M. Jean Uy-Kroh1
Department of Obstetrics and Gynecology, Women’s Health Institute, Cleveland Clinic, Mail Code A81, 9500 Euclid Avenue, 44195 Cleveland, OH, USA
M. Jean Uy-Kroh
BleedingHemorrhageBleeding ectopic pregnancyEctopic pregnancyBleedingSalpingectomySalpingostomyHemostasisShockLaparoscopy
A 30-year-old G2P0 woman presented to the emergency department with the complaint of 2 weeks of intermittent generalized lower abdominal pain. The pain worsened by the early hours of the morning and was so severe it awakened her from sleep.
She had a history of irregular menses and her last menstrual period was approximately 6 weeks ago. Three months prior to this presentation, she was hospitalized for pelvic inflammatory disease (PID). Two years ago, she underwent a right salpingectomy for an ectopic pregnancy.
Upon initial presentation, she was afebrile, blood pressure was 110/70, pulse 98, and her exam was notable for a moderately to severely tender abdomen. Her serum laboratory tests revealed human chorionic gonadotropin (hCG) level of 32,269 mIU/mL, hemoglobin 9.5 g/dL, and platelets 219 K/uL.
Transvaginal ultrasound examination revealed a 4-mm anechoic lesion suggestive of a pseudogestational sac and an irregularly contoured gestational sac adjacent to the left ovary. The crown rump length measured 17 mm and was consistent with an 8-week 1-day gestation with a fetal heart rate of 162 beats per minute. A moderate-to-large amount of complex free fluid was present in the cul-de-sac.
With these findings, the consulting gynecologist advised the emergency physician to obtain two separate IVs, a type and cross-match of serum, to begin fluid resuscitation with normal saline, and to keep the patient Nil Per Os in preparation for the operating room. The patient was counseled on the diagnosis and consented for a laparoscopic salpingostomy, and possible blood transfusion. While the patient was being informed that she may need postsurgical serum hCG evaluation to ensure no residual pregnancy remained, she became markedly tachycardic.
Diagnosis and Assessment
This patient’s factors for failed methotrexate treatment include: serum hCG greater than 5000 mIU/mL, fetal cardiac activity, and maternal tachycardia/signs of hemodynamic compromise. The complex free fluid may be organized blood clot and heme and/or products of conception. Ectopic pregnancies bleed slowly and gradually and may harbor more than 1 L of hemoperitoneum. In cases of suspected bleeding ectopic pregnancy , surgical management is indicated . Radiologic embolization, medical management, or delayed observational management increases the risk of rupture and maternal hemorrhage and is unacceptable treatment.
The route of surgery depends on a triad of the surgeon’s comfort and experience with laparoscopy , the patient’s history, and the anesthesiologist’s comfort and experience. Even in the setting of hemoperitoneum, laparoscopy is considered standard surgical treatment . Cornual ectopic and heterotopic pregnancies are safely treated in a laparoscopic fashion. A systematic review of randomized trials demonstrated that compared to laparotomy, laparoscopy had the advantage of less blood loss, shorter hospital duration, shorter operative time, shorter return to baseline function, and therefore, lower cost/case .
Furthermore, there is no difference in repeat ectopic pregnancy or subsequent intrauterine pregnancy (IUP) between the two approaches. Even in cases of moderate maternal hemodynamic compromise, laparoscopic surgery is a safe option and expedites hemostasis versus laparotomy . Laparotomy is still an acceptable mode of surgery if the surgery team is inexperienced or uncomfortable with operative laparoscopy or for patients with severe pelvic adhesions, multiple laparotomies, or when hemostasis cannot be achieved laparoscopically.
The decision to perform salpingostomy versus salpingectomy for ectopic pregnancy is controversial and also depends on the patient’s clinical state. In the rare event that the patient is in class III–IV hemorrhage , a salpingectomy should be performed to rapidly cease bleeding. More often though, the patient is in class I–II hemorrhage  and a salpingostomy should be attempted in patients who desire fertility.
The condition of the tube rather than the chosen procedure likely predicts the rate of future IUPs so the risks of each procedure must be weighed. The risk of salpingostomy is the persistence and recurrence of ectopic pregnancy. The risk of salpingectomy depends on the condition and presence of the contralateral or existing tube. If the contralateral or existing tube is normal, rates of subsequent IUP are not compromised .
A salpingectomy should be performed when preserving the compromised tube confers no benefit or places the patient at unnecessary risk. Common indications for salpingectomy include: an ectopic that has recurred in the same tube, a tubal pregnancy greater than 5 cm, a severely damaged tube, uncontrolled hemorrhage, or no desire to retain fertility. Conversely, for patients who desire fertility but who already have IVF treatment plans , salpingectomy is also indicated. A complete salpingectomy is performed using either bipolar cautery and excision or serial loop occlusions and excision. For severe damage limited to the distal tube, a partial salpingectomy may provide adequate, acute treatment and allow for future reanastamosis. Either way, the affected tubal segment is elevated and removed without compromising the adjacent ovarian vessels.
