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Tubal ectopic pregnancies have historically been treated by laparotomy, with removal of the affected tube considered the definitive treatment. This remains the preferred option in cases complicated by major intraperitoneal bleeding and haemorrhagic shock. However, owing to the wide availability of transvaginal ultrasound and sensitive urine pregnancy tests, nowadays most tubal ectopic pregnancies are diagnosed in women who are haemodynamically stable with minimal clinical symptoms. This has led to the introduction of less invasive options for the surgical treatment of tubal ectopic pregnancies. This chapter reviews current strategies for surgical treatment of tubal ectopic pregnancy, focusing on the advantages and disadvantages of the various approaches.
Indications for surgical treatment of tubal ectopic pregnancy
Laparoscopic surgery has evolved from being a main diagnostic to a primary treatment modality as a result of the improved accuracy of non-invasive diagnosis of tubal ectopic pregnancy. In women with a confirmed diagnosis of tubal ectopic pregnancy, the following are the indications for surgical treatment:
• woman who is haemodynamically unstable or evidence of significant intraperitoneal bleeding on ultrasound
• viable tubal ectopic pregnancy
• significant clinical symptoms
• initial serum human chorionic gonadotrophin (hCG) over 3000 iu/ml
• failure of or non-compliance with medical or expectant management
• heterotopic pregnancy with a normal viable intrauterine gestation.
Surgery should not be delayed in women with suspected tubal pregnancy showing signs of hypovolaemic shock.
The fallopian tube is the most common location for pregnancies that implant outside the uterine cavity. In the minds of the lay public and many health professionals, tubal implantation is often considered synonymous with ectopic pregnancy. However, there are many other locations within the pelvis and abdominal cavity where a pregnancy could implant and grow. Cases of ectopic pregnancy have been described affecting organs as distant as the liver or omentum. It has been reported that approximately 7% of all ectopic pregnancies are located outside the fallopian tubes. Such pregnancies are often referred to as non-tubal ectopic pregnancies.
In recent years the incidence of ectopic pregnancy has increased owing to many factors such as improved sensitivity of urine pregnancy tests, better ultrasound diagnosis, wide use of assisted reproductive techniques and, possibly, the increased incidence of tubal damage caused by pelvic inflammatory disease. In addition, the increase in the number of surgical procedures involving the uterus, in particular the high rate of caesarean sections, has played an important role in the higher number of both tubal and non-tubal ectopic gestations.
Although non-tubal ectopic pregnancies are relatively rare, they are associated with significantly higher maternal morbidity and mortality rates compared with tubal ectopic pregnancies. This is primarily because of their tendency to remain clinically silent in early gestation and to present with acute, severe symptoms either late in the first trimester or during the second trimester of pregnancy.
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