Challenging Diagnosis of Late Abdominal Pregnancy: A Case Study of Misdiagnosis and Fetal Death in the Third Trimester.

BACKGROUND Abdominal pregnancy is a rare form of extrauterine pregnancy that usually results in a poor outcome; it is associated with serious fetal and maternal morbidity. The diagnosis of advanced abdominal pregnancy is sometimes challenging and should be identified early, at a routine antenatal examination. There are still no evidence-based management strategies for late abdominal pregnancy. This report presents a case of a patient with an abdominal pregnancy and a non-viable fetus. CASE REPORT A 34-year-old woman presented as an emergency 2 months after the diagnosis of intrauterine fetal death at 33 weeks of gestation. During subsequent surgery, the pregnancy was found to be an undiagnosed abdominal pregnancy. The patient had been admitted due to abdominal pain and increasingly deteriorating general condition. On admission, clinical examination and abdominal ultrasound were carried out and the diagnosis of fetal death was confirmed. The diagnosis of extrauterine pregnancy, however, was initially missed, and a decision to induce labor was made. After unsuccessful induction of labor and deterioration of the patient's general condition, a laparotomy was performed, and the diagnosis of abdominal pregnancy was confirmed. A severely macerated fetus and placenta were delivered. Relative to others with this condition, the patient had a very good postoperative outcome with prolonged healing of the surgical incision. Informed consent for publication was obtained from the patient. CONCLUSIONS The diagnosis of late abdominal pregnancy can be missed despite clinical and sonographic examination. This diagnosis should be considered and excluded in similar suspected clinical findings. Proper operative planning in a tertiary center with a well-experienced team is crucial.

Prolonged abdominal pregnancy incidentally discovered during cesarean section: a case report.

BACKGROUND: Abdominal pregnancy is a rare medical condition that is still missed in developing countries due to inadequate medical facilities. The clinical indicators manifest in various forms and are nonspecific, making it challenging to diagnose and often leading to delayed detection. However, obstetric ultrasound serves as an essential tool in early detection. Our objective was to share our experience dealing with this condition and emphasise the importance of early ultrasound diagnosis through efficient pregnancy monitoring in our regions. CASE PRESENTATION: 35-year-old Black African woman who had ten months of amenorrhea sought consultation due to an absence of active foetal movements. Her pregnancy was of 39 weeks with fetal demise which was confirmed following clinical examination and ultrasound. She underwent cesarean section in view of transverse position of fetus. During cesarean section, the fetus was found within the abdominal cavity with the placenta attached over the left iliac fossa including surface of left ovary. The uterus and right adnexa were within normal limits. A 2600 g macerated fetus with placenta and membranes were extracted without any complications. The maternal outcome was successful. CONCLUSIONS: Abdominal pregnancy remained an inadequately diagnosed condition in developing countries. It is imperative to increase awareness among pregnant women regarding high-quality prenatal care, including early obstetric ultrasound, from conception. Meanwhile, healthcare professionals should receive continuous training and the technical platform modernised. To ensure accurate diagnosis, the location of the gestational sac must be identified for every pregnant woman during their initial ultrasound appointment.

Large unruptured tubal pregnancy mimicking abdominal pregnancy.

Ectopic pregnancy accounts for 1-2% of all pregnancies. Ultrasound is the primary diagnostic tool to locate pregnancy outside the uterus and identify complications such as haemoperitoneum. In inconclusive cases, MRI is an adjunctive imaging modality offering more precise tissue differentiation and helpful to location identification. Presented is an unusual case of tubal pregnancy. The patient in her 30s, who was 14 weeks into her first pregnancy, had a suspected abdominal pregnancy. Both transabdominal ultrasound and an MRI indicated an ectopic pregnancy, likely originating from the right fallopian tube. A successful laparotomy and right salpingectomy were performed without complications. Rarely, as in this case, large unruptured and advanced tubal pregnancies can mimic an abdominal pregnancy, underscoring the importance of disease recognition and familiarity with uncommon image findings. An accurate diagnosis of pregnancy location is crucial for effective case management.

Abdominal pregnancy secondary to uterine horn pregnancy: a case report.

