Chronic interstitial ectopic pregnancy presenting with a negative urine pregnancy test.

The ampulla portion of the fallopian tube is the most common site of ectopic pregnancy (70%), with approximately 2% of pregnancies implanted in the interstitial portion. In general, an interstitial ectopic pregnancy (IEP) is difficult to diagnose and is associated with a high rate of complications-most patients with an IEP present with severe abdominal pain and haemorrhagic shock due to an ectopic rupture. Chronic tubal pregnancy (CTP) is an uncommon condition with an incidence of 20%. The CTP has a longer clinical course and a negative or low level of serum beta-human chorionic gonadotropin due to perished chorionic villi. This study presents a case of a woman who was diagnosed with a chronic IEP (CIEP) which was successfully treated by surgery. This case also acts as a cautionary reminder of considering a CIEP in women of reproductive age presenting with amenorrhea, vaginal bleeding and a negative pregnancy test.

Bilateral tubal ectopic pregnancy after spontaneous conception.

OBJECTIVE: Presentation of a case report of a rare case of bilateral tubal pregnancy in a female patient after spontaneous conception. OBSERVATION: We present a case of a 26-year-old female patient first hospitalized in the Gynecology Obstetrics Clinic of the Pilsen University Hospital, where a laparoscopy was indicated for suspicion of ectopic tubal pregnancy during which a left-sided salpingectomy was performed for a macroscopically clear finding of a tubal pregnancy on the left side, this finding was also confirmed histologically. Subsequently, the patient was discharged to home care. During a follow-up examination by a district gynaecologist, the patient complained of a recurrence of pain in the lower abdomen, on collection of hCG (human chorionic gonadotropin) its increase was detected and the patient was sent for a control gynaecological examination to Mulacova Hospital in Pilsen. On the examination in the outpatient clinic, she reported significant lower abdominal pain and collapsed during transvaginal ultrasound and was hospitalized. Subsequently, diagnostic laparoscopy was indicated during hospitalization, during which tubal pregnancy on the right and hemoperitoneum were macroscopically evident. A right-sided salpingectomy was performed for this finding with subsequent hCG drop, resolution of the discomfort and histological confirmation of tubal pregnancy on the right. CONCLUSION: The incidence of such cases without prior ovulation stimulation is 1 out of 200,000 pregnancies and an estimated 1 out of 725 to 1 out of 1,580 ectopic pregnancies. Even so, bilateral tubal or heterotopic ectopic pregnancy should be considered in the differential diagnosis, as both conditions can be immediately life-threatening.

Quadruplet Heterotopic Pregnancy Following In Vitro Fertilization and Embryo Transfer with Laparotomic Removal of Ruptured Twin Tubal Ectopic Pregnancy: A Case Report.

Heterotopic pregnancy (HP) is a rare occurrence in natural pregnancies. However, it can be a life-threatening condition and should be taken into account in all assisted reproductive treatments. Diagnosis and treatment of ectopic pregnancy are challenging issues in patients with HP. Here, we report a rare case of quadruplet HP following an in vitro fertilization-embryo transfer with a viable twin intrauterine pregnancy and ruptured live twin left tubal ectopic pregnancy. A 35-year-old woman (gravida 5, para 1, ectopic pregnancies 2, and abortion 1) was presented to the Emergency Department of Arash Women's Hospital (Tehran, Iran) in March 2021 with abdominal pain. The patient was at six weeks and five days of pregnancy following in vitro fertilization-embryo transfer. Transvaginal sonography (TVS) revealed a live twin intrauterine pregnancy with a ruptured live twin left tubal ectopic pregnancy. The latter was removed via laparotomy to preserve the intrauterine pregnancy. The patient subsequently delivered a female infant at 38 weeks of pregnancy.

Tubal ectopic twin pregnancy of complete hydatidiform mole and coexisting embryo: A rare case report.

RATIONALE: Ectopic twin gestation involving a complete hydatidiform mole (CHM) and coexisting embryo is an exceedingly rare occurrence. PATIENT CONCERNS: In this report, we present the case of a 22-year-old female (gravida2, para 1) who was in her 8th week of gestation and presented with abdominal pain. Due to the detection of active bleeding and a ruptured right fallopian tube, the patient underwent a salpingectomy on the right side. DIAGNOSIS: The patient was diagnosed with an ectopic twin gestation involving a CHM and coexisting embryo. INTERVENTIONS: The patient was treated with right-side salpingectomy. OUTCOMES: The operation was successful and her recuperation was satisfactory. LESSONS: In the management of ectopic pregnancy involving CHM, it is crucial to enhance the accuracy of preoperative diagnosis. Additionally, histopathological examination of the salpingectomy specimen and conceptus is definitely essential for accurate diagnosis and appropriate follow-up management of tubal pregnancies.