Performing a salpingectomy in this patient may diminish the risk of subsequent tubal ectopic pregnancy, but it would also render her sterilized and with no possibility for subsequent IUP without reproductive assistance. This highlights the importance of preoperative counseling and appropriate informed consent. If the patient’s tube appears normal, it is standard care to perform a salpingostomy, allowing her the opportunity to conceive spontaneously. A simple linear salpingostomy is performed by grasping the tube and injecting a dilute vasopressin solution with a 22-gauge needle into the tubal pregnancy along the anti-mesenteric border (Fig. 6.1). Then, using a needle cautery or an equivalent hemostatic device, a 10-mm incision is made over the pregnancy and the products of conception are gently extruded using hydro-dissection and blunt dissection (Figs. 6.2, 6.3, 6.4). The placenta and pregnancy are removed from the abdomen in an endoscopic bag and the implantation site is inspected for hemostasis. Hemostasis is achieved with sparse bipolar cautery. Excessive coagulation causes tubal damage and should be avoided. Because there is an increased risk of retained pregnancy, serial postoperative serum beta-hCG can be followed to undetectable levels. The anti-mesenteric tubal incision is not reapproximated since this has not been proven to be beneficial and fertility and adhesion formation are equivalent for secondary and primary closure .
Bleeding tubal ectopic pregnancy with hemoperitoneum. (Courtesy of Dr. Togas Tulandi)
Injecting dilute vasopressin solution into an adherent and bleeding ectopic pregnancy
Adhesiolysis of ectopic pregnancy to ovary and pelvic sidewall led to even more bleeding
Continued bleeding and abnormal tubal anatomy that could not be salvaged led to the final decision to perform salpingectomy
The patient underwent laparoscopy . The ectopic was clearly identified and the remainder of her tube appeared normal. Therefore, salpingostomy with excision of the ectopic pregnancy was performed but this was complicated by brisk bleeding. Pressure and bipolar cautery were applied with unsatisfactory result. The bleeding was too brisk for hemostatic agents and interrupted, 6–0 polyglactic sutures were placed. Pneumoperitoneum was then decreased and slow, bright red oozing was noted from a sutured area. Therefore, a thrombin matrix hemostatic agent was applied. The area was reinspected and was confirmed to be hemostatic. The patient recovered uneventfully and her serum beta-hCG was followed to undetectable levels.
· Bleeding ectopic pregnancy requires aggressive fluid resuscitation and stabilization prior to operative interventions. Blood transfusion may be necessary.
· Appropriate patient counseling and informed, preoperative consent is necessary.
· For women who desire fertility and are clinically stable, laparoscopic salpingostomy, followed by serum beta-hCG if necessary, is the preferred method of treatment.
· The route of surgery is highly dependent on the surgeon’s comfort and expertise with laparoscopy and the patient’s history. In the vast majority of bleeding ectopic pregnancies, operative laparoscopy should be utilized to provide efficient hemostasis and treatment.
Oron G, Tulandi T. A pragmatic and evidence-based management of ectopic pregnancy. J Minim Invasive Gynecol. 2013;20(4):446–54.CrossRefPubMed
Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev. 2007, Issue 1, 1-106; 8, Art. No.: CD000324. DOI: 10.1002/14651858.
Cohen A, Almog B, Satel A, Lessing JB, Tsafrir Z, Levin I. Laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum. Int J Gynecol Obstet. 2013;123(2):139–41.CrossRef
Class II hemorrhage is defined as 15 to 30 % blood volume loss with clinical signs such as increased heart rate of 100 to 120 bpm, increased respiratory rate of 20 to 24, and a decreased pulse pressure. Delayed capillary refill and cool clammy skin may also be present. Class III hemorrhage involves a 30 to 40 % blood volume loss. This results in hypotension (defined as systolic blood pressure less than 90 mmHg or a 20–30 % decrement of blood pressure since presentation) and may also include altered mental status. American College of Surgeons. Advanced Trauma Life Support® (Student Manual). American College of Surgeons 1997.
Dubuisson JB, Morice P, Chapron C, De Gayffier A, Mouelhi T. Salpingectomy: the laparoscopic surgical choice for ectopic pregnancy. Hum Reprod. 1996;11(6):1199.CrossRefPubMed
Fujishita A, Masuzaki H, Khan KN, Kitajima M, Hiraki K, Ishimaru T. Laparoscopic salpingotomy for tubal pregnancy: comparison of linear salpingotomy with and without suturing. Hum Reprod. 2004;19(5):1195.CrossRefPubMed