BACKGROUND: Pregnancy begins with a fertilized ovum that normally attaches to the uterine endometrium. However, an ectopic pregnancy can occur when a fertilized egg implants and grows outside the uterine cavity. Tubal ectopic pregnancy is the most common type (over 95%), with ovarian, abdominal, cervical, broad ligament, and uterine cornual pregnancy being less common. As more cases of ectopic pregnancy are diagnosed and treated in the early stages, the survival rate and fertility retention significantly improve. However, complications of abdominal pregnancy can sometimes be life-threatening and have severe consequences. CASE PRESENTATION: We present a case of intraperitoneal ectopic pregnancy with fetal survival. Ultrasound and magnetic resonance imaging showed a right cornual pregnancy with a secondary abdominal pregnancy. In September 2021, we performed an emergency laparotomy, along with additional procedures such as transurethral ureteroscopy, double J-stent placement, abdominal fetal removal, placentectomy, repair of the right uterine horn, and pelvic adhesiolysis, in the 29th week of pregnancy. During laparotomy, we diagnosed abdominal pregnancy secondary to a rudimentary uterine horn. The mother and her baby were discharged eight days and 41 days, respectively, after surgery. CONCLUSIONS: Abdominal pregnancy is a rare condition. The variable nature of ectopic pregnancy can cause delays in timely diagnosis, resulting in increased morbidity and mortality, especially in areas with inadequate medical and social services. A high index of suspicion, coupled with appropriate imaging studies, can help facilitate its diagnosis in any suspected case.

Rudimentary horn pregnancy, a differential diagnosis of an intraabdominal pregnancy: a case report.

BACKGROUND: Rudimentary horn pregnancy is a rare life-threatening obstetric condition with clinical and sonographic presentation resembling that of an abdominal pregnancy. Preoperative diagnosis of advanced rudimentary horn pregnancy is difficult and cases are often identified incidentally during laparotomy for a presumed abdominal pregnancy. CASE PRESENTATION: We report a case of a 29-year-old African woman, gravida 2 para 1 at 28 weeks of gestation complaining of epigastric pain for 7 days with no other associated gastrointestinal or genitourinary symptoms. On examination, she had normal vital signs and an enlarged abdomen sized at 33 cm with unremarkable fetal lie and presentation. She had normal laboratory blood results with an ultrasound revealing an abdominal pregnancy of 28 weeks. The informed decision for conservative management was planned after informing of the benefit and risks of early termination versus conservative management, however, with worsening symptoms an emergency laparotomy had to be performed in which a left unruptured rudimentary horn pregnancy with a viable fetus was identified incidentally and delivery of the fetus followed by surgical excision of the horn was done. The postoperative period was uneventful, and the patient was discharged home with her newborn. CONCLUSION: Rudimentary horn pregnancy is very rare and often indistinguishable from an abdominal pregnancy in advanced gestation age. First trimester ultrasound is by far the only noninvasive sensitive diagnostic modality for rudimentary horn pregnancy. Laparotomy with horn excision remains the standard of care for advanced rudimentary horn pregnancy.

A 27-Year-Old Brazilian Woman with a History of Left Salpingectomy and Late Diagnosis of an Extra-Uterine Intra-Abdominal Pregnancy and Live Birth at 26 Weeks' Gestation.

BACKGROUND Abdominal pregnancy is a special type of ectopic pregnancy, characterized by implantation of the embryo in the peritoneal cavity, with tubal, ovarian, and intraligamentary pregnancies excluded, accounting for approximately 1% of all cases. It was first reported in 1708 after an autopsy and since then numerous cases have been reported, with a current incidence of 1: 10 000 to 1: 30 000 pregnancies. CASE REPORT We report the case of a 27-year-old woman, resident of the city of Caxias do Sul, Brazil, with an extra-uterine pregnancy by ultrasound diagnosis at 25 weeks and 1 day of gestational age and a live fetus. CONCLUSIONS Abdominal gestation is a rare type of ectopic pregnancy and is characterized as a life-threatening situation. Its biggest challenge is to make an early diagnosis, since most cases go unnoticed at the ultrasound performed in the first trimester, and when symptomatic, they do not present themselves in a specific way. When necessary, MRI has been shown to greatly elucidate such cases. Moreover, the therapeutic decision also presents some disparities in the literature. Although it is known that open surgery is best option, there are still many doubts regarding whether to perform placental extraction since its removal process can cause abundant bleeding, putting the patient at risk during the surgical procedure, in the same way that its maintenance and the use of drug treatment can also aggravate the patient's clinical picture.