Trophoblastic Tissue Reimplantation below the Spleen Following Laparoscopic Bilateral Salpingectomy for Ectopic Tubal Pregnancy: A Case Report.

BACKGROUND: Trophoblastic tissue reimplantation after laparoscopic salpingectomy is a very rare complication. These cases may present a diagnostic challenge and the majority of patients need a surgical treatment. CASE PRESENTATION: A 31-year-old patient came to a tertiary referral center for nausea and pain in the upper left abdominal quadrant. Ultrasound and abdominal CT scan showed a 68 × 60 × 87 mm size heterogenic mass below the spleen with arterial extravasation from the lower spleen pole. Recent history of surgery for ectopic pregnancy and serum hCG testing allowed to diagnose extratubal secondary trophoblastic tissue reimplantation below the spleen. Embolization of the bleeding vessel and successful treatment with methotrexate was achieved. CONCLUSIONS: In cases of a nondisseminated trophoblastic tissue reimplantation, consider embolization and treatment with methotrexate if the patient is hemodynamically stable; thus, secondary surgical treatment is preventable.

Novel marker to predict rupture risk in tubal ectopic pregnancies: the systemic immune-inflammation index.

OBJECTIVES: Ectopic pregnancy is a life-threatening condition; delaying treatment can result in mortality or serious complications. Identification of a biomarker that can predict tubal rupture may be helpful for guiding treatment. In this study, we evaluated the association between serum ß-hCG, biochemical markers, Systemic Immunity-inflammation Index (SII) score, and the trophoblastic invasion stage. MATERIAL AND METHODS: Tubal pregnancy was classified into three groups based on the depth of trophoblastic infiltration: stage I - limited to the mucosa; stage II - invaded the muscular layer, and stage III - invaded the serosa/subserosa of the tuba uterine. The association between groups, serum ß-hCG, biochemical markers, and the SII score were assessed. RESULTS: There was no significant difference between the groups, hemoglobin, platelet count, MPV, RDW, NLR or PLR values (p > 0.05). A ROC analysis was performed to evaluate the accuracy of serum ß-hCG predictions for infiltration level. At a 95% confidence interval upper limit, cut-off value of the serum ß-hCG that best predicted stage III trophoblastic infiltration, was 2799 mIU/mL, with 78.9% sensitivity, 53.8% specificity (positive predictive value was 71.4%, and a negative predictive value was 63.6%). Moreover, ROC curve analysis showed that The SII value of 792 was the best predictor of trophoblastic infiltration at stage III, with a sensitivity of 92.3% and a specificity of 63.1%. CONCLUSIONS: A linear relationship exists between depth of trophoblastic infiltration and serum ß-hCG and the SII were observed. These findings suggested that the SII score can be used for predicting tubal ectopic pregnancy rupture.

A case report of a successful multidisciplinary management of an abdominal pregnancy.

Abdominal pregnancy is defined as one that occurs outside of the uterus and fallopian tubes in the abdominal cavity. We present the case of a 30-year-old Peruvian female patient from Lima with a surgical history of exploratory laparotomy due to tubal ectopic pregnancy and appendectomy without further relevant personal or family histories. She attended the emergency room of a social security hospital in Peru with a referral from a district hospital and a diagnosis of abdominal pregnancy at 14 weeks of gestational age without previous prenatal controls. Symptomatology at hospital admission was colic-type abdominal pain in the hypogastrium without vaginal bleeding, fluid loss or fever. During hospitalization, she underwent an exploratory laparotomy with embolization of the uterine artery, left salpingectomy, and removal of the abdominal ectopic pregnancy. The evolution was favorable after the surgery, and she was discharged. Without further complications, she continues her controls at the obstetrics and gynecology outpatient service without complications.

