Ectopic pregnancy

Introduction

The ectopic pregnancy is an extra-uterine pregnancy with an incidence between 0.5% and 1% of pregnancies (approximately 1/200). The most common location of the ectopic pregnancy is the fallopian tubes (approximately 90%), while less common lare the ovaries, the cervix, the peritoneal cavity (abdominal pregnancy) (Figure 1) and pregnancy in to the scar of previous caesarean section (scar pregnancy) (Figure 2). The rate of ectopic pregnancy has almost doubled the last two decades because of the increased rate of the ART (artificial reproductive technology). The transvaginal ultrasound (TVUS) and the blood plasma β-hCG (serial evaluation), contributes significantly to the early diagnosis of ectopic pregnancy (≤ 63 days or ≤ 7 weeks) offering the successful medical management. Mifepristone and misoprostol are the most common agents which are used for the medical treatment of ectopic pregnancy. In case of not available mifepristone or because of allergic symptoms noted by previous use of mifepristone, the chemotherapeutic agent of methotrexate (MTX) could be used, as well.

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Figure 1. Peritoneal (abdominal) pregnancy
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Figure 2. Scar pregnancy (pregnancy in to the scar of previous cesarean section)

Treatment

Surgical approach can be also used for the management of ectopic pregnancy. The main indications for the surgical treatment of extra-uterine pregnancy are:
• Pregnancy of more than >7th weeks [fetal heart (+), β-hCG >5000iu]
• Rupture of the ectopic pregnancy (hemoperitoneum)
• Abdominal pregnancy
• Failure of medical treatment
Surgical approach (salpigotomy or salpingectomy) can be done via laparotomy (open surgery) or laparoscopy using high quality endoscopic tools (Figure 3, 4). However, laparoscopy is the standard approach of extra-uterine pregnancy.
Salpingectomy (total excision of the fallopian tube with the ectopic pregnancy) is the preferable laparoscopic approach worldwide. However, in case of un-ruptured ectopic fallopian pregnancy, hemodynamically stable patient or in case of patient’s selection to preserve the fallopian tube, salpingotomy (incision of the fallopian tube and suction of the ectopic pregnancy from the canal of the tube) is an alternative surgical approach. However, in case of salpingotomy patient must be informed for the increased risk of the residual trophoblastic tissue (residual pregnancy) in the fallopian tube, which is almost 15% and the rate of almost 11% of second surgical operation. In case of the second surgery, the excision of the fallopian tube with the residual pregnancy is the optimal surgical choice. The rate of recurrence of ectopic pregnancy after salpingotomy is almost double compared to salpingectomy (30% vs 16%, respectively).

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Figure 3. Laparoscopic atraumatic grasper
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Figure 4. Laparoscopic bipolar diathermy

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Kalogiannidis doctor

IOANNIS Α. KALOGIANNIDIS MD, PhD

Associate Professor
Obstetrics Gynecology -
Gynecologic Oncology

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