Non-tubal ectopic pregnancy–case reports on diagnosis and management of ruptured primary abdominal ectopic and caesarean scar ectopic pregnancy in low resource setting

Isaac M. K.  Ahorklo; Nana A. Nimoh-Brema; Samuel K. Attuah; Francis Wuobar

doi:10.18203/2320-1770.ijrcog20252354

Authors

Isaac M. K. Ahorklo Department of Obstetrics and Gynaecology, Eastern Regional Hospital, Koforidua, Ghana, Komfo Anokye Teaching Hospital, Kumasi, Ghana
Nana A. Nimoh-Brema Komfo Anokye Teaching Hospital, Kumasi, Ghana, Department of Surgery, Tarkwa Municipal Hospital, Tarkwa, Ghana
Samuel K. Attuah Department of Obstetrics and Gynaecology, Eastern Regional Hospital, Koforidua, Ghana
Francis Wuobar Department of Obstetrics and Gynaecology, Eastern Regional Hospital, Koforidua, Ghana

DOI:

https://doi.org/10.18203/2320-1770.ijrcog20252354

Keywords:

Ectopic pregnancy, Beta-human chorionic gonadotropin, Exploratory laparotomy, Caesarean section, Gestation

Abstract

Non-tubal ectopic pregnancy is a rare form of ectopic pregnancy with high morbidity and mortality. The diagnosis of non-tubal ectopic pregnancy requires a high index of suspicion. Clinical history, physical examination, and laboratory and ultrasonographic features may all be non-specific. Fortunately, a low threshold for diagnosis, urine and serum beta-human chorionic gonadotrophin (β-hCG) assays and transvaginal sonography allow earlier diagnosis. Consequently, both maternal survival rates and conservation of reproductive capacity are improved. We present 2 cases of non-tubal ectopic pregnancy. The first is a case of a 17-year-old female para 0+0 with a period of amenorrhea, who presented with lower abdominal pain and moderate bleeding per vaginam. A suspicion of a ruptured ectopic gestation was made and an emergency exploratory laparotomy done which revealed a ruptured ectopic gestation implanted on the lower edge of the omentum with intact tubes and ovaries bilaterally was seen intra op. The second case is a 32-year-old female gravida 4 para 2 + 1ectopic (2 previous caesarean section) who presented with recurrent bleeding per vaginam and lower abdominal pain. Transvaginal ultrasound (USG) report showed a cervical ectopic gestation and patient was counselled accordingly and prepared for curettage or total abdominal hysterectomy. However, about 18weeks gestation uterus, a gestation implanted in an old caesarean section scar extending into the cervix was seen intra op. No obvious intrauterine gestation, tubes and ovaries were all normal and hence a total abdominal hysterectomy was done with conservation of both ovaries. Non-tubal ectopic pregnancy is a rare but potentially life-threatening and often misdiagnosed condition. Our case presents an opportunity to discuss 2 different cases of rare forms of ectopic pregnancy and the importance of having a high index of suspicion to make a diagnosis and prompt management to reduce maternal morbidity and mortality.

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References

Marion LL, Meeks GR. Ectopic Pregnancy: History, Incidence, Epidemiology, and Risk Factors. Clin Obstet Gynecol. 2012;55(2):376-86. DOI: https://doi.org/10.1097/GRF.0b013e3182516d7b

Long Y, Zhu H, Hu Y, Shen L, Fu J, Huang W. Interventions for non-tubal ectopic pregnancy. Cochrane Database Syst Rev. 2020;7(7):CD011174.

Fan YY, Liu YN, Mao XT, Fu Y. The Prevalence of Ectopic Gestation: A Five-Year Study of 1273 Cases. Int J Gen Med. 2021;14:9657-61. DOI: https://doi.org/10.2147/IJGM.S344648

Long Y, Zhu H, Hu Y, Shen L, Fu J, Huang W. Interventions for non‐tubal ectopic pregnancy. Cochrane Database Syst Rev. 2020;2020(7):CD011174. DOI: https://doi.org/10.1002/14651858.CD011174.pub2

Nkyekyer K. Ectopic Pregnancy in Ghana-Time for Change. Ghana Med J. 2006;40(1):1-2.

