Abdominal pregnancy, cesarean scar pregnancy, and heterotopic pregnancy
- Thomas A Molinaro, MD
Thomas A Molinaro, MD
- Clinical Assistant Professor, Division of Reproductive Endocrinology
- Robert Wood Johnson Medical School
- Kurt T Barnhart, MD, MSCE
Kurt T Barnhart, MD, MSCE
- Associate Professor of Obstetrics and Gynecology
- University of Pennsylvania
- Section Editors
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Co-Chief of Ultrasound
- Beth Israel Deaconess Medical Center
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Ectopic pregnancy is estimated to occur in 1 to 2 percent of pregnancies [1,2]. Over 90 percent are located in the fallopian tube, while the remainder implant in locations such as the abdomen, cesarean (hysterotomy) scar, cervix, and ovary . Given the rarity of implantation at these sites, much of the information surrounding diagnosis and treatment of these pregnancies has been derived from small observational studies and case reports. This makes the optimal approach to their evaluation and management difficult to determine.
Abdominal pregnancy, cesarean scar pregnancy, and heterotopic pregnancy will be reviewed here. The goal is to prompt clinicians to think of these diagnoses and to make suggestions for management, especially for avoiding catastrophe.
The diagnosis and management of ectopic pregnancies at other locations are discussed separately. (See "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Ectopic pregnancy: Incidence, risk factors, and pathology" and "Ectopic pregnancy: Choosing a treatment and methotrexate therapy" and "Ectopic pregnancy: Surgical treatment" and "Cervical pregnancy" and "Ectopic pregnancy: Expectant management".)
Abdominal pregnancy refers to a pregnancy that has implanted in the peritoneal cavity, external to the uterine cavity and fallopian tubes. The estimated incidence is 1 per 10,000 births  and 1.4 percent of ectopic pregnancies [4-6]. There are reports of abdominal pregnancy occurring after hysterectomy [7,8].
Potential sites include the omentum, pelvic sidewall, broad ligament, posterior cul-de-sac, abdominal organs (eg, spleen, bowel, liver), large pelvic vessels, diaphragm, and the uterine serosa [5,9-17].
- Pregnancy-Related Mortality Ratios, United States 1991-1999. CDC. MMWR Vol 52, ss-2, February 21, 2003.
- Centers for Disease Control and Prevention (CDC). Ectopic pregnancy--United States, 1990-1992. MMWR Morb Mortal Wkly Rep 1995; 44:46.
- Bouyer J, Coste J, Fernandez H, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 2002; 17:3224.
- Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 1987; 69:333.
- Dover RW, Powell MC. Management of a primary abdominal pregnancy. Am J Obstet Gynecol 1995; 172:1603.
- Fisch B, Peled Y, Kaplan B, et al. Abdominal pregnancy following in vitro fertilization in a patient with previous bilateral salpingectomy. Obstet Gynecol 1996; 88:642.
- Binder DS. Thirteen-week abdominal pregnancy after hysterectomy. J Emerg Med 2003; 25:159.
- Fader AN, Mansuria S, Guido RS, Wiesenfeld HC. A 14-week abdominal pregnancy after total abdominal hysterectomy. Obstet Gynecol 2007; 109:519.
- Varma R, Mascarenhas L, James D. Successful outcome of advanced abdominal pregnancy with exclusive omental insertion. Ultrasound Obstet Gynecol 2003; 21:192.
- Onan MA, Turp AB, Saltik A, et al. Primary omental pregnancy: case report. Hum Reprod 2005; 20:807.
- Kitade M, Takeuchi H, Kikuchi I, et al. A case of simultaneous tubal-splenic pregnancy after assisted reproductive technology. Fertil Steril 2005; 83:1042.
- Cormio G, Santamato S, Vimercati A, Selvaggi L. Primary splenic pregnancy. A case report. J Reprod Med 2003; 48:479.
- Ludwig M, Kaisi M, Bauer O, Diedrich K. The forgotten child--a case of heterotopic, intra-abdominal and intrauterine pregnancy carried to term. Hum Reprod 1999; 14:1372.