Abdominal heterotopic pregnancy post-IVF double embryo transfer.

Uterosacral ligament (USL) is an uncommon site of implantation for abdominal ectopic pregnancies. This is the first case of USL heterotopic pregnancy post invitro fertilisation (IVF). The patient presented 6 weeks after a double embryo transfer with acute onset abdominal pain and was diagnosed with a suspected live tubal ectopic pregnancy with a viable intrauterine pregnancy on ultrasound. A diagnostic laparoscopy revealed an ectopic pregnancy implanted on the left USL which was resected and confirmed on histology. The patient was discharged well on postoperative day 2 with a viable intrauterine pregnancy. This case highlights the importance of considering non-tubal heterotopic pregnancies in the context of risk factors including IVF with double embryo transfer presenting with abdominal pain.

Laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy.

OBJECTIVE: To report a case of laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy (AEP). DESIGN: Video article. SETTING: Academic medical center. PATIENT(S): A 40-year-old G5P3013 woman at approximately 7 weeks of pregnancy was referred to our emergency department because of abnormally rising ß-human chorionic gonadotropin levels. Transvaginal ultrasonography revealed a cystic structure measuring 2.8 × 1.6 ×1.9 cm in the posterior cul-de-sac distinct from the cervix. The mass was noted to have peripheral hypervascularity and a thickened wall. A moderate amount of complex free fluid was noted adjacent to the mass. The patient's baseline ß-human chorionic gonadotropin level and hematocrit were 6,810.7 mIU/mL and 42.4%, respectively. INTERVENTION(S): Laparoscopy for suspected AEP. MAIN OUTCOME MEASURE(S): Laparoscopic excision of a primary AEP. RESULT(S): Diagnostic laparoscopy revealed a normal uterus, normal right ovary, normal left ovary with a corpus luteal cyst, and normal bilateral fallopian tubes without dilatation or hemorrhage. The AEP was noted in the right posterior cul-de-sac and was excised from the underlying peritoneum. The left lateral aspect of the AEP extended into the posterior vaginal wall. The patient was admitted for overnight observation, and her postoperative hematocrit was 35.1%. CONCLUSION(S): AEPs are extremely rare and account for 1% of all ectopic pregnancies. Approximately 90% of AEPs require surgical management. Historically, AEPs were treated with laparotomy because of the high risk of hemorrhage and hemodynamic instability. However, as exemplified by the current case, laparoscopy is a safe and feasible option for surgical management of AEPs.

Abdominal ectopic pregnancy complicated with a large bowel injury: a case report.

BACKGROUND: Abdominal pregnancy accounts for 0.6 to 4% of all ectopic pregnancies. Due to delays in diagnosis and difficulties in the management of abdominal pregnancy, the risk of mortality is significantly higher than for uncomplicated ectopic pregnancies. A 23 years-old gravida-II, ectopic-I Ethiopian woman was initially managed as a case of missed second trimester abortion. Later on, abdominal ectopic pregnancy was diagnosed with ultrasound and she underwent a laparotomy. Though fetus and placenta was removed successfully without significant hemorrhage, there was inadvertent sigmoid colon injury. CONCLUSION: In the management of abdominal ectopic pregnancy, the possibility of bowel injury during entry to the abdominal cavity at laparotomy should always be considered and an experienced general surgeon should always be in attendance before opening the abdomen, to prevent it from happening.

The use of FIESTA sequence MRI in successful management of abdominal pregnancy.

Identification of fetal location and its relations to abdominal organs is extremely important in reducing fetal and maternal morbidity in rare cases of abdominal pregnancy. Ultrasound examination is inadequate for helping to successfully manage such cases. In this case report, FIESTA sequence MRI is used to provide high-resolution, better contrast, and higher signal-to-noise ratio fetal and abdominal images. A case of advanced abdominal pregnancy with a live fetus is reported. The surgery was conducted successfully on 34 weeks of gestation.

Rectal ectopic pregnancy: A case report.

