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Benha University Hospital, EGYPT
> 80% of ECTOPIC can be diagnosed & managed
prior to tubal rupture. That is due to 3 diagnostic
advances :
1-Laparoscopy.
2-Ultrasonography
Pansky et al,1991
3-Specific and sensitive (HCG).
What is the current place of laparoscopy in
management of ectopic, in regards to other
modalities? ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
Laparoscopy represents the gold standard for
the diagnosis of ectopic pregnancy:
•Distension of the tubal wall seen in the majority
of cases (Klentzeris, 2003).
•Free blood in the peritoneal cavity is another
pointer suggesting careful examination of the
fallopian tubes
In the very early stages a small ectopic
pregnancy may not be visualized & 3% of cases
the diagnosis will be missed.
ABOUBAKR ELNASHAR
It is needed for :
1-Definite diagnosis if there is doubt
2-Concurrent operative Laparoscopy
3-Local injection of methotrexate
The need decreased after the use
of B-HCG & TVS.
Speroff et al, 1999 ABOUBAKR ELNASHAR
S. B HCG levcl Mu/mL
<2000 >2000
Ectopic PRepeat in 2-3 D
Abnormal rise Normal rise IUP
Active
management
Suspected Ectopic Pregnancy Positive B Qualitative B-HCG 25mu/Ml
No Sac
TV.U/S
IUP Extr UP
Active
management
.B S HCG level mu/ml
ABOUBAKR ELNASHAR
Failed IUP Decreasing
Villi identified No Villi
Rising or
plateauing
Follow HCG until negative
Repeat HCG in 2-3 D
ExpectantActive
management
Suspected Ectopic Pregnancy Cont.
Uterine Curettage
Abnormal S. B HCG rise
Laparoscopy
>2000 Mu/mL <2000 Mu/mL
ABOUBAKR ELNASHAR
TVS had a specificity of 73.7% and a positive
predictive value of 89.8%.
Laparoscopy had a specificity of 84.8% and a positive
predictive value of 94.6%.
The use of laparoscopy could avoid laparotomy in
only 3.4% of patients.
(Chama et al, 2001).
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
Shapiro & Adler performed the first surgery
for ectopic pregnancy through the
laparoscope in 1973
ABOUBAKR ELNASHAR
Active (1) Expectant
Surgical T. (2) Medical T.
Laparotomy (3) Laparoscopy
Salpingectomy (5) Salpingotomy
Systemic Local (4)
Modern treatment of ectopic pregnancy
Kim and Fox, 1999 ABOUBAKR ELNASHAR
(Chocrane library,2002)
ABOUBAKR ELNASHAR
Cochrane library (2002)
laparoscopic surgery appears to be tt of choice.
• Compared to open surgery, laparoscopic conservative
surgery was:
1. less successful in the elimination of tubal pregnancy,
due to the higher persistence of trophoblast
2. Safe and less costly.
3. Long term follow-up showed: a comparable
intrauterine
PR and a lower repeat ectopic pregnancy rate.
ABOUBAKR ELNASHAR
Indications of Laparotomy (Klentzeris, 2003)
* Hemodynamic unstability.
* Severe adhesions
* Cornual or ovarian pregnancy
* Surgeon is not trained in laparoscopic surgery
* Necessary laparoscopic equipment is not available
•A ruptured ectopic pregnancy does not necessarily
require laparotomy.
•In the hands of an experienced laparoscopist all the
indications for laparotomy are relative if the patient is
haemodinamically stable ABOUBAKR ELNASHAR
• Operative laparoscopy in patients with
hopovolemic shock can be safely and
effectively performed by experienced
laparoscopists with the aid of optimal
anesthesia, advanced cardiovascular
monitoring and autologous blood transfusion. Sagiv etal,2001; Li et al,2002.
shock and intraperitoneal hemorrhage more than
1000 ml.
Laparoscopic salpingectomy was performed to 86%.
The operating time was longer (50 +/- 24) and (43
+/- 24) min, but the difference was not significant.
All patients had no perioperative complications.