- Shippey SH, Bhoola SM, Royek AB, Long ME. Diagnosis and management of hepatic ectopic pregnancy. Obstet Gynecol 2007; 109:544.
- Phupong V, Tekasakul P, Kankaew K. Broad ligament twin pregnancy. A case report. J Reprod Med 2001; 46:144.
- Kalof AN, Fuller B, Harmon M. Splenic pregnancy: a case report and review of the literature. Arch Pathol Lab Med 2004; 128:e146.
- Fishman DA, Padilla LA, Joob A, Lurain JR. Ectopic pregnancy causing hemothorax managed by thoracoscopy and actinomycin D. Obstet Gynecol 1998; 91:837.
- Tsudo T, Harada T, Yoshioka H, Terakawa N. Laparoscopic management of early primary abdominal pregnancy. Obstet Gynecol 1997; 90:687.
- Rahman MS, Al-Suleiman SA, Rahman J, Al-Sibai MH. Advanced abdominal pregnancy--observations in 10 cases. Obstet Gynecol 1982; 59:366.
- Lamina MA, Akinyemi BO, Fakoya TA, et al. Abdominal pregnancy: a cause of failed induction of labour. Niger J Med 2005; 14:213.
- Deshpande N, Mathers A, Acharya U. Broad ligament twin pregnancy following in-vitro fertilization. Hum Reprod 1999; 14:852.
- Morita Y, Tsutsumi O, Kuramochi K, et al. Successful laparoscopic management of primary abdominal pregnancy. Hum Reprod 1996; 11:2546.
- Jazayeri A, Davis TA, Contreras DN. Diagnosis and management of abdominal pregnancy. A case report. J Reprod Med 2002; 47:1047.
- Rahaman J, Berkowitz R, Mitty H, et al. Minimally invasive management of an advanced abdominal pregnancy. Obstet Gynecol 2004; 103:1064.
- Lockhat F, Corr P, Ramphal S, Moodley J. The value of magnetic resonance imaging in the diagnosis and management of extra-uterine abdominal pregnancy. Clin Radiol 2006; 61:264.
- Tromans PM, Coulson R, Lobb MO, Abdulla U. Abdominal pregnancy associated with extremely elevated serum alpha-fetoprotein. Case report. Br J Obstet Gynaecol 1984; 91:296.
- Pisarska MD, Casson PR, Moise KJ Jr, et al. Heterotopic abdominal pregnancy treated at laparoscopy. Fertil Steril 1998; 70:159.
- Olsen ME. Laparoscopic treatment of intraligamentous pregnancy. Obstet Gynecol 1997; 89:862.
- Ginath S, Malinger G, Golan A, et al. Successful laparoscopic treatment of a ruptured primary abdominal pregnancy. Fertil Steril 2000; 74:601.
- Gerli S, Rossetti D, Baiocchi G, et al. Early ultrasonographic diagnosis and laparoscopic treatment of abdominal pregnancy. Eur J Obstet Gynecol Reprod Biol 2004; 113:103.
- Cardosi RJ, Nackley AC, Londono J, Hoffman MS. Embolization for advanced abdominal pregnancy with a retained placenta. A case report. J Reprod Med 2002; 47:861.
- Zinger M, Rosenfeld D. Failed treatment of abdominal pregnancy with methotrexate. A case report. J Reprod Med 2001; 46:392.
- Beddock R, Naepels P, Gondry C, et al. [Diagnosis and current concepts of management of advanced abdominal pregnancy]. Gynecol Obstet Fertil 2004; 32:55.
- Oneko O, Petru E, Masenga G, et al. Management of the placenta in advanced abdominal pregnancies at an East african tertiary referral center. J Womens Health (Larchmt) 2010; 19:1369.
- Mitra AG, LeQuire MH. Minimally invasive management of 14.5-week abdominal pregnancy without laparotomy: a novel approach using percutaneous sonographically guided feticide and systemic methotrexate. J Ultrasound Med 2003; 22:709.
- Cetinkaya MB, Kokcu A, Alper T. Follow up of the regression of the placenta left in situ in an advanced abdominal pregnancy using the Cavalieri method. J Obstet Gynaecol Res 2005; 31:22.