Gerema U, Alemayehu T, Chane G, Desta D, Diriba A. Determinants of ectopic pregnancy among pregnant women attending referral hospitals in southwestern part of Oromia regional state, Southwest Ethiopia: a multi-center case control study. BMC Pregnancy Childbirth. 2021;21(1):130. DOI: https://doi.org/10.1186/s12884-021-03618-7

Mahajan N, Raina R, Sharma P, Mahajan N, Raina R, Sharma P. Risk factors for ectopic pregnancy: a case-control study in tertiary care hospitals of Jammu and Kashmir. Iberoam J Med. 2021;3(4):293-9. DOI: https://doi.org/10.53986/ibjm.2021.0048

Harlev A, Wiznitzer A, Sheiner E. Ectopic Pregnancy. In: Sheiner E, editor. Bleeding During Pregnancy: A Comprehensive Guide [Internet]. New York, NY: Springer. 2011;45-63. DOI: https://doi.org/10.1007/978-1-4419-9810-1_3

Hendriks E, Rosenberg R, Prine L. Ectopic Pregnancy: Diagnosis and Management. Ectopic Pregnancy. 2020;101(10):8.

Sivalingam VN, Duncan WC, Kirk E, Shephard LA, Horne AW. Diagnosis and management of ectopic pregnancy. J Fam Plan Reprod Health Care Fac Fam Plan Reprod Health Care R Coll Obstet Gynaecol. 2011;37(4):231-40. DOI: https://doi.org/10.1136/jfprhc-2011-0073

Betz D, Fane K. Human Chorionic Gonadotropin. In: StatPearls. Treasure Island (FL): StatPearls Publishing. 2025.

Chetty M, Elson J. Treating non-tubal ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol. 2009;23(4):529-38. DOI: https://doi.org/10.1016/j.bpobgyn.2008.12.011

Alalade AO, Smith FJE, Kendall CE, Odejinmi F. Evidence-based management of non-tubal ectopic pregnancies. J Obstet Gynaecol. 2017;37(8):982-91. DOI: https://doi.org/10.1080/01443615.2017.1323852

Grigoriu C, Bohiltea RE, Mihai BM, Zugravu CA, Furtunescu F, Georgescu TA, et al. Success rate of methotrexate in the conservative treatment of tubal ectopic pregnancies. Exp Ther Med. 2022;23(2):150. DOI: https://doi.org/10.3892/etm.2021.11073

Lin R, DiCenzo N, Rosen T. Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment. Fertil Steril. 2023;120(3):563-72. DOI: https://doi.org/10.1016/j.fertnstert.2023.07.018

Rahman MS, Al-Suleiman SA, Rahman J, Al-Sibai MH. Advanced abdominal pregnancy--observations in 10 cases. Obstet Gynecol. 1982;59(3):366-72.

Vadakekut ES, Gnugnoli DM. Ectopic Pregnancy. In: StatPearls. Treasure Island (FL): StatPearls Publishing. 2025.

George R, Powers E, Gunby R. Abdominal ectopic pregnancy. Proc Bayl Univ Med Cent. 2021;34(4):530-1. DOI: https://doi.org/10.1080/08998280.2021.1884932

Tolefac PN, Abanda MH, Minkande JZ, Priso EB. The challenge in the diagnosis and management of an advanced abdominal pregnancy in a resource-low setting: a case report. J Med Case Rep. 2017;11:199. DOI: https://doi.org/10.1186/s13256-017-1369-1