El embarazo abdominal es aquel embarazo que ocurre fuera del útero y las trompas de Falopio en la cavidad abdominal. Presentamos el caso de una paciente peruana de 30 años proveniente de la ciudad de Lima, con antecedentes quirúrgicos de laparotomía exploradora por embarazo ectópico tubárico y apendicectomía, sin otras patologías ni antecedentes familiares de importancia. La paciente acude al servicio de urgencias de un hospital del seguro social en Perú derivada de un hospital distrital con diagnóstico de embarazo abdominal a las 14 semanas de edad gestacional, sin controles prenatales previos. La sintomatología al ingreso hospitalario fue dolor abdominal de tipo cólico a nivel del hipogastrio, sin sangrado vaginal, pérdida de líquidos o fiebre. Durante su hospitalización se le realizó una laparotomía exploratoria con embolización de la arteria uterina, salpingectomía izquierda y extracción del embarazo abdominal. La evolución fue favorable tras la intervención quirúrgica, siendo dada de alta. Actualmente continúa sus controles en el servicio de consulta externa del servicio de ginecología y obstetricia sin complicaciones.

Intrauterine hydatidiform mole complicated with tubal ectopic pregnancy: a case report.

Heterotopic pregnancies are rare pathological pregnancy disorders in clinical practice. However, the number of cases has increased with the widespread use of ovulation induction drugs in recent years. The clinical manifestations of heterotrophic pregnancies are diverse and easy to missed or misdiagnosed. A 33-year-old married Gravida1 Para 0 + 0 patient was admitted on December 8, 2020 with intermittent abdominal pain 18 days after uterine curettage for complete hydatidiform mole of 8 weeks gestation. She had ovulation-promoting drugs prior to the index pregnancy. Hysteroscopic-directed endometrial biopsy and laparoscopic left tubal surgery were offered to her; and she is being followed up with serial pelvic ultrasounds and ß-Human Chorionic Gonadotrophin (ßHCG) assays. This case study presents a case of intrauterine hydatidiform mole complicated with tubal pregnancy to highlight the problems associated with its diagnosis and treatment.

[A particular state of shock: spontaneous rupture of a heterotopic pregnancy]. / Cas clinique. Un état de choc particulier : une rupture spontanée de grossesse hétérotopique.

Heterotopic pregnancy is a rare pathology. It is defined as the coexistence of an intrauterine pregnancy and an extrauterine pregnancy, whatever its location. The presence of an intrauterine pregnancy in a woman of childbearing age does not therefore exclude the presence of an associated ectopic pregnancy. Late diagnosis can lead to fatal consequences for the mother, subsequent fertility as well as for the intrauterine pregnancy. We report the case of a 28-year old female patient, without any notion of assisted reproduction, who was admitted to the emergency department for hemorrhagic shock. The diagnosis of ruptured tubal heterotopic pregnancy was made intraoperatively.

La grossesse hétérotopique est une pathologie rare. Elle est décrite comme la coexistence d'une grossesse intra-utérine et d'une grossesse extra-utérine, quelle que soit la localisation de cette dernière. Nous rapportons le cas d'une patiente âgée de 28 ans, sans notion de procréation médicalement assistée, qui a été admise aux soins d'urgence dans un état de choc hémorragique. Le diagnostic de grossesse hétérotopique tubaire rompue a été posé en peropératoire. Malgré la rareté de cette entité, il est fondamental pour les cliniciens de la connaître afin d'évoquer la possibilité de ce diagnostic. L'échographie endovaginale précoce est l'examen de choix pour l'aide au diagnostic. Ce dernier reste néanmoins difficile en raison d'une symptomatologie déroutante. La présence d'une grossesse intra-utérine chez une femme en âge de procréer n'exclut dès lors pas la présence d'une grossesse ectopique associée. Le diagnostic tardif peut conduire à des conséquences fatales pour la maman, pour sa fertilité ultérieure ainsi que pour l'évolution de la grossesse intra-utérine.

Forensic Analysis of Eighteen Tubal Pregnancy-Related Medical Damage.

OBJECTIVES: To analyze the cases of medical damage after misdiagnosis of tubal pregnancy, to explore the causes of medical damage, the causal relationship between medical malpractice and the damage consequences, as well as the causative potency, in order to provide evaluation ideas for forensic identification of such cases. METHODS: Eighteen cases of forensic identification of tubal pregnancy related medical damage were collected and retrospectively analyzed from the aspects of age, maternity history, fertility requirements, risk factors, diagnosis and treatment, medical malpractice, damage consequences, and causative potency. RESULTS: All 18 cases were tubal pregnancy, of which 17 cases had medical malpractice, resulting in 14 cases of affected tubal resection, 2 cases of hemorrhagic shock death, 1 case of intrauterine fetal death and affected tubal resection. The other case had the consequence of affected tubal resection, but there was no malpractice in the treatment. CONCLUSIONS: Correct diagnosis is helpful to make appropriate treatment plan, prevent disease progression and reduce serious adverse consequences and the occurrence of medical disputes. Scientific and reasonable analysis of the causal relationship between medical malpractice and damage consequences and the causative potency is of great significance to the successful settlement of medical disputes.

