Management of cervical ectopic pregnancies includes medical treatment with methotrexate and surgical dilation and curettage. The ideal regimen for medical management is unknown and success is reported with both the single-and multidose regimens, as previously described. More advanced gestations, especially with fetal cardiac activity, may require a combination of multidose methotrexate and intra-amniotic/intrafetal injection of PCl. These injections require skill to avoid rupture of membranes during the procedure (240). As with tubal ectopic pregnancies, medical management is appropriate only for those patients who are hemodynamically stable.
If the patient and physician elect to proceed with surgical management, the preoperative preparation should include blood typing and cross-matching, establishment of intravenous access, and detailed informed consent. This consent should include the possibility of hemorrhage that may require transfusion or hysterectomy.
The diagnosis may not be suspected until the patient is undergoing suction curettage for a presumed incomplete abortion and hemorrhage occurs. In some cases, bleeding is light, whereas in others, there is hemorrhage. Various techniques that can be used to control bleeding include uterine packing, lateral cervical suture placement to ligate the lateral cervical vessels, placement of a cerclage, and insertion of an intracervical 30-mL Foley catheter in an attempt to tamponade the bleeding. Alternatively, angiographic artery embolization can be used. If laparotomy is required, an attempt can be made to ligate the uterine or internal iliac arteries (242–244). When none of these methods is successful, hysterectomy is required.
Ovarian Pregnancy A pregnancy confined to the ovary accounts for up to 3% of all ectopic pregnancies and is the most common type of nontubal ectopic pregnancy (1). The incidence ranges from 1 in 40,000 to 1 in 7,000 deliveries (245,246). The diagnostic criteria were described in 1878 by Spiegelberg (Table 20.6) (247). Unlike tubal gestation, ovarian pregnancy is associated with neither PID nor infertility. The risk of ovarian ectopic pregnancies in patients using IUDs is controversial.
Patients have symptoms similar to those of ectopic pregnancies in other sites. Misdiagnosis is common because it is confused with a ruptured corpus luteum in up to 75% of cases (245). As with other types of ectopic pregnancy, an ovarian pregnancy was reported after hysterectomy (248). Ultrasonography makes preoperative diagnosis possible in some cases (249).
The treatment of ovarian pregnancy has changed. Whereas oophorectomy was advocated in the past, ovarian cystectomy and/or wedge resection is now utilized with success (250–252). Successful treatment with methotrexate is reported (253–255).
Table 20.6 Criteria for Ovarian Pregnancy Diagnosis 1.
The fallopian tube on the affected side must be intact.
2.
The fetal sac must occupy the position of the ovary.
3.
The ovary must be connected to the uterus by the ovarian ligament.
4.
Ovarian tissue must be located in the sac wall.
From Spiegelberg O. Casusistik der ovarialschwangerschaft. Arch Gynaecol 1878;13:73.