- Oki T, Baba Y, Yoshinaga M, Douchi T. Super-selective arterial embolization for uncontrolled bleeding in abdominal pregnancy. Obstet Gynecol 2008; 112:427.
- Ayinde OA, Aimakhu CO, Adeyanju OA, Omigbodun AO. Abdominal pregnancy at the University College Hospital, Ibadan: a ten-year review. Afr J Reprod Health 2005; 9:123.
- Stevens CA. Malformations and deformations in abdominal pregnancy. Am J Med Genet 1993; 47:1189.
- Worley KC, Hnat MD, Cunningham FG. Advanced extrauterine pregnancy: diagnostic and therapeutic challenges. Am J Obstet Gynecol 2008; 198:297.e1.
- Odom SR, Gemer M, Muyco AP. Lithopedion presenting as intra-abdominal abscess and fecal fistula: report of a case and review of the literature. Am Surg 2006; 72:77.
- Lee CL, Wang CJ, Chao A, et al. Laparoscopic management of an ectopic pregnancy in a previous Caesarean section scar. Hum Reprod 1999; 14:1234.
- Valley MT, Pierce JG, Daniel TB, Kaunitz AM. Cesarean scar pregnancy: imaging and treatment with conservative surgery. Obstet Gynecol 1998; 91:838.
- Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006; 107:1373.
- Marchiolé P, Gorlero F, de Caro G, et al. Intramural pregnancy embedded in a previous Cesarean section scar treated conservatively. Ultrasound Obstet Gynecol 2004; 23:307.
- Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG 2007; 114:253.
- Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2000; 16:592.
- Graesslin O, Dedecker F Jr, Quereux C, Gabriel R. Conservative treatment of ectopic pregnancy in a cesarean scar. Obstet Gynecol 2005; 105:869.
- Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH. Detection of cesarean scars by transvaginal ultrasound. Obstet Gynecol 2003; 101:61.
- Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the "niche" in the scar. J Ultrasound Med 2001; 20:1105.
- Ofili-Yebovi D, Ben-Nagi J, Sawyer E, et al. Deficient lower-segment Cesarean section scars: prevalence and risk factors. Ultrasound Obstet Gynecol 2008; 31:72.
- Shih JC. Cesarean scar pregnancy: diagnosis with three-dimensional (3D) ultrasound and 3D power Doppler. Ultrasound Obstet Gynecol 2004; 23:306.
- Shufaro Y, Nadjari M. Implantation of a gestational sac in a cesarean section scar. Fertil Steril 2001; 75:1217.
- Timor-Tritsch IE, Monteagudo A, Santos R, et al. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol 2012; 207:44.e1.
- Deans R, Abbott J. Hysteroscopic management of cesarean scar ectopic pregnancy. Fertil Steril 2010; 93:1735.
- Smith A, Ash A, Maxwell D. Sonographic diagnosis of cesarean scar pregnancy at 16 weeks. J Clin Ultrasound 2007; 35:212.
- Jurkovic D, Hillaby K, Woelfer B, et al. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Ultrasound Obstet Gynecol 2003; 21:220.
- Sugawara J, Senoo M, Chisaka H, et al. Successful conservative treatment of a cesarean scar pregnancy with uterine artery embolization. Tohoku J Exp Med 2005; 206:261.
- Yang MJ, Jeng MH. Combination of transarterial embolization of uterine arteries and conservative surgical treatment for pregnancy in a cesarean section scar. A report of 3 cases. J Reprod Med 2003; 48:213.
- Chou MM, Hwang JI, Tseng JJ, et al. Cesarean scar pregnancy: quantitative assessment of uterine neovascularization with 3-dimensional color power Doppler imaging and successful treatment with uterine artery embolization. Am J Obstet Gynecol 2004; 190:866.
- Ghezzi F, Laganà D, Franchi M, et al. Conservative treatment by chemotherapy and uterine arteries embolization of a cesarean scar pregnancy. Eur J Obstet Gynecol Reprod Biol 2002; 103:88.
- Zhuang Y, Huang L. Uterine artery embolization compared with methotrexate for the management of pregnancy implanted within a cesarean scar. Am J Obstet Gynecol 2009; 201:152.e1.