Extratubal secondary trophoblastic implants (ESTI) following laparoscopic bilateral salpingectomy for ectopic pregnancy: problems that have been neglected for a long time.

Background: Extratubal secondary trophoblastic implants following laparoscopic salpingectomy is an extremely rare form of persistent ectopic pregnancy. These cases usually result in a small amount of vaginal bleeding and sudden lower abdominal pain thereby presenting with hemoperitoneum in emergencies. Owing to the urgency of hemoperitoneum and the uncertainty of the location of persistent ectopic pregnancy after laparoscopic salpingectomy, the risk of reoperation is increased. It is necessary to prevent in first surgery and diagnose these cases in the early following up phase.Methods: We report a case of 26-year-old woman, gravida 3, para 0, presenting a little vaginal bleeding and slight lower abdominal pain after laparoscopic bilateral salpingectomy for more than 1 month. The patient's serum ß-HCG was still high (3981 mIU/ml), and no abnormalities were found through auxiliary examination (ultrasound, abdominal CT, and pelvic MRI).Results: Finally, emergency laparoscopy revealed many blue purple nodules on the surface of ovaries, small intestine, omentum, and periumbilical peritoneum, with a diameter of 3-20 mm. The lesions were completely removed as far as possible. Pathology showed trophoblastic proliferation and ß-HCG soon decreased to negative after this operation.Conclusion: Therefore, it is important to follow up serum ß-HCG even after salpingectomy and avoid iatrogenic dissemination of trophoblast tissue through careful operation.

FERTILITY OUTCOMES AFTER MEDICAL AND SURGICAL MANAGEMENT OF TUBAL ECTOPIC PREGNANCY.

The objective was to investigate whether the method of treatment (surgical or medical) affects achieving a new pregnancy, as well as the time to and prognosis of the new pregnancy, in women with ectopic pregnancy (EP). Information on patients treated in our hospital between 2013 and 2014 for EP was retrieved from the computerized patient records. Data on whether these patients achieved pregnancy after EP treatment, time from treatment to new pregnancy, and prognosis of pregnancy were collected by phone interviews. A total of 101 women were analyzed. In addition to descriptive analysis, the χ2-test and Kruskal Wallis test were used to compare the groups. A new pregnancy was present in 84 (83.2%) of the women after EP treatment. There was no significant difference among the women having undergone medical treatment (methotrexate), surgical treatment, medical treatment followed by surgical treatment, or observational management approach in terms of achieving a new pregnancy after treatment and time to and prognosis of the new pregnancy. The study could not determine which treatment method would be superior in women with EP and in planning future pregnancy, but concluded that close clinical and laboratory monitoring is appropriate before deciding on aggressive interventions.

Simultaneous bilateral fallopian tubal pregnancy of a laparoscopic definite spontaneous unilateral ovulation: a case report.

BACKGROUND: Bilateral simultaneous fallopian tubal pregnancy is one of the rarest forms of ectopic pregnancy. Due to the lack of unique features and clinical presentation to distinguish bilateral from unilateral ectopic pregnancy, challenges the diagnosis. CASE REPORT: A 27-year-old Asian woman presented with pelvic pain and vaginal bleeding. Pelvic transvaginal ultrasound showed fluid in Douglas Pouch and posterior fornix puncture revealed unclotted blood. Laparoscopic examination unveiled bilateral ectopic pregnancy with two corpus luteum visible in the right ovary, suggesting a double spontaneous unilateral ovulation. Bilateral fallopian tube fenestration and embryo extraction were performed to preserve fertility. CONCLUSION: Diagnosis of bilateral tubal pregnancy is difficult during preoperative ultrasound examination and careful examination during laparoscopic inspection of the whole pelvic cavity to avoid missed diagnosis.

Management of a uterine serosal heterotopic pregnancy after in vitro fertilization in a woman with bilateral salpingectomy: A case report and literature review.