RATIONALE: Abdominal ectopic pregnancy is a very rare form of ectopic pregnancy, yet is associated with higher morbidity due to atypical clinical presentation and misdiagnosis. In this report, we present a case of abdominal ectopic pregnancy with placenta invading to the rectal wall. PATIENT CONCERNS: A 32-year-old woman was admitted to our hospital with an increasing serum ß-hCG level after diagnostic laparoscopy for ectopic pregnancy in the provincial hospital. During the laparoscopy, no gestational sac was found. She was discharged and scheduled for a follow-up visit to assess the level of ß-hCG. One week later, her serum ß-hCG level increased from 7000 IU/l to 12000 IU/l. Transvaginal Doppler ultrasound and abdominal computed tomography (CT) angiography demonstrated a right adnexal mass adherent to the rectal wall. DIAGNOSIS: A rectal ectopic pregnancy is suspected. INTERVENTIONS: Laparoscopic surgery was successfully performed in our hospital to remove the products of conception. OUTCOMES: Histologic examination confirmed the diagnosis of a rectal ectopic pregnancy. The patient had an uneventful recovery and was discharged the next few days. LESSONS: This case report reveals that an abdominal pregnancy is remarkably difficult to diagnose and manage. The gynecologists need to be aware of the possibility of gestational sac between the uterus and the rectum. To make early diagnosis of abdominal pregnancy, they need to combine clinical findings, imaging techniques (ultrasound, CT, MRI) and serial human chorionic gonadotropin measurements. Laparoscopic management should be considered in early abdominal pregnancy. A multidisciplinary team of gynecologists and gastrointestinal surgeons is required to deal with rectal ectopic pregnancy.

Abdominal ectopic pregnancy with implantation on the rectum.

We report a patient who presented to our unit 26 days following in vitro fertilisation (IVF) and embryo transfer with vaginal staining, diarrhoea and mild crampy abdominal pain. On transvaginal ultrasound the uterus was empty with an extrauterine sac identified containing a yolk sac and a fetal pole with cardiac activity. Diagnostic laparoscopy was undertaken which confirmed an abdominal pregnancy with implantation on the rectum.

Neglected intrauterine fetal demise for more than two decades leading to the development of a lithopedion: a case report.

BACKGROUND: Lithopedion is a word derived from the Greek words lithos, meaning stone, and paidion, meaning child, to describe a fetus that has become stony or petrified. Lithopedion is a rare complication of pregnancy which occurs when a fetus dies and becomes too large to be reabsorbed by the body. This entity in rare circumstances can be challenging for physicians to diagnose since it has a range of clinical manifestations. CASE PRESENTATION: We present a case of a 55-year-old, gravida IV para III, Ethiopian woman from Ethiopia with a retained fetus and vesicovaginal fistula after an obstructed labor and a neglected intrauterine fetal demise of approximately 22 years. The diagnosis was confirmed by suggestive clinical history, physical examination findings, and an abdominopelvic computed tomography scan. Laparotomy and removal of the lithopedion was done and our patient was sent to a fistula hospital for vesicovaginal fistula repair. CONCLUSION: This case is a rare phenomenon in which the dead fetus remained in the uterus for a long time after a neglected obstructed labor and uterine rupture.

Rare primary abdominal ectopic pregnancy in the pouch of Douglas.

A 35-year-old Nepalese woman, referred by her general practitioner for per vaginal spotting and abdominal pain for the past 12 days with a background history of 5 weeks of amenorrhoea and a quantifiable beta-human chorionic gonadotrophin of 18 900 IU/L. Subsequent pelvic ultrasound revealed a cystic lesion with peripheral vascularity in the pouch of Douglas indicating possible ectopic pregnancy with no intrauterine gestational sac seen. Subsequent to that, she underwent a diagnostic laparoscopy that revealed 150 mL of blood in the pouch of Douglas with no other obvious evidence of tubal or ovarian ectopic pregnancy seen. There was, however, a resemblance of trophoblastic tissue noted on the wall of the pouch of Douglas that was further investigated to reveal a primary ectopic pregnancy of the pouch of Douglas with no trophoblastic infiltration.

