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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.
For the past 50 years, the mainstay of treatment for the management of miscarriage has been surgical management, or the evacuation of retained products of conception. Until recently, up to 88% of women diagnosed with a miscarriage would be offered an evacuation of retained products of conception under general anaesthesia. The rationale for surgical management was based on the assumption that the presence of a non-viable pregnancy within the uterus would increase the risk of infection and haemorrhage. In the past, these complications were more likely to develop from infected retained products of conception following poorly performed illegal abortions but, with the legalisation of abortion in developed countries, the introduction of antibiotics and a general improvement in women's health, these risks have decreased substantially. Over the past decade, there has been less emphasis on urgent surgical management and more on individualised treatment and patient choice between expectant, medical and semi-elective surgical treatment.
Expectant management is chosen by women because of a desire for a natural approach to management. It is becoming an increasingly popular option; in one observational study, 70% of women opted to wait for the pregnancy to resolve spontaneously. The first randomised controlled trial of expectant management compared with surgical management of miscarriage, carried out by Nielsen and Hahlin, showed a 79% success rate for cases of incomplete or inevitable miscarriage when managed expectantly for 3 days, with no increased risk of pelvic infection or excessive bleeding.