Laparoscopic Management of Ectopic Pregnancy

Ectopic pregnancy is one of the abnormal outcomes of pregnancy in 2% of pregnant woman and is defined as implantation of a fertilized egg outside the endometrial cavity. It remains a major cause of maternal morbidity and mortality when left untreated and accounts for as much as 9% of maternal death in this country. Quantitative measurements of the beta subunit of human chorionic gonadotropin (ß-hCG) and transvaginal ultrasonography have improved the accuracy of diagnosis and allow earlier detection of ectopic pregnancies.

History of the Procedure:

In modern medicine the ability to diagnose and treat ectopic pregnancies has significantly improved, thereby reducing the maternal risks. Recently Laparoscopy has revolutionized the way of dealing with the ectopic pregnancy says Prof. R.K. Mishra the recipient of Global Laparoscopic Trainer award of 2008 and Director of Laparoscopy Hospital, New Delhi.

Approximately 97.7% of all ectopic pregnancies occur in the fallopian tubes, and the others in the ovary, abdomen, or cervix. The ampullary pregnancy is the most common site of implantation (80%), followed by the isthmus (11%), fimbria (4%), cornua (2%), and interstitia (3%). Approximately 85% of ectopic pregnancies occur in multigravid women. In the United States, rates are nearly twice as high for women of other races compared with white women.

Aetiology:

Common risk factors for ectopic pregnancy include tubal damage, smoking, and altered motility in the fallopian tube. Bad smoking habits in the new generation women is a risk factor in about one third of ectopic pregnancies and may contribute to decreased tubal motility by damage to the ciliated cells in the fallopian tubes. Altered tubal motility can also occur as the result of oral contraceptive. Progesterone only oral contraceptive and progesterone intrauterine devices have been associated with increased risk of an ectopic pregnancy.
 
Clinical Symptoms:

Ectopic pregnancy can be diagnosed by typical triad which includes bleeding and abdominal pain and a positive pregnancy test result. The clinical presentation can therefore be confusing, since symptoms overlap with miscarriage. One third of women have no clinical signs and 9% have no symptoms of ectopic pregnancy. As a result, almost half of cases are not diagnosed at the first prenatal visit by their gynecologists.

On physical examination signs include lower abdominal tenderness with or without rebound and pelvic tenderness usually much worse on the affected side. Gynaecologists can find abdominal rigidity, involuntary guarding, and severe tenderness as well as evidence of hypovolemic shock with tachycardia, should alert the clinician to a surgical emergency; this may occur in up to 20% of cases. On per vaginal examination, the uterus may be slightly enlarged and soft, and uterine or cervical motion tenderness may suggest peritoneal inflammation.

Indications for surgery in ectopic pregnancy include women with the following criteria:

· Not suitable candidate for medical therapy

· Failed medical therapy

· Heterotopic pregnancy with a viable intrauterine pregnancy

• Hemodynamically unstable and need immediate treatment

Medical therapy:

While methotrexate has remained the most effective and popular drug used in medical therapy for an ectopic pregnancy, other protocols have been used, such as potassium chloride, hyperosmolar glucose, RU 486, and prostaglandins.
 
Surgical therapy:

Surgical therapy may be open laparotomy or via the laparoscopy. According to Prof. R. K. Mishra all ectopic pregnancies requiring surgery should be treated laparoscopically. Risk factors for converting laparoscopy to laparotomy should be considered and include multiple prior surgeries, pelvic adhesions, skill of the surgeon and surgical staff, availability of the equipment, and condition of the patient. If the ectopic pregnancy is at the fimbria, then fimbrial evacuation is feasible, in the absence of indications for salpingectomy. Partial salpingectomy may be indicated if the pregnancy is in the mid portion of the tube, none of the indications for salpingectomy is present, and the patient may be a candidate for later tubal reanastomosis.

Laparoscopy Technique:
 
Desiccate the tube between the uterus and the ectopic pregnancy using bipolar cautery and compress and desiccate the tuboovarian artery, while preserving the uteroovarian artery and ligament. Cut along the desiccated path, closer to the specimen, leaving a pedicle for hemostasis. Infiltration of the mesosalpinx with vasopressin (20 IU in 50 mL of isotonic sodium chloride solution [ie, normal saline or NS]; some authors use only 10 IU in 50 mL of NS) to get transient ischemia and to avoid bleeding. Needle electrode, is used to make a 1- to 2-cm incision on the antimesenteric side of the tube.  Aquadissector, under pressure can be used to dissects and dislodges the ectopic pregnancy and clots.