Tubal ectopic pregnancy: comparative management between pre and Covid-19 pandemic periods.

Objective: To evaluate whether there were differences in the presentation of patients with tubal ectopic pregnancy (EP) during the first year of the COVID-19 pandemic. Methods: We performed a retrospective cohort study of all cases of tubal EP between March 2019 and March 2020 (pre-pandemic) and between March 2020 and March 2021 (pandemic). We compared between these two groups the risk factors, clinical characteristics, laboratory data, sonographic aspects, treatment applied and complications. Results: We had 150 EP diagnoses during the two years studied, of which 135 were tubal EP. Of these, 65 were included in the pre-pandemic and 70 in the pandemic period. The prevalence of lower abdominal pain was significantly higher in the pandemic compared to the pre-pandemic period (91.4% vs. 78.1%, p=0.031). There was no significant difference in shock index, initial beta-hCG level, hemoglobin level at diagnosis, days of menstrual delay, aspect of the adnexal mass, amount of free fluid on ultrasound, and intact or ruptured presentation between the groups. Expectant management was significantly higher during the pandemic period (40.0% vs. 18.5%, p=0.008), surgical management was lower during the pandemic period (47.1% vs. 67.7%, p=0.023), and number of days hospitalized was lower in the pandemic period (1.3 vs. 2.0 days, p=0.003). Conclusion: We did not observe a significant difference in patient history, laboratory and ultrasound characteristics. Abdominal pain was more common during the pandemic period. Regarding treatment, we observed a significant increase in expectant and a decrease in surgical cases during the pandemic period.

The Effectiveness of Letrozole Alone or in Combination with Methotrexate in the Management of Ectopic Pregnancy, A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to investigate the effect of letrozole alone or in combination with Methotrexate on the management of ectopic pregnancy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were applied for reporting. The EMBASE, PubMed, Scopus, and Web of Science databases were searched for relevant studies focused on women diagnosed with ectopic pregnancy and managed non-surgically with letrozole alone or in combination with methotrexate (MTX) until April 2024. The success rate, laboratory findings, and complications were analyzed and reported. Meta-analysis was done using RevMan 5.4.1 software. Out of 129 unique studies obtained, 7 of them were found eligible for final review; of which, 3 were nonrandomized prospective cohort studies, 2 were randomized clinical trials, and 2 study were case studies. In 5 studies letrozole was used as monotherapy. While in another study letrozole was used with MTX. The meta-analysis showed a significantly lower level of ß-HCG in the letrozole group compared to MTX, 7 days after initiation of treatment (Fixed effect model, MD = -92.22, 95%CI: [-159.39, -25.04], P = 0.007, I2 = 0%). There was no significant difference in the level of anti-mullerian hormone (AMH) between groups (Fixed effect model, MD = 0.18, 95%CI: [-0.09, 0.45], P = 0.20, I2 = 0%). Success rate, platelet count, and level of liver enzymes seemed to be better or similar among patients receiving Letrozole compared to patients receiving Methotrexate. Letrozole exhibits potential as a therapeutic option for ectopic pregnancies; however, further randomized clinical trials are necessary to establish strong evidence.

Primi at 16 weeks and 5 days of Gestation with Hypovolemic Shock Secondary to Ruptured Rudimentary Horn Ectopic Pregnancy: A Case Report.

ABSTRACT: Developmental anomalies of genital tract result from defective fusion and absorption of various parts of Mullerian ducts in fetal life. Rudimentary horn pregnancy (RHP) is a rare occurrence of one in 76,000 and one in 160,000. We present a case of a 24-year-old primigravida with ruptured RHP initially managed in the line of an intrauterine pregnancy with severe anemia. Hemodynamic instability made us suspect ruptured RHP and lifesaving laparotomy was performed for the same. A 1.5-liter hemoperitoneum was encountered with a right RHP. Multiple adhesions were present with necrotic tissue adherent and clumped together as tubo-ovarian mass. Resection of rudimentary horn was performed. We report this case to emphasize the need to consider rare uterine anomalies as a possibility in patients presenting with acute abdomen in early pregnancy. So, Obstetricians can consider these rare entities in differential diagnosis and management.

Diagnostic and management challenges of a rare case of caesarean scar pregnancy in a low-resource setting: a case report.

