Ectopic Pregnancy: A Clinical Casebook

5. Surgical Treatment of Ectopic Pregnancy

Jillian Main  and Camran Nezhat1

(1)

Stanford University Medical Center, OBGYN, 900 Welch Rd., Suite 403, 94304 Palo Alto, CA, USA

Jillian Main

Email: jillianmain@gmail.com

Keywords

Ectopic pregnancySurgical treatmentSalpingostomySalpingectomyPersistent ectopic pregnancy

Case Study

A 28-year-old woman presented to the emergency department with right-sided pelvic pain and a last menstrual period 6 weeks prior to presentation. Her past history revealed a history of a left-sided ectopic pregnancy treated with methotrexate 3 years ago. She also had a history of chlamydia, which was treated. On physical examination, she had significant abdominal tenderness with mild rebound and involuntary guarding. Her heart rate was 121 beats per minute and her blood pressure was 90/65. The serum human chorionic gonadotropin (hCG) level was 470 IU/L. Transvaginal ultrasound examination revealed a small fluid collection without a definitive yolk sac in the uterus and a 2.5-cm heterogeneous mass in the right adnexa.

My Management

A.

B.

C.

Diagnosis and Assessment

The example patient most likely has a recurrent ectopic pregnancy . Ectopic pregnancy accounts for 2 % of all pregnancies, and approximately 4 % of all pregnancy-related deaths [1]. Although the overall incidence is low, 6–16 % of women who present to the emergency room (ER) with vaginal bleeding and/or abdominal pain have an ectopic pregnancy, so the index of suspicion needs to be high [2].

The common risk factors for ectopic pregnancy are a history of a prior ectopic pregnancy, tubal surgery, pelvic inflammatory disease, infertility, and smoking, but up to 50 % of patients with an ectopic pregnancy will have no prior risk factors [3]. A history of prior ectopic pregnancy, as with our patient, is one of the most important factors because 8–15 % of patients will have a repeat ectopic pregnancy, depending on the treatment modality [4].

The ER physician proceeded with the correct initial evaluation: a physical exam to assess for patient stability, a serum hCG, and a transvaginal ultrasound . The serum hCG level is used to determine whether an intrauterine pregnancy should be visualized by ultrasound, the so-called “discriminatory zone,” or to trend the hCG over time to assess for an abnormal pregnancy. The discriminatory value has classically been 1500 mIU/mL for a transvaginal ultrasound, but there is marked variation depending on the patient, the ultrasonographer, the ultrasound machine, and the number of gestations. In multiple gestations, the hCG level can be as high as 9000 mIU/mL in triplets, with no intrauterine findings [5]. Uterine fibroids, adenomyosis, endometrial polyps, and obesity are associated with nonvisualization of a normal intrauterine pregnancy with hCG level above the discriminatory level [5].

Serum hCG levels can also be serially followed to assess for an abnormal pregnancy. The common threshold for a normal hCG rise is 53 % in 48 h. This is the lowest recorded increase that resulted in a viable pregnancy, but most healthy pregnancies show a greater hCG increase over 48 h [6]. When the diagnosis of a spontaneous miscarriage is being considered, the hCG level is expected to decrease by 21–35 % in 48 h, depending on the initial level [7]. However, a normal rise or fall in serum hCG over 48 h does not exclude the possibility of an ectopic pregnancy as 21 % of women with ectopic pregnancy will have a normal rise in hCG and 8 % of women with ectopic pregnancies will have a normal decrease in hCG values [8].

The transvaginal ultrasound is one of the standard modalities in the diagnosis of ectopic pregnancy. The earliest ultrasound finding is the gestational sac, which should be noted by about 5 weeks. This must not be confused with a “pseudogestational sac,” as noted in the example patient, which is simply an intrauterine fluid collection often seen with extrauterine pregnancies. A gestational sac cannot be reliably differentiated from a pseudogestational sac until the presence of a yolk sac is visualized, usually when the gestational sac reaches 8 mm or more in diameter [9]. The ultrasound should also evaluate for any adnexal masses, as in the case example. The majority of ectopic pregnancies are found in the fallopian tube so the ectopic pregnancy sac is usually noted between the ovary and the uterus. Ovarian ectopic pregnancies are rare, and must be differentiated from benign corpus luteum cysts.

Management

Our patient is not clinically stable to allow prolonged observation. She is at high risk for an ectopic pregnancy and has pain, peritoneal irritation on physical exam, and tachycardia. This warrants urgent surgical evaluation to prevent tubal rupture or to stop bleeding from a ruptured ectopic pregnancy . It must be noted that most healthy young women will often have excellent compensation for acute blood loss, with the only initial sign being mild tachycardia.