Embarazo ectópico abdominal. Presentación de un caso y revisión de la literatura / Gravidez ectópica abdominal. Apresentação de caso e revisão de literatura / Abdominal ectopic pregnancy. Case report and literature review

Introducción: el embarazo ectópico es una de las afecciones que más incrementan la morbilidad y la mortalidad maternas. La incidencia varía de 1:40 a 1:100 embarazos. Se caracteriza por la implantación del embrión dentro de la cavidad peritoneal, por fuera de la trompa de Falopio, el ovario y el ligamento ancho del útero. Objetivo: familiarizar a los médicos generales timorenses con las características clínicas, la etiopatogenia y el diagnóstico y el manejo de esta condición obstétrica. Método: se presentó un caso clínico de embarazo ectópico abdominal atendido por un equipo multidisciplinarios de profesionales cubanos colaboradores en el Hospital Referal Maubisse (República Democrática de Timor Leste). Se revisó la literatura sobre el tema en bases de datos electrónicas (SciELO, ClinicalKey, RedALyC, Scopus, PubMed, Clinical Evidence, Cochrane). Se realizó una selección por título y resumen por los tres autores, en caso de encontrar una diferencia se sometió a un cuarto evaluador. Resultados: el examen clínico y la ultrasonografía abdominal posibilitaron el diagnóstico de embarazo ectópico abdominal con feto muerto. Se realizó laparotomía y se encontró un feto de 17 semanas en estado de momificación y maceración aséptica, ubicado en el fondo de saco de Douglas. Fue posible la extracción completa del tejido placentario sin complicaciones transoperatorias y evolución satisfactoria. Conclusiones: el cuadro clínico es inespecífico y aunque se reconoce el valor diagnóstico de la ecografía abdominal, al no existir signos específicos y ante la ausencia de imágenes ultrasonográficas características, se hace indispensable una laparotomía exploradora(AU)

Introduction: Ectopic pregnancy is one of the conditions that most increase maternal morbidity and mortality. The incidence varies from 1:40 to 1: 100 pregnancies. It is characterized by implantation of the embryo into the peritoneal cavity, outside the fallopian tube, the ovary and the broad ligament of the uterus. Objective: to familiarize Timorese general practitioners with the clinical characteristics, etiopathogenesis and diagnosis and management of this obstetric condition. Method: A clinical case of abdominal ectopic pregnancy was presented attended by a multidisciplinary team of Cuban professionals collaborating at the Hospital Referal Maubisse (Democratic Republic of Timor Leste). Literature on the subject was reviewed in electronic databases (SciELO, ClinicalKey, RedALyC, Scopus, PubMed, Clinical Evidence, Cochrane). A selection was made by title and summary by the three authors, in case of finding a difference it was submitted to a fourth evaluator. Results: the clinical examination and abdominal ultrasonography made it possible to diagnose abdominal ectopic pregnancy with dead fetus. Laparotomy was performed and a 17-week fetus was found in a state of mummification and aseptic maceration, located at the bottom of Douglas's sac. It was possible the complete extraction of the placental tissue without transoperative complications and satisfactory evolution. Conclusions: the clinical picture is nonspecific and although the diagnostic value of abdominal ultrasound is recognized, as there are no specific signs and in the absence of characteristic ultrasound images, an exploratory laparotomy is essential(AU)

Introdução: A gravidez ectópica é uma das condições que mais aumentam a morbimortalidade materna. A incidência varia de 1:40 a 1: 100 gestações. É caracterizada pelo implante do embrião na cavidade peritoneal, fora da trompa de Falópio, do ovário e do ligamento largo do útero. Objectivo: familiarizar os clínicos gerais timorenses com as características clínicas, etiopatogenia e diagnóstico e tratamento desta condição obstétrica. Método: Foi apresentado um caso clínico de gravidez ectópica abdominal, atendido por uma equipe multidisciplinar de profissionais cubanos que colaboraram no Hospital Referal Maubisse (República Democrática de Timor Leste). A literatura sobre o assunto foi revisada em bancos de dados eletrônicos (SciELO, ClinicalKey, RedALyC, Scopus, PubMed, Clinical Evidence, Cochrane). Uma seleção foi feita por título e resumo pelos três autores; no caso de encontrar diferença, foi submetida a um quarto avaliador. Resultados: o exame clínico e a ultrassonografia abdominal possibilitaram o diagnóstico de gravidez ectópica abdominal com feto morto. Foi realizada laparotomia e um feto de 17 semanas foi encontrado em estado de mumificação e maceração asséptica, localizado no fundo do saco de Douglas. Foi possível a extração completa do tecido placentário sem complicações transoperatórias e evolução satisfatória. Conclusões: o quadro clínico é inespecífico e, embora o valor diagnóstico da ultrassonografia abdominal seja reconhecido, pois não há sinais específicos e na ausência de imagens ultrassonográficas características, é essencial uma laparotomia exploradora(AU)

A rare case of ectopic pregnancy - retroperitoneal ectopic pregnancy.

