Surgical Management of Ectopic Pregnancy

In the shocked patient with intraperitoneal bleeding, which is the typical presentation in the tropics, laparotomy should be undertaken. In subacute presentation of unruptured ectopic pregnancies, transvaginal ultrasound alone or combined with a discriminatory zone serum b-hCG titre are useful diagnostic aids. Serial serum hCG titre and direct visualization at laparoscopy are also useful. Identification of empty uterus with an adnexal mass that is not of ovarian origin (e.g. tubal ring or bagel sign) and free fluid in the pelvis is 85-95% predictive of ectopic pregnancy [6].

The discriminatory zone of hCG is the minimal hCG titre above which an intrauterine gestational sac is expected to be visualised by pelvic ultrasound. An ectopic pregnancy can be diagnosed when an intrauterine gestational sac is absent but serum hCG titre is above the discriminatory zone. Transvaginal ultrasound with higher resolution than transabdominal ultrasound detects intrauterine gestation 1 week earlier or when the serum hCG is greater than or equal to 1000-1,500 i.u/L6. Absence of an intrauterine gestational sac with transvaginal scan when the serum hCG titre is above this discriminatory zone is highly predictive of ectopic pregnancywith 90-95% sensitivity and 95% specificity [2, 6].

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The serum hCG titre doubles every 2-3 days in normal pregnancy. In abnormal pregnancies including ectopics however, the doubling rate is impaired with < 66% increase in 48 hours. However 15% of normal pregnancies may not follow the usual pattern6. Combining empty uterus, discriminatory zone principles and serial hCG titre, the diagnosis of ectopic pregnancy can be made with high accuracy8 (sensitivity and specificity of 95-99% and 98% respectively).

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Unless in shocked or haemodynamically compromised patient, and in situations where surgical skill is not available, current surgical management of ectopic pregnancy involves laparoscopic salpingotomy or salpingostomy. Randomized trials have shown that in the haemodynamically stable patient, laparoscopic conservative surgery was associated with shorter duration of surgery and recovery time, less blood loss, lower analgesic requirement and reduced overall cost [6, 8, 9]. Although the number of patients studied was small, subsequent ectopic pregnancy rate and surgical adhesion formation were lower while tubal patency and subsequent intra-uterine pregnancy rate were higher with the laparoscopic route. Conservative laparoscopic surgery was however associated with relatively higher rate of persistent trophoblasts.

Compared with salpingectomy, salpingostomy is associated with higher recurrent ectopic pregnancy rare (14% vs 10%) and persistent trophoblast. However, subsequent intrauterine pregnancy rates are similar [6] [53% (salpingostomy) vs 49.3% (salpingectomy)]. The Royal College of Obstetricians and Gynaecologists (RCOG) recommends salpingectomy when the contralateral tube is healthy. When the contralateral tube is severely diseased or absent, the recommended treatment is salpingotomy [10]. These recommendations lack a strong evidence base however as they are based on observational studies.

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