laparoscopic management of tubal pregnancy

Benha University Hospital, EGYPT

> 80% of ECTOPIC can be diagnosed & managed

prior to tubal rupture. That is due to 3 diagnostic

advances :

1-Laparoscopy.

2-Ultrasonography

Pansky et al,1991

3-Specific and sensitive (HCG).

What is the current place of laparoscopy in

management of ectopic, in regards to other

modalities? ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

Laparoscopy represents the gold standard for

the diagnosis of ectopic pregnancy:

•Distension of the tubal wall seen in the majority

of cases (Klentzeris, 2003).

•Free blood in the peritoneal cavity is another

pointer suggesting careful examination of the

fallopian tubes

In the very early stages a small ectopic

pregnancy may not be visualized & 3% of cases

the diagnosis will be missed.

ABOUBAKR ELNASHAR

It is needed for :

1-Definite diagnosis if there is doubt

2-Concurrent operative Laparoscopy

3-Local injection of methotrexate

The need decreased after the use

of B-HCG & TVS.

Speroff et al, 1999 ABOUBAKR ELNASHAR

S. B HCG levcl Mu/mL

<2000 >2000

Ectopic PRepeat in 2-3 D

Abnormal rise Normal rise IUP

Active

management

Suspected Ectopic Pregnancy Positive B Qualitative B-HCG 25mu/Ml

No Sac

TV.U/S

IUP Extr UP

Active

management

.B S HCG level mu/ml

ABOUBAKR ELNASHAR

Failed IUP Decreasing

Villi identified No Villi

Rising or

plateauing

Follow HCG until negative

Repeat HCG in 2-3 D

ExpectantActive

management

Suspected Ectopic Pregnancy Cont.

Uterine Curettage

Abnormal S. B HCG rise

Laparoscopy

>2000 Mu/mL <2000 Mu/mL

ABOUBAKR ELNASHAR

TVS had a specificity of 73.7% and a positive

predictive value of 89.8%.

Laparoscopy had a specificity of 84.8% and a positive

predictive value of 94.6%.

The use of laparoscopy could avoid laparotomy in

only 3.4% of patients.

(Chama et al, 2001).

ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR

Shapiro & Adler performed the first surgery

for ectopic pregnancy through the

laparoscope in 1973

ABOUBAKR ELNASHAR

Active (1) Expectant

Surgical T. (2) Medical T.

Laparotomy (3) Laparoscopy

Salpingectomy (5) Salpingotomy

Systemic Local (4)

Modern treatment of ectopic pregnancy

Kim and Fox, 1999 ABOUBAKR ELNASHAR

(Chocrane library,2002)

ABOUBAKR ELNASHAR

Cochrane library (2002)

laparoscopic surgery appears to be tt of choice.

• Compared to open surgery, laparoscopic conservative

surgery was:

1. less successful in the elimination of tubal pregnancy,

due to the higher persistence of trophoblast

2. Safe and less costly.

3. Long term follow-up showed: a comparable

intrauterine

PR and a lower repeat ectopic pregnancy rate.

ABOUBAKR ELNASHAR

Indications of Laparotomy (Klentzeris, 2003)

* Hemodynamic unstability.

* Severe adhesions

* Cornual or ovarian pregnancy

* Surgeon is not trained in laparoscopic surgery

* Necessary laparoscopic equipment is not available

•A ruptured ectopic pregnancy does not necessarily

require laparotomy.

•In the hands of an experienced laparoscopist all the

indications for laparotomy are relative if the patient is

haemodinamically stable ABOUBAKR ELNASHAR

• Operative laparoscopy in patients with

hopovolemic shock can be safely and

effectively performed by experienced

laparoscopists with the aid of optimal

anesthesia, advanced cardiovascular

monitoring and autologous blood transfusion. Sagiv etal,2001; Li et al,2002.

shock and intraperitoneal hemorrhage more than

1000 ml.

Laparoscopic salpingectomy was performed to 86%.

The operating time was longer (50 +/- 24) and (43

+/- 24) min, but the difference was not significant.

All patients had no perioperative complications.