The recommended surgical approach for an ectopic pregnancy is laparoscopic surgery [10]. With appropriate experience, hemorrhage can be managed quickly and with less morbidity than with a laparotomy [11]. It is important to have adequate blood resuscitation products available, an excellent suction and irrigation device, dilute vasopressin to inject into the surrounding tissue, and two insufflation systems to maintain visualization while using the suction. A standard laparoscopic entry technique with a Veress needles, direct trocar entry with or without camera guidance, or an open entry can be used, depending on the surgeon’s preference and experience. Once the bleeding is controlled and the blood evacuated, the ectopic pregnancy tissue needs to be removed.

In cases of uncontrolled bleeding, severely damaged fallopian tube or a recurrent ectopic pregnancy in the same tube, a unilateral salpingectomy is usually preferred. In other cases, there is controversy whether a salpingostomy or salpingectomy should be performed. Linear salpingostomy carries a risk of repeat ectopic pregnancy of 15.4 % and a risk of persistent trophoblast risk of 4–15 %, so the hCG level needs to be followed until it is undetectable [4,10]. Salpingectomy confers a risk of repeat ectopic pregnancy of 9.8 %. Although there have been many studies examining the effect of salpingostomy or salpingectomy on future reproduction, the results are conflicting. Many suggest that if the contralateral fallopian tube appears normal, there is no difference in fertility rate between the procedures [12].

Outcome

The patient underwent a diagnostic laparoscopy and an unruptured ectopic pregnancy in the ampulla of the right fallopian tube was discovered (Fig. 5.1). A linear salpingostomy was performed and the products of conception were removed (Fig. 5.2). Tubal bleeding was controlled with vasopressin and light application of electrocautery. The patient recovered without incident and was discharged home that same day with the plan to follow a serum hCG in 2 days, then weekly, until it was undetectable.

A321655_1_En_5_Fig1_HTML.jpg

Fig. 5.1

Unruptured ampullary ectopic pregnancy seen by laparoscopy

A321655_1_En_5_Fig2_HTML.jpg

Fig. 5.2

Linear salpingostomy reveals the products of conception inside the fallopian tube, seen by laparoscopy

Clinical Pearls/Pitfalls

·               The discriminatory hCG level is not always reliable and may be altered by multiple gestations, uterine fibroids, adenomyosis, endometrial polyps, and obesity.

·               Laparoscopy, which is the preferred surgical treatment modality, is necessary if the patient is unstable, ongoing hemorrhage is suspected, or there is a contraindication to methotrexate therapy.

·               Laparoscopic salpingostomy increases the risk of recurrent ectopic pregnancy and persistent trophoblastic disease, but preserves the fallopian tube for possible improved future fertility.

·               If a salpingostomy is performed, the serum hCG needs to be serially examined until it is undetectable due to the risk of persistent trophoblastic disease.

·               Recent studies, however, demonstrate that the rates of subsequent intrauterine as well as ectopic pregnancies after salpingostomy or salpingectomy are comparable.

References

1.

Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol. 2010;116:1302–9.CrossRefPubMed

2.

Murray H, Baakdah H, Bardell T, Tulandi T. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005;173(8):905.CrossRefPubMedCentralPubMed

3.

Stovall TG, Kellerman AL, Ling FW et al. Emergency department diagnosis of ectopic pregnancy. Ann Emerg Med. 1990;19:1098–103.CrossRefPubMed

4.

Yao M, Tulandi T. Current status of surgical and nonsurgical management of ectopic pregnancy. Fertil Steril. 1997;67(3):421.CrossRefPubMed

5.

Ko JK, Cheung VY. Time to revisit the human chorionic gonadotropin discriminatory level in the management of pregnancy of unknown location. J Ultrasound Med. 2014;33(3):465–71.CrossRefPubMed

6.

Barnhart KT, Sammel MD, Rinaudo PF, Zhou L, Hummel AC, Guo W. Symptomatic patients with an early viable intrauterine pregnancy: hCG curves redefined. Obstet Gynecol. 2004;104(1):50.CrossRefPubMed

7.

Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynecol. 2006;107(2 Pt 1):399–413.CrossRefPubMed

8.

Silva C, Sammel MD, Zhou L, Gracia C, Hummel AC, Barnhart K. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol. 2006;107(3):605.CrossRefPubMed

9.

Albayram F, Hamper UM. First-trimester obstetric emergencies: spectrum of sonographic findings. J Clin Ultrasound. 2002;30:161–77.CrossRefPubMed

10.

Nezhat C, Nezhat F, Nezhat CH. Nezhat’s operative gynecologic laparoscopy and hysteroscopy, 4th edn. Cambridge: Cambridge University Press; 2013.

11.

Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev. 2007.

12.

Mol F, van Mello NM, Strandell A, Strandell K, Jurkovic D, Ross J, et al. European Surgery in Ectopic Pregnancy (ESEP) study group. Salpingotomy versus salpingectomyin women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet. 2014;383(9927):1483–9.CrossRefPubMed