Opare-Addo HS, Deganus S. Advanced Abdominal Pregnancy: A Study of 13 Consecutive Cases Seen in 1993 and 1994 at Komfo Anokye Teaching Hospital, Kumasi, Ghana. Afr J Reprod Health Rev Afr Santé Reprod. 2000;4(1):28-39. DOI: https://doi.org/10.2307/3583240

Allibone GW, Fagan CJ, Porter SC. The sonographic features of intra-abdominal pregnancy. J Clin Ultrasound JCU. 1981;9(7):383-7. DOI: https://doi.org/10.1002/jcu.1870090706

Oppenheimer DC, Mazaheri P, Ballard DH, Yano M, Fowler KJ. Magnetic Resonance Imaging of the Placenta and Gravid Uterus: A Pictorial Essay. Abdom Radiol N Y. 2019;44(2):669-84. DOI: https://doi.org/10.1007/s00261-018-1755-1

Molinaro T, Barnhart K. Ectopic Pregnancies in Unusual Locations. Semin Reprod Med. 2007;25(2):123-30. DOI: https://doi.org/10.1055/s-2007-970051

Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol. 1942;44(3):487-91. DOI: https://doi.org/10.1016/S0002-9378(42)90488-5

Cosentino F, Rossitto C, Turco LC, Gueli Alletti S, Vascone C, Di Meglio L, et al. Laparoscopic Management of Abdominal Pregnancy. J Minim Invasive Gynecol. 2017;24(5):724-5. DOI: https://doi.org/10.1016/j.jmig.2017.01.023

Anderson PM, Opfer EK, Busch JM, Magann EF. An Early Abdominal Wall Ectopic Pregnancy Successfully Treated with Ultrasound Guided Intralesional Methotrexate: A Case Report. Obstet Gynecol Int. 2009;2009:247452. DOI: https://doi.org/10.1155/2009/247452

Sapuri M, Klufio C. A case of advanced viable extrauterine pregnancy. P N G Med J. 1997;40(1):44-7.

Kun K, Wong P, Ho M, Tai C, Ng T. Abdominal pregnancy presenting as a missed abortion at 16 weeks’ gestation. Hong Kong Med J. 2000;6(4):425-7.

Ombelet W, Vandermerwe JV, Van Assche FA. Advanced extrauterine pregnancy: description of 38 cases with literature survey. Obstet Gynecol Surv. 1988;43(7):386-97. DOI: https://doi.org/10.1097/00006254-198807000-00003

Hallatt JG, Grove JA. Abdominal pregnancy: A study of twenty-one consecutive cases. Am J Obstet Gynecol. 1985;152(4):444-9. DOI: https://doi.org/10.1016/S0002-9378(85)80155-1

Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG Int J Obstet Gynaecol. 2007;114(3):253-63. DOI: https://doi.org/10.1111/j.1471-0528.2006.01237.x

Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006;107(6):1373-81. DOI: https://doi.org/10.1097/01.AOG.0000218690.24494.ce

Al Farsi AR. Cesarean Scar Pregnancy: Time to Initiate Universal Screening. Oman Med J. 2023;38(6):e564. DOI: https://doi.org/10.5001/omj.2023.131

Maheux-Lacroix S, Li F, Bujold E, Nesbitt-Hawes E, Deans R, Abbott J. Cesarean Scar Pregnancies: A Systematic Review of Treatment Options. J Minim Invasive Gynecol. 2017;24(6):915-25. DOI: https://doi.org/10.1016/j.jmig.2017.05.019

Jurkovic D, Knez J, Appiah A, Farahani L, Mavrelos D, Ross JA. Surgical treatment of Cesarean scar ectopic pregnancy: efficacy and safety of ultrasound-guided suction curettage. Ultrasound Obstet Gynecol. 2016;47(4):511-7. DOI: https://doi.org/10.1002/uog.15857

Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Nielsen HS. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril. 2016;105(4):958-67. DOI: https://doi.org/10.1016/j.fertnstert.2015.12.130