ABOUBAKR ELNASHAR

Prerequisites for laparoscopic surgery (Murphy & Reddy, 1997)

1. Skilled surgeon

2. An appropriately selected patient

3. Appropriate instrumentation:

a. Suction & irrigation system to irrigate large volumes

of fluids rapidly to ensure good visualization & remove

any remaining trophoblast from the pelvis.

b. Bipolar coagulator to achieve hemostasis quickly,

safely & effectively

c. Methods of removing the resected tissue

ABOUBAKR ELNASHAR

Salpingostomy:

Types of laparoscopic surgery

Salpingotomy:

Salpingectomy

ABOUBAKR ELNASHAR

Linear salpingotomy is currently the

procedure of choice

Indications (Mencaglia & Wattiez,2001):

1. Preservation of potentially desired fertility

2. Haemodynaic stability

3. Size of ectopic <5cm

4. Ectopic is ampullary, infundibular or ishmic

5. Normal or absence of the contralateral tube

ABOUBAKR ELNASHAR

Salingectomy (Klentzeris, 2003)

Indications:

1. Ruptured tubal pregnancy

2. Recurrent ectopic pregnancy in a tube

already treated conservatively

3. Previous sterilization & reversal of

sterilization.

4. Previous tubal surgery for infertility.

5. Ectopic >5 cm (Mencaglia & Wattiez,2001)

ABOUBAKR ELNASHAR

Postoperative care

(Mencaglia & Wattiez,2001):

1. Discharge after 24-36 hrs

2. Antibiotics

3. Removal of the Foley catheter immediately

after surgery

4. B HCG : 2nd postoperative day & at least

70% decrease if the treatment is successful.

Follow-up till it is negative

ABOUBAKR ELNASHAR

Risks of laparoscopic

management (Murphy & Reddy, 1997)

1. Hemorrhage is the most common

complication.

2. Damage to adjacent structures

particularly when there are dense

adhesions

3. Persistent trophoblastic tissue

ABOUBAKR ELNASHAR

Reproductive outcome: Salpingostomy vs salpingotomy:

No significant difference in the:

Number of subsequent IU

pregnancies,

Number of ectopic pregnancies or

Incidence of adhesion formation (Tulandi & Guralnilk, 1991)

ABOUBAKR ELNASHAR

Salpigotomy vs salpingectomy

(Yao & Tulandi, 1997) meta-analysis of 2635 cases

Salpingotomy Salpingectomy

Subsequent IU pregnancy rate 53% 49%

Recurrent ectopic pregnancy 14% 10%

Salpingotomy is associted with higher subsequent IU

pregnancy & higher recurrent ectopic pregnancy

ABOUBAKR ELNASHAR

(Cochcrane library, 2002)

1. No significant differences in short

and long term medical outcome

measures.

ABOUBAKR ELNASHAR

2. Health related quality of life was more severely

impaired after systemic methotrexate. However,

in a case control study women indicated that they

were willing to trade off the increased treatment

burden of systemic methotrexate for the benefit

of a totally noninvasive management of tubal

pregnancy

ABOUBAKR ELNASHAR

3. Systemic methotrexate would become

less expensive only in women with an initial serum

hCG concentration < 1,500 IU/l,

whereas costs would be similar to laparoscopic

salpingostomy in women with an initial serum

hCG concentration between 1,500 and 3,000 IU/l,

and higher in patients with an initial serum hCG

concentration > 3000 IU/l.

ABOUBAKR ELNASHAR

Cochrane library,2002

• Laparoscopic surgery is the

cornerstone of treatment in the

majority of women with tubal

pregnancy.

ABOUBAKR ELNASHAR

•If the diagnosis of tubal pregnancy can be made

noninvasively, methotrexate in a multiple dose IM

regimen is an alternative treatment option but

only in

1. Hemodynamically stable women

2. An unruptured tubal pregnancy and no signs of

active bleeding

3. Low initial serum hCG concentrations (<3000 IU/L),

4. After properly informing them about the risks and

benefits of the available treatment options.

ABOUBAKR ELNASHAR