The diagnosis and management of extrauterine and uterine ectopic pregnancy

In the last two decades, we have consolidated our knowledge of the epidemiology and risk factors for ectopic pregnancies. Minimally invasive surgical skills are now widespread, and laparoscopic surgery is recognized as the best and safest operative treatment for extrauterine ectopic pregnancies. Based on the evidence from randomized trials published a decade ago, laparoscopic salpingectomy is accepted as the optimal surgical treatment for tubal ectopic pregnancy. However, with recent advances in surgical techniques and improvement in surgical skills, the appropriateness of tubal removal versus conservation is under increasing scrutiny. Improvements in the organization and provision of care for women presenting with early pregnancy complications, in conjunction with better quality and wider use of ultrasound imaging, have resulted in an increased ability to detect small failing ectopic pregnancies, which were impossible to diagnose in the past. Many of these pregnancies are destined to resolve spontaneously without the need for any intervention. The necessity to avoid overtreatment and the potential for iatrogenic harm in such cases has facilitated the introduction of expectant management into mainstream clinical practice. This represents one of the key developments in the care for women with ectopic pregnancies. By contrast, the efficacy of medical management with methotrexate has been questioned. Another important development in recent years has been a rapid rise in the prevalence of ectopic pregnancies that are located outside the uterine cavity but within the confines of the uterus, the largest burden of which is from Caesarean scar ectopic pregnancies. This has promoted the development of new terminology and classification of ectopic pregnancies, with the aim of raising awareness of these increasingly prevalent types and minimizing the risk of misdiagnosis. In comparison to ectopic pregnancies outside the uterus, uterine ectopic pregnancies are more difficult to diagnose and manage, and are also associated with increased maternal morbidity, mortality, and adverse reproductive outcomes. Another challenge, which is peculiar to uterine ectopic pregnancies, is their potential to progress to reach foetal viability, albeit with a high risk of extreme prematurity. This requires women and clinicians to make difficult decisions about whether these pregnancies should be terminated to protect maternal health, despite some possibility of a good foetal outcome. Herein, we provide a comprehensive review of published literature to summarize new evidence and explore emerging themes with respect to ectopic pregnancy. Our aim is to provide an overview of modern classification and diagnosis, to summarize available treatment options and recommendations, and to emphasize longer-term outcomes, including the potential psychological impact of ectopic pregnancy. We examine current knowledge gaps and outline priorities for further research.