ABOUBAKR ELNASHAR
Prerequisites for laparoscopic surgery (Murphy & Reddy, 1997)
1. Skilled surgeon
2. An appropriately selected patient
3. Appropriate instrumentation:
a. Suction & irrigation system to irrigate large volumes
of fluids rapidly to ensure good visualization & remove
any remaining trophoblast from the pelvis.
b. Bipolar coagulator to achieve hemostasis quickly,
safely & effectively
c. Methods of removing the resected tissue
ABOUBAKR ELNASHAR
Salpingostomy:
Types of laparoscopic surgery
Salpingotomy:
Salpingectomy
ABOUBAKR ELNASHAR
Linear salpingotomy is currently the
procedure of choice
Indications (Mencaglia & Wattiez,2001):
1. Preservation of potentially desired fertility
2. Haemodynaic stability
3. Size of ectopic <5cm
4. Ectopic is ampullary, infundibular or ishmic
5. Normal or absence of the contralateral tube
ABOUBAKR ELNASHAR
Salingectomy (Klentzeris, 2003)
Indications:
1. Ruptured tubal pregnancy
2. Recurrent ectopic pregnancy in a tube
already treated conservatively
3. Previous sterilization & reversal of
sterilization.
4. Previous tubal surgery for infertility.
5. Ectopic >5 cm (Mencaglia & Wattiez,2001)
ABOUBAKR ELNASHAR
Postoperative care
(Mencaglia & Wattiez,2001):
1. Discharge after 24-36 hrs
2. Antibiotics
3. Removal of the Foley catheter immediately
after surgery
4. B HCG : 2nd postoperative day & at least
70% decrease if the treatment is successful.
Follow-up till it is negative
ABOUBAKR ELNASHAR
Risks of laparoscopic
management (Murphy & Reddy, 1997)
1. Hemorrhage is the most common
complication.
2. Damage to adjacent structures
particularly when there are dense
adhesions
3. Persistent trophoblastic tissue
ABOUBAKR ELNASHAR
Reproductive outcome: Salpingostomy vs salpingotomy:
No significant difference in the:
Number of subsequent IU
pregnancies,
Number of ectopic pregnancies or
Incidence of adhesion formation (Tulandi & Guralnilk, 1991)
ABOUBAKR ELNASHAR
Salpigotomy vs salpingectomy
(Yao & Tulandi, 1997) meta-analysis of 2635 cases
Salpingotomy Salpingectomy
Subsequent IU pregnancy rate 53% 49%
Recurrent ectopic pregnancy 14% 10%
Salpingotomy is associted with higher subsequent IU
pregnancy & higher recurrent ectopic pregnancy
ABOUBAKR ELNASHAR
(Cochcrane library, 2002)
1. No significant differences in short
and long term medical outcome
measures.
ABOUBAKR ELNASHAR
2. Health related quality of life was more severely
impaired after systemic methotrexate. However,
in a case control study women indicated that they
were willing to trade off the increased treatment
burden of systemic methotrexate for the benefit
of a totally noninvasive management of tubal
pregnancy
ABOUBAKR ELNASHAR
3. Systemic methotrexate would become
less expensive only in women with an initial serum
hCG concentration < 1,500 IU/l,
whereas costs would be similar to laparoscopic
salpingostomy in women with an initial serum
hCG concentration between 1,500 and 3,000 IU/l,
and higher in patients with an initial serum hCG
concentration > 3000 IU/l.
ABOUBAKR ELNASHAR
Cochrane library,2002
• Laparoscopic surgery is the
cornerstone of treatment in the
majority of women with tubal
pregnancy.
ABOUBAKR ELNASHAR
•If the diagnosis of tubal pregnancy can be made
noninvasively, methotrexate in a multiple dose IM
regimen is an alternative treatment option but
only in
1. Hemodynamically stable women
2. An unruptured tubal pregnancy and no signs of
active bleeding
3. Low initial serum hCG concentrations (<3000 IU/L),
4. After properly informing them about the risks and
benefits of the available treatment options.
ABOUBAKR ELNASHAR