- Robinson JK, Dayal MB, Gindoff P, Frankfurter D. A novel surgical treatment for cesarean scar pregnancy: laparoscopically assisted operative hysteroscopy. Fertil Steril 2009; 92:1497.e13.
- Ben Nagi J, Helmy S, Ofili-Yebovi D, et al. Reproductive outcomes of women with a previous history of Caesarean scar ectopic pregnancies. Hum Reprod 2007; 22:2012.
- Seow KM, Huang LW, Lin YH, et al. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol 2004; 23:247.
- Seow KM, Hwang JL, Tsai YL, et al. Subsequent pregnancy outcome after conservative treatment of a previous cesarean scar pregnancy. Acta Obstet Gynecol Scand 2004; 83:1167.
- Rosen T. Placenta accreta and cesarean scar pregnancy: overlooked costs of the rising cesarean section rate. Clin Perinatol 2008; 35:519.
- Reece EA, Petrie RH, Sirmans MF, et al. Combined intrauterine and extrauterine gestations: a review. Am J Obstet Gynecol 1983; 146:323.
- Pisarska MD, Carson SA. Incidence and risk factors for ectopic pregnancy. Clin Obstet Gynecol 1999; 42:2.
- Rojansky N, Schenker JG. Heterotopic pregnancy and assisted reproduction--an update. J Assist Reprod Genet 1996; 13:594.
- Goldstein JS, Ratts VS, Philpott T, Dahan MH. Risk of surgery after use of potassium chloride for treatment of tubal heterotopic pregnancy. Obstet Gynecol 2006; 107:506.
- Barrenetxea G, Barinaga-Rementeria L, Lopez de Larruzea A, et al. Heterotopic pregnancy: two cases and a comparative review. Fertil Steril 2007; 87:417.e9.
- Habana A, Dokras A, Giraldo JL, Jones EE. Cornual heterotopic pregnancy: contemporary management options. Am J Obstet Gynecol 2000; 182:1264.
- Hsieh BC, Hwang JL, Pan HS, et al. Heterotopic Caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selective embryo reduction: case report. Hum Reprod 2004; 19:285.
- Shojai R, Chaumoitre K, Chau C, et al. Advanced combined abdominal and intrauterine pregnancy: a case report. Fetal Diagn Ther 2007; 22:128.
- Hassiakos D, Bakas P, Pistofidis G, Creatsas G. Heterotopic pregnancy at 16 weeks of gestation after in-vitro fertilization and embryo transfer. Arch Gynecol Obstet 2002; 266:124.
- Tal J, Haddad S, Gordon N, Timor-Tritsch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: a literature review from 1971 to 1993. Fertil Steril 1996; 66:1.
- Cheng PJ, Chueh HY, Qiu JT. Heterotopic pregnancy in a natural conception cycle presenting as hematometra. Obstet Gynecol 2004; 104:1195.
- Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynecol 2006; 107:399.
- Clayton HB, Schieve LA, Peterson HB, et al. A comparison of heterotopic and intrauterine-only pregnancy outcomes after assisted reproductive technologies in the United States from 1999 to 2002. Fertil Steril 2007; 87:303.
- Louis-Sylvestre C, Morice P, Chapron C, Dubuisson JB. The role of laparoscopy in the diagnosis and management of heterotopic pregnancies. Hum Reprod 1997; 12:1100.
- Goldberg JM, Bedaiwy MA. Transvaginal local injection of hyperosmolar glucose for the treatment of heterotopic pregnancies. Obstet Gynecol 2006; 107:509.
- Salomon LJ, Fernandez H, Chauveaud A, et al. Successful management of a heterotopic Caesarean scar pregnancy: potassium chloride injection with preservation of the intrauterine gestation: case report. Hum Reprod 2003; 18:189.
- ABDOMINAL PREGNANCY
- Clinical manifestations
- Diagnostic evaluation
- Differential diagnosis
- CESAREAN SCAR PREGNANCY
- Clinical manifestations
- Diagnostic evaluation
- Differential diagnosis
- HETEROTOPIC PREGNANCY
- Clinical manifestations
- Diagnostic evaluation
- Differential diagnosis
- SUMMARY AND RECOMMENDATIONS