Definition and Overview

An ectopic pregnancy refers to a condition wherein the embryo becomes implanted outside the uterus. In certain situations, this resolves without any treatment but in the majority of cases, termination is required as a life-saving procedure.

Who Should Undergo and Expected Results

An ectopic pregnancy occurs at a site aside from its normal location in the uterus. The majority of cases are found in the fallopian tubes (tubal pregnancies) while others are found in the ovaries, the cervix, and the abdominal cavity. Ectopic pregnancies occur in approximately 2-4% of live births.

Patients with ectopic pregnancy classically present with abdominal pain (usually described as sharp or crampy) and vaginal bleeding. They are also at risk of various serious complications including rupture, which can result in massive bleeding, shock, and death.

In certain situations, ectopic pregnancy resolves without any treatment and expectant management is typically carried out especially if there are no symptoms or the symptoms are very mild. In other patients, termination of ectopic pregnancy, which can be done medically or surgically, has to be performed in order to prevent the development of complications. Some medications, such as methotrexate, have been shown to be effective in the termination of early ectopic pregnancy or when the size of the embryo is small and the beta-HCG is low. This medication stops the growth of the cells. Surgery, however, remains to be the mainstay of therapy in the majority of cases, particularly when complications such as rupture have occurred, or when the patient is unstable. In these cases, termination is necessary in order to save the life of the mother. This is followed by the monitoring of beta-HCG levels until they normalise. This is necessary particularly for patients undergoing medical treatment or conservative surgery (salpingostomy).

If diagnosed early, ectopic pregnancy has good outcomes and fertility is frequently preserved. Fertility also increased with the increasing utilisation of salpingostomy rather than salpingectomy. Reports have shown up to 88% fertility rate in patients who were subjected to conservative management and surgery. However, approximately 8% of patients develop a subsequent ectopic pregnancy.

How is the Procedure Performed?

The approach to the surgical termination of ectopic pregnancy may be via a laparotomy (open surgery) or laparoscopy (minimally invasive). The major difference between the two is the length of the incision. In laparotomy, a midline incision is created to gain access to the abdominal cavity, while in laparoscopy, several small incisions are made where various instruments are placed. Laparoscopy is the preferred approach for most cases as it has been shown by many studies to result in less blood loss, fewer adhesions, and faster recovery. A laparotomy, on the other hand, is recommended for urgent cases of ectopic pregnancy rupture or massive bleeding. It may also be performed for patients whose circumstances make a laparoscopic approach difficult to carry out, such as in patients with a previous history of pelvic surgery where dense adhesions are expected.

Once the abdominal cavity has been successfully accessed, the ectopic pregnancy is then identified and the fallopian tube is freed from nearby structures. The surgeon can then proceed with either of two operations: a salpingostomy or salpingectomy.

A salpingostomy involves only the removal of the pregnancy. An incision is made over the area of pregnancy, which usually protrudes out. Ectopic tissues are then extracted and irrigation is performed to remove any residual ectopic tissues in the affected fallopian tube. The fallopian tube may then either be left open or repaired.

Meanwhile, a salpingectomy involves the removal of either part of or the entire fallopian tube. The procedure becomes necessary in cases wherein there’s a history of a prior ectopic pregnancy in the same side, severe damage of rupture of the fallopian tube, and massive bleeding. This procedure may also be performed for patients who no longer desire to become pregnant in the future. In this procedure, the fallopian tube is clamped and the tuboovarian artery is identified and ligated. The mesosalpinx is then clamped and cut, until finally the affected fallopian tube with the pregnancy is mobilised and removed. Partial salpingectomy, wherein only a part of the affected fallopian tube is removed and the healthy tissues re-connected, may also be an option in certain cases.

Possible Risks and Complications

For patients undergoing laparoscopic termination of ectopic pregnancy, pain is usually minimal. Most patients recover immediately and are typically discharged the following day after adequate observation. Patients undergoing laparotomy, on the other hand, experience more pain after the procedure, and may require a few days of hospitalisation before being sent home. Pain after the operation can usually be managed adequately with pain medications.

The major risk associated with the termination of an ectopic pregnancy is bleeding. This is best managed by careful haemostasis during the operation. Certain medications may be given to minimise bleeding or embolisation by an interventional radiologist may be necessary. Patients with this complication may require blood transfusions.

References:

  • Dicker D, Feldberg D, Samuel N, Goldman JA (1985). “Etiology of cervical pregnancy. Association with abortion, pelvic pathology, IUDs and Asherman’s syndrome.”. J Reprod Med 30 (1): 25–7. PMID 4038744.

  • Al-Azemi M, Refaat B, Amer S, Ola B, Chapman N, Ledger W (May 2009). “The expression of inducible nitric oxide synthase in the human fallopian tube during the menstrual cycle and in ectopic pregnancy”. Fertil. Steril. 94 (3): 833–840.doi:10.1016/j.fertnstert.2009.04.020. PMID 19482272.

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