Caesarean scar pregnancy is a rare type of ectopic pregnancy with the potential for catastrophic outcomes. A high index of suspicion is required for prompt diagnosis and intervention to improve outcomes. This report describes a rare case of Caesarean scar pregnancy, which was initially misdiagnosed as a threatened miscarriage and cervical ectopic pregnancy. A 35-year-old multiparous lady with two previous caesarean sections presented to the Gynaecology Unit of the Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nigeria, at an estimated gestational age of 10 weeks, with recurrent vaginal bleeding of eight weeks' duration. She was referred to our facility from a private hospital, where she had first been managed as a case of threatened miscarriage and later as a cervical ectopic pregnancy. The transvaginal ultrasound in our facility was in keeping with a viable Caesarean scar pregnancy. The urine pregnancy test was positive, and the quantitative serum beta human chorionic gonadotropin was 75.6 mIU/ml. She had initial medical treatment with a combination of systemic multidose and intrauterine sac methotrexate and, subsequently, hysterotomy. Following systemic and local methotrexate, there was the demise of the foetus, which was evacuated at hysterotomy, and the uterine scar defect was repaired. She was discharged home in stable clinical condition one week after surgery. Her serum beta human chorionic gonadotropin dropped to 51.6 mIU/mL two weeks post-hysterotomy, and her urine pregnancy test became negative three weeks later. Though rare, caesarean scar pregnancy should be considered a differential diagnosis in reproductive-aged women with a previous caesarean section who present with vaginal bleeding in the first trimester.

Bilateral Tubal Ectopic Pregnancy: A Case Report and Review.

A bilateral ectopic pregnancy is a rare condition, and even more so with spontaneous conception. The known risk factors and clinical presentation are shared by both unilateral and bilateral ectopic pregnancy. This poses a risk for misdiagnosis, treatment failure, and, ultimately, maternal mortality. The current standard for diagnostics is not discernible for a bilateral ectopic pregnancy, thus, medical management tends to be sub-therapeutic. In fact, it is fairly common for the correct diagnosis and efficient treatment to be achieved by surgical intervention. As there are no established diagnostic or treatment guidelines for this rare condition, the possibility of a bilateral ectopic pregnancy should not be ruled out lightly.

A Rare Case of Diaphragmatic Rupture Due to Ectopic Pregnancy Leading to Haemorrhagic Shock in a Multipara: A Case Report.

Abdominal pregnancy is a rare and life-threatening form of ectopic pregnancy. Although the underlying mechanism of this abnormal disorder is unknown, a number of risk factors have been identified, including pelvic inflammatory disease, history of pelvic surgery, intrauterine device use and previous ectopic pregnancy. Diaphragmatic rupture due to ectopic pregnancy is a rare and life-threatening condition that can lead to massive intraperitoneal haemorrhage and haemorrhagic shock. This report presents the case of a 21-year-old woman who presented with 7 weeks and 4 days of amenorrhoea and 14 hours of acute abdominal pain. On examination, she was in haemorrhagic shock with signs of acute abdomen. Emergency exploratory laparotomy revealed a haemoperitoneum of 1500 mL and active bleeding from a 3×2 cm rupture in the right hemidiaphragm. Haemostasis was achieved and the patient recovered well post-operatively. This case highlights the importance of considering diaphragmatic rupture in the differential diagnosis of acute abdomen and haemorrhagic shock, especially in patients with ectopic pregnancy.

Outcome and treatment of cesarean scar ectopic pregnancy under ultrasound-guided vacuum aspiration.

OBJECTIVE: This study aimed to describe cases of cesarean scar pregnancies that were successfully treated with suction curettage under ultrasound guidance and their outcome. METHODS: This retrospective, descriptive case-series study was performed on 17 patients diagnosed with cesarean scar ectopic pregnancy in Sulaimani Maternity Teaching Hospital from May 2022 to April 2023. The patients' sociodemographic and clinical data were collected. The patients were treated with suction curettage alone or in combination with local injection of methotrexate under ultrasound guidance. RESULTS: Patients with a viable fetus (n = 4) received local intrinsic methotrexate injection into the gestational sac and suction curettage, while those in whom the fetus had died (n = 13) underwent only suction curettage. Five patients required intrauterine balloon insertion to stop bleeding without further treatment, and only three required a blood transfusion owing to severe bleeding. CONCLUSIONS: Cesarean scar ectopic pregnancy is a dangerous and complex disorder with an increasing occurrence in recent years. Accurate early diagnosis and effective management are essential to reduce maternal mortality and mortality of this type of pregnancy.

