management for these conditions have been developed (34, 35). The gestation sac can be injected directly with methotrexate, removed by suction evacuation (36), then tamponade performed with a balloon catheter (32, 37). The use of systemic methotrexate works best in those with low initial serum hCG concentrations; however, it is widely used in most cases with patient admission to the ward for close observation and access to operating theatres. The potential for vaginal bleeding with a cervical EP and vaginal and intraperitoneal bleeding with a caesarean EP rupturing the cervico-isthmic junction is present until complete resolution has occurred. Medical management is generally preferred as long as rapid access to surgical management is available in the event of bleeding.