RATIONALE: Heterotopic pregnancy (HP) is defined as the simultaneous presence of intrauterine pregnancy and ectopic pregnancy (EP). HP after bilateral salpingectomy is extremely rare and may lead to serious complications if it is misdiagnosed and untreated timely. Here, we presented the first reported case of uterine serosal HP in a woman after assisted reproductive technology with bilateral salpingectomy because of bilateral tubal ectopic pregnancy. PATIENT CONCERNS: A 27-years-old pregnant woman after in vitro fertilization with bilateral salpingectomy complained of a sudden onset of unprovoked abdominal pain, which was persistent and dull. She denied vaginal bleeding. DIAGNOSES: Serum beta-human chorionic gonadotropin levels are difficult to predict HP. Transvaginal ultrasonography demonstrated 1 gestational sac in the uterine cavity and 1 thick-walled cystic mass over the upper of the uterus, with a large amount of fluid in the Pouch of Douglas. Emergency laparotomy revealed a uterine serosal pregnancy combined with intrauterine pregnancy. INTERVENTIONS: This patient was successfully managed via emergency laparotomy to remove residual tissue and repair the rupture of the uterine serosal pregnancy. OUTCOMES: At postoperative 4 days, repeat transvaginal ultrosonography presented 1 intrauterine gestational sac with a visible fetal bud and cardiac tube pulsation. Now the patient recover well and is in an ongoing pregnancy. LESSONS: It is noteworthy that HP/ectopic pregnancy is still not prevented after bilateral salpingectomy. In cases of multiple embryo transfer, even if intrauterine pregnancy has been established, it is important to rule out HP/ectopic pregnancy in time. Early diagnosis and early management can significantly improve clinical outcomes.

Serum calponin 2 is a novel biomarker of tubal ectopic pregnancy.

OBJECTIVE: To evaluate serum protein calponin 2 (CNN2) as a candidate biomarker for tubal ectopic pregnancy (EP). DESIGN: Retrospective study. SETTING: Single University affiliated tertiary hospital. PATIENT(S): Serum samples were obtained from 84 patients with EP, 39 with viable intrauterine pregnancy (vIUP), and 42 with miscarriage. Moreover, 10 fallopian tube and corresponding villous tissue samples from patients with EP, 6 villous tissue samples from patients with vIUP, and 10 villous tissue samples from patients with miscarriage were collected. INTERVENTION(S): Serum CNN2 concentrations were measured using enzyme-linked immunosorbent assay; CNN2 expression in tissues was evaluated via immunohistochemistry and quantitative real-time polymerase chain reaction analysis. MAIN OUTCOME MEASURE(S): The diagnostic performance of serum CNN2 to discriminate an EP from vIUP and miscarriage. RESULT(S): CNN2 was highly expressed in villous stromal cells isolated from patients with EP, and CNN2 messenger ribonucleic acid expression was upregulated in villous tissues from women with EP compared with that in women with vIUPs and miscarriages. Serum CNN2 concentration was higher in women with EP than that in women with vIUP and miscarriage. The serum CNN2 predicted EP from vIUP and miscarriage with areas under the curve (AUCs) of 0.931 (95% confidence interval: 0.889-0.975). For discriminating EP from miscarriage only, the AUC was 0.906 (95% confidence interval: 0.835-0.977). In contrast, the AUCs for serum human chorionic gonadotropin were 0.809 and 0.637, respectively. CONCLUSION(S): Our data highlight the possibility of serum CNN2 as a single biomarker for the diagnosis of EP. CLINICAL TRIAL REGISTRATION NUMBER: ChiCTR 1900020483.

Guideline No. 414: management of pregnancy of unknown location and tubal and nontubal ectopic pregnancies

To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. All patients of reproductive age. The implementation of this guideline aims to benefit patients with positive ß-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage,methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows.

Increase rate of ruptured tubal ectopic pregnancy during the COVID-19 pandemic.

OBJECTIVE: During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP). STUDY DESIGN: This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018-2019. RESULTS: The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P < 0.005) and a 4-fold larger volume of blood in the entrance to the abdomen (P < 0.002). We found that there were no cases of ruptured EP in the group of women who were pregnant after assisted reproduction. CONCLUSION: We found a higher rate of ruptured ectopic pregnancies in our institution during the COVID-19 pandemic. Health care providers should be alerted to this collateral damage in the non-infected population during the COVID-19 pandemic.

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies.

OBJECTIVE: To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION: All patients of reproductive age. BENEFITS, HARMS, AND COSTS: The implementation of this guideline aims to benefit patients with positive ß-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE: The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).