Hepatic ectopic pregnancy with hemorrhage secondary diaphragmatic adhesion: A case report.

BACKGROUND: Primary abdominal pregnancy is an extremely rare form of ectopic pregnancy. Ectopic pregnancies that occur in the liver and diaphragm are even rarer, limited case reports are available in the literature. CASE SUMMARY: A woman of childbearing age was transferred to the emergency department due to lumbar and abdominal pain radiating to the back toward the lower right. After a series of physical and auxiliary examinations, she was clinically diagnosed with hepatic ectopic pregnancy. Laparoscopic surgery was performed to remove the pregnancy tissue and achieve hemostasis. After a period of follow-up, the patient was successfully cured. CONCLUSION: Paying attention to the patient's signs and utilizing imaging examination methods can help avoid missed diagnoses of liver pregnancy.

Abdominal Ectopic Pregnancy: A Case Report of an Uncommon Complication of Pregnancy Without Prenatal Care.

Ectopic pregnancy (EP) is a life-threatening condition requiring a high clinical suspicion. This diagnosis must be considered in all female patients of reproductive age presenting with abdominal pain or discomfort who may possibly be pregnant. Ectopic pregnancies occur in a small percentage of all pregnancies and are a significant cause of maternal morbidity and mortality. Abdominal ectopic pregnancy (AEP) is a rare and potentially fatal form of ectopic pregnancy where the implantation occurs in the abdominal cavity. We present the following case of a 23-year-old female who was transferred following an initial workup for abdominal pain and subsequently found to have an abdominal ectopic pregnancy at 37 weeks gestation. After transferring to our emergency department, the patient continued to have abdominal pain and her presenting FAST exam was positive for free fluid concerning for active hemorrhage and hematoma. Her clinical presentation was consistent with ruptured abdominal ectopic pregnancy, and she was taken to the operating room for emergent exploratory laparotomy and delivery. Her clinical course was complicated by adherent placenta and re-bleeding with significant hemoperitoneum requiring re-entry laparotomy and transfusion. We present the details of this case along with the diagnostic imaging and management of the rarely seen and life-threatening condition of secondary abdominal ectopic pregnancy (AEP).

Multimodal management of ectopic hepatic pregnancy: a systematic review of the literature.

PURPOSE: Ectopic pregnancies with implantation in the upper abdomen are exceptionally rare. Here we provide a systematic review of hepatic ectopic pregnancies and the corresponding management strategies. Furthermore, this report details a case of ectopic hepatic pregnancy, successfully treated with primary methotrexate (MTX) followed by a two-staged robotic-assisted resection. METHODS: Two independent investigators performed a systematic review using the online search engine PubMed and MEDLINE database. The search utilized the following terms: 'Hepatic Ectopic Pregnancy,' 'Hepatic Extrauterine Pregnancy,' 'Hepatic Abdominal Pregnancy,' and 'Ectopic Liver Pregnancy.' Cross-referencing was employed to identify possible additional publications. FINDINGS: Forty-seven case reports on hepatic pregnancies were identified. Of these, 40 provided manuscripts in the English language. Most patients with hepatic pregnancy presented with mild to moderate abdominal pain, while only a minority exhibited signs of hemodynamically relevant intraperitoneal hemorrhage. Most cases were managed through open surgical removal, although in recent years, there has been an increase in laparoscopically managed cases. Conservative approaches using methotrexate are seldom employed. CONCLUSION: Hepatic pregnancies present a rare and challenging clinical scenario. Until now, these cases have usually been treated primarily with open explorative surgery. As reported in this case, primary conservative treatment approaches with MTX before surgery hold promise as a strategy to reduce surgery-related bleeding and morbidity, particularly for asymptomatic or oligosymptomatic patients.

Advanced abdominal pregnancy complicated by pelvic inflammatory disease: A compelling case report.