Ectopic pregnancy is a condition when fertilized egg implants outside the uterine cavity. The reported incidence is about 0.5-1% of all pregnancies. Retroperitoneal ectopic pregnancies (REP) are extremely rare and early diagnosis and treatment is very difficult. For the adequate management and elimination of risks of maternal morbidity and even mortality, timely diagnosis is of a key importance. A 38-year-old woman was referred to our department for RCUI due to missed abortion/anembryonic pregnancy. Re-RCUI was later indicated due to suspicion of residua post RCUI. Histological examination didn't confirm intrauterine pregnancy, ß-hCG blood levels were flat. Further ultrasonographic examination identified retroperitoneal ectopic pregnancy, most likely in the precaval lymph node. The surgical and subsequently histological examination confirmed this diagnosis. Our case describes successful management of rare retroperitoneal ectopic pregnancy. When common sites of ectopic pregnancy do not have any positive finding, then the presence of REP should be taken into consideration.

Abdominal Cocoon Syndrome following Primary Subfertility Management with IVF-ET.

Abdominal cocoon syndrome is a rarely encountered surgical emergency first described by Foo et al. in 1978. This condition is characterised by a thick fibrous membrane which encases the small bowel partially or completely. Diagnosis of this condition is usually made per operatively and the treatment of choice is surgical release of entrapped bowel. This is a case report of abdominal cocoon syndrome diagnosed during laparotomy done with the provisional diagnosis of abdominal pregnancy following In vitro fertilization- embryo transfer. A 30 Years lady was admitted at Kathmandu Medical College for suspected ovarian hyper stimulation syndrome following In vitro fertilization- embryo transfer. Conservative treatment was done as the first line of management. Failing this, she was treated surgically with the provisional diagnosis of abdominal pregnancy. Abdominal cocoon syndrome was observed intraoperatively. Patient was managed medically with injection due to raised ßhCG level and empty uterine cavity. Intrauterine gestational sac was seen after about seven weeks of In vitro fertilization- embryo transfer. Pregnancy was terminated medically and patient was discharged. Sub fertility is a common gynecological problem. Its management may sometimes produce challenging health hazards. Thorough screening for medical and surgical illness is very important before proceeding to any kind of assisted reproductive technologies. A multidisciplinary approach is very important to manage such cases. Keywords: abdominal cocoon syndrome; embryo transfer; In Vitro fertilization; ovarian Hyper stimulation syndrome; sub fertility.

Successful management of a spontaneous viable monochorionic diamniotic twin pregnancy on cesarean scar with systemic methotrexate: A case report.

RATIONALE: Cesarean scar twin pregnancy is exceedingly rare and it remains to be a life-threatening condition even in the early weeks of gestation. Because of its rare occurrence, there is no consensus on the treatment modality of cesarean ectopic pregnancy. PATIENT CONCERNS: A 41-year-old, woman, gravida 7, para 6, with a history of low transverse cesarean section 2 years back presented with an estimated 6 weeks gestational age and viable spontaneous twin, monochorionic diamniotic gestation. The patient presented to the Emergency Department with complaints of vaginal bleeding and mild lower abdominal pain for 5 days. DIAGNOSES: An ultrasound examination was performed demonstrating a single intrauterine gestational sac with 2 viable embryos (monochorionic diamniotic) implanted in the lower uterine segment at the level of the prior cesarean section scar. A diagnosis of viable cesarean scar twin pregnancy was made. INTERVENTIONS: A 2 doses of 50 mg/m methotrexate (MTX) was given intramuscularly. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (ß-hCG) and ultrasound. OUTCOMES: Patient was followed up with ß-hCG weekly levels which became 0 after 68 days of treatment. During the follow-up, the patient was asymptomatic, no side effects of MTX were noticed. LESSONS: We reported a rare case of viable monochorionic diamniotic twin pregnancy on a cesarean scar that was successfully treated with systemic MTX without any additional therapy. Additionally, the decline of ß-hCG in twin ectopic cesarean scar pregnancy appears to be similar to a singleton ectopic pregnancy.