This case report discusses the rare and complex occurrence of an advanced abdominal pregnancy in a 36-year-old multiparous woman at 26 weeks of gestation, compounded by chronic pelvic inflammatory disease and Fitz-Hugh-Curtis syndrome. The patient was presented with severe symptoms, including abdominal pain, fever, chills, constipation, and vaginal spotting, leading to her hospital admission. Diagnosis was challenging due to the advanced stage of the pregnancy and its abdominal location, particularly in the Douglas pouch, as detected through ultrasonography. According to anatomical standards, this is an intraperitoneal pregnancy rather than an intra-abdominal pregnancy because the fetus developed in the peritoneal cavity. This case is significant for illustrating the critical need for high clinical suspicion and skilled sonographic evaluation to identify such advanced abdominal pregnancies. The successful management of this case through laparotomy, despite the complexities of concurrent conditions, emphasizes the possibility of safe placental removal without increased hemorrhage risk. This report highlights the importance of awareness and expertise in handling rare presentations of ectopic pregnancies, underscoring the potential for positive outcomes with appropriate surgical intervention.

Diagnosis of 42 Cases of Intrauterine Twin Pregnancy Complicated With Ectopic Pregnancy: A Retrospective Cohort Study.

OBJECTIVES: The coexistence of intrauterine twin pregnancy and ectopic pregnancy (EP), known as heterotopic pregnancy, is a rare but potentially life-threatening condition. In this study, we aimed to investigate the pregnancy outcomes in women with intrauterine twin pregnancies complicated with EP after assisted reproductive technology. METHODS: This retrospective study analyzed the medical records of 42 women diagnosed with intrauterine twin pregnancies complicated with EP via ultrasound or surgery at our hospital between January 2005 and December 2020. We collected data on patient general characteristics, high-risk factors, clinical symptoms, ultrasound features, treatment methods, and pregnancy outcomes. RESULTS: Among the 42 included women, 47.6% (20/42) had a history of tubal surgery, while 52.4% (22/42) and 47.6% (20/42) received the transfer of 2 and 3 embryos, respectively. In terms of treatment, 21.4% (9/42) women received expectant management, whereas 78.6% (33/42) underwent surgical treatment, with laparoscopic surgery accounting for 71.4% (30/42). Tracking the pregnancy outcomes revealed a live birth rate of 81.0% (34/42) and a full-term birth rate of 50.0% (21/42). The preterm birth rate was 31.0% (13/42), with a breakdown of 1 singleton (7.7%, 1/13) and 12 twin births (92.3%, 12/13) among the total 13 premature deliveries. Among the neonates, 33.3% (14/42) were singletons and 47.6% (20/42) twins. Caesarean section accounted for 31 out of 34 deliveries (91.2%). CONCLUSIONS: Though the incidence of EP in twin pregnancies has declined in the last decade, early diagnosis and proper management are still crucial for favorable outcomes in twin pregnancies with EP.

Ovarian Ectopic Pregnancy in a Female With Mitral Valve Repair and Mitral Stenosis: A Case Report on a Rare Type of Ectopic Pregnancy.

Ovarian ectopic pregnancy (OEP) occurs in cases where the fertilized egg is implanted outside the uterus in either of the ovaries. Assisted reproductive technologies and intrauterine device failure are high-risk factors associated with ovarian ectopic pregnancy. Pregnancies categorized under OEP have a higher risk of serious morbidities to maternal health. Clinical presentations of OEP are usually noted as abdominal pain and vaginal bleeding. Transvaginal ultrasound is considered the preferred primary modality for the diagnosis of OEC. It can be life threatening, especially in patients with mitral valve replacement (MVR) or heart diseases like rheumatic heart disease, majorly due to anticoagulant therapy. Pregnancy in MVR-mitral stenosis patients has been reported to have an increased risk of obstetric hemorrhage, miscarriage, and associated complications during delivery. Management of OEP depends on the patient's physical and clinical condition, with a primary focus on preserving the affected ovary function. This is a case of a 35-year-old pregnant female with a history of MVR presented with per vaginal bleeding and ruptured ectopic pregnancy. Radio imaging showed the product of conception attached to the right ovarian cyst. The patient was counseled for exploratory laparotomy and subsequently had right ovarian cystectomy alone with bilateral tubal ligation by modified Pomeroy's method.

Pathology of the Salpinx: A Retrospective Literature Review.

The fallopian tube is a common surgical specimen, yet there is limited research on the histomorphologic findings. This study seeks to review the various abnormalities found in the fallopian tube and establish the primary disease processes linked to it. These findings can provide valuable insights for future preventive healthcare measures. Utilizing PubMed, a search was conducted for articles published between 2009 and 2024 to investigate fallopian tube pathologies using case reports. The inclusion criteria focused on patients older than 18 years with confirmed or incidental fallopian tube pathology diagnoses. The study considered both common and uncommon presentations of fallopian tube pathologies, with a primary focus on identifying the presenting symptoms related to these conditions, such as primary infertility, severe abdominal pain, tachycardia, hypotension, and breathlessness (the last three could indicate a surgical emergency with ruptured ectopic pregnancy and subsequent hemoperitoneum). Fifteen studies were included in this review. The findings revealed three cases of genital tuberculosis, two cases of endometriosis, two cases of fallopian tube prolapse, three cases of ovarian cancer, and four cases of ectopic pregnancy. To confirm the presence of these conditions, histopathological examination was performed using specimens obtained through salpingectomy/salpingostomy. This study effectively highlighted the occurrence of rare presentations associated with common fallopian tube pathologies. By identifying different pathologies present in the fallopian tube, healthcare professionals can expand the range of existing pathologies that may be considered as potential differential diagnoses. This knowledge is essential in directing patient care and has the potential to improve patient outcomes significantly.

Spontaneous Heterotopic Pregnancy: A Case Report of a Potentially Life-Threatening Condition.

Heterotopic pregnancy involves the coexistence of both an intrauterine and an extrauterine pregnancy occurring simultaneously. The spontaneous incidence of heterotopic pregnancy in the general population has been estimated to be 1/30,000. This report discusses the case of a 37-year-old female who presented to the emergency department with vaginal bleeding and lower abdominal pain. Upon workup, a transabdominal and transvaginal ultrasound demonstrated a heterotopic pregnancy with an estimated gestational age of seven weeks. The ultrasounds confirmed an intrauterine pregnancy with fetal cardiac activity and a fetal pole along with a right adnexal ectopic pregnancy with fetal cardiac activity and a fetal pole. Additionally, a right paratubal cyst was incidentally found. The patient subsequently underwent exploratory laparotomy with a right salpingectomy for the removal of the right tubal pregnancy and a right paratubal cyst. This case denotes the significance of a carefully performed ultrasound examination, especially in the early weeks of pregnancy. Even when a standard pregnancy is visualized with ultrasound examination, it remains imperative for the examiner to meticulously examine the adnexa and interstitial portion of the fallopian tube. A heterotopic pregnancy has the potential to be life-threatening and can often go undetected, resulting in missed diagnoses.

Multimodality Imaging for Rare Presentation of Placenta Increta in the First Trimester in a Patient with Previous Cesarean Section and Asherman Syndrome.

We report multi-modality imaging (Ultrasound and Magnetic Resonance Imaging) findings of a rare complication in a multi-gravida patient with history of Asherman syndrome presenting with placenta increta in a cesarean scar ectopic pregnancy. The appropriate diagnosis was established with imaging and patient was managed surgically with total abdominal hysterectomy and bilateral salpingectomy. Asherman syndrome and its management of hysteroscopic adhesiolysis are associated with increased odds of placenta accreta spectrum and postpartum hemorrhage. Patients with Asherman syndrome are considered high risk in pregnancy and should be closely monitored for placental site abnormalities during current and subsequent pregnancies.

Nomogram to predict methotrexate treatment success in ectopic pregnancy.

OBJECTIVE: To evaluate clinical factors prior to methotrexate (MTX) treatment for tubal ectopic pregnancy and to apply the data to a prediction model for treatment success. METHODS: A retrospective cohort study was conducted during 2014-2022. Of the 808 patients with a tubal ectopic pregnancy, 372 with a ß-hCG level less than 5000 IU/L were treated with a single dose of MTX and were included in this study. Pretreatment factors, including patient characteristics, initial ß-hCG level, and sonographic parameters, were compared between those who achieved complete resolution and those who needed additional MTX or surgical intervention. A logistic regression model and multivariable analysis were used to predict success. A graphic nomogram was generated to represent the model. RESULTS: Complete resolution of the ectopic pregnancy was achieved in 290 (77.9%) patients after a single dose of MTX. A second dose or surgical intervention was required for 82 (22.0%): 49 (13.2%) received a second dose of MTX and 33 (8.9%) underwent laparoscopic salpingectomy. In the MTX Success group compared to the MTX Failure group, the median ß-hCG levels were lower (746 vs 1347 IU/L, P < 0.001) and the presence of a yolk sac and a fetal pole were less frequent. The predictive model, based on significant variables, includes initial ß-hCG concentration and the visibility of a yolk sac or fetal pole. Analysis with cross-validation techniques revealed that the model was both accurate and discriminative. CONCLUSION: A predictive nomogram was developed to predict the success of single-dose MTX treatment for tubal ectopic pregnancy.

Clinical Ultrasound in Obstetrics and Gynecology.

Point-of-care ultrasound is a useful tool in the evaluation of women with pelvic complaints in the emergency department. Transabdominal and transvaginal approaches may be employed to assess a variety of obstetric or gynecologic pathologies.

Comparison of 2-year reproductive outcomes of tubal ectopic pregnancies treated with surgery, methotrexate or expectant management.

INTRODUCTION: To compare the 2-year reproductive outcomes of tubal ectopic pregnancies (EP) treated with surgery, methotrexate (MTX) or expectant management. MATERIALS AND METHODS: This case-control study was conducted retrospectively at the Obstetrics-Gynecology and Perinatology Clinics of Etlik Zubeyde Hanim Women's Health Education and Training Hospital. 985 of 1156 patients, who were managed between January 2015 and December 2019 for a tubal EP, tried to conceive in 2 years after treatment: 366 patients underwent surgical treatment; 549 patients were treated with MTX, and 70 patients had expectant management. Clinical data and fertility outcomes were retrieved by medical and hospital records. We compared the three groups based on the 2-year reproductive outcomes of three treatment modalities of tubal EP. RESULTS: There was a significant difference in the frequency of no pregnancy in patients who underwent surgery compared to patients who received expectant management and MTX therapy (p < 0.001). The frequency of no pregnancy was higher in patients who underwent surgery. There was no significant difference between expectant management and MTX therapy (p = 0.411). In the reproductive outcomes of patients who underwent surgery, the incidence of viable pregnancies was statistically lower than in the group treated with expectant management and MTX therapy (p = 0.003). CONCLUSIONS: Patients with an EP often have a future desire to have children, the treatment options are also important. The earlier the diagnosis is made, the more likely it is that expectant management or MTX treatment will be considered. With these two treatment methods, the likelihood of having a child in the future is higher than with surgical treatment.

A case control study of vNOTES vs conventional laparoscopic salpingectomy for ectopic pregnancy.

STUDY OBJECTIVE: While the laparoscopic approach is the surgical treatment of choice for ectopic pregnancy, vNOTES is emerging as an alternative route with its good optical visibility and avoidance of abdominal incisions. The authors compare demographics and outcome data of vNOTES vs conventional laparoscopic salpingectomy for the surgical management of ectopic pregnancy. DESIGN: Case control study SETTING: A London University hospital PATIENTS: Women with ectopic pregnancy unsuitable for medical management who underwent surgical management INTERVENTION: 25 cases of vNOTES vs 25 conventional laparoscopic salpingectomy MEASUREMENTS AND MAIN RESULTS: The mean patient age (29.7±53 vs 31.4±6.7 days), parity (1.2±1.1 vs 1.6±2.1), BMI (26.7±5.3 vs 27.2±5.4 kg/m3), gestation age (8.44±2.1 vs 7.3±1.7 weeks) and ßhCG levels (3725.4±3674.8 vs 4376.5±6493.4 IU/litre) were comparable (p>0.05, t test) between patients having vNOTES vs conventional laparoscopic salpingectomy. While estimated blood loss was similar (218.2±491.7 vs 173.5±138.7 mls)(p>0.001), vNOTES patients had statistically shorter duration of surgery (35.8±14.4 vs 75.8±19.7 mins)(p<0.001, t test) and length of stay (median: 11.5 vs 19.7 hours)(U=72, p<0.05, Mann-Whitney U test). Less patients in the vNOTES group required postoperative opioids (9% vs 25%) and median Visual Analogue Score (/10) for pain at 24 hours was significantly lower (2.0 vs 4.0)(U=75, p<0.05, Mann-Whitney U test). Patients from the vNOTES group were able to return to normal daily activity 11.3 days quicker (5.8±4.3 vs 17.1±8.2 days)(p<0.05, t test). vNOTES cases cost approximately USD150 more due to the price of the commercial kits but this is offset by reduced intraoperative time, length of stay and need for postprocedure analgesia. CONCLUSION: Patients undergoing vNOTES have shorter intraoperative times and length of stays, less postoperative pain and more rapid recovery, which help mitigate higher cost incurred by commercial kits. While the vNOTES approach for ectopic pregnancy appears safe and efficacious, more robust data from larger randomised studies are needed.