Page 33 - World's Most Popular Laparoscopic Journal

Amardeep Bhimrao Tembhare

30 years ago, to the present day of 2 per 100 pregnancies depending on the surgeon's skill, equipment availability, and
(Hankins et al 1995, Lehner et al 2000). The Center for condition of the patient (Braun et al 2005). Over the past
Disease Control (CDC) reports that the incidence of ectopic few decades, the management of ectopic pregnancy has
pregnancies is 1 in 70 pregnancies (Hill et al 1993). been revolutionized. This has resulted in the emergence of
Further, an increased incidence of sexually transmitted several nonsurgical options to what had once been thought
infections, early diagnosis of pelvic inflammatory disease to be a solely surgically treatable condition. An earlier
resulting in tubal damage but not complete blockage, diagnosis can be made with transvaginal (TVUS) ultrasound
complications of infections, including therapeutic abortions, and quantitative ß-hCG. This increases the chances of
the wide clinical use of reconstructive tubal surgery, success of medical treatment and minimizes the morbidity,
exposure to diethylstilbestrol and the conservative surgical mortality, and financial burden created by this health problem
treatment of ectopic pregnancy, and the rise in the number (Sawter et al 2001, Braun et al 2005). Nonsurgical
of ectopic pregnancies resulting from assisted reproductive management, like treatment with methotrexate has an
technologies (ART) may account for the overall increase established role in the treatment of ectopic pregnancy
(Westrom et al 1991, Chungt et al 1992, Majumdar et al (Grudzinskas et al 1999, RCOG 2004), but little data are
1983, Wolf et al 1980, DeCherney et al 2008). The incidence available on international scale.
of tubal pregnancy after oocyte retrieval/embryo transfer AIMS AND OBJECTIVES
may be as high as 4.5%, although this may be due to already
existing tubal pathology in these patients and not solely due The aim of the review is to summarize the role of minimal
to ART intervention. The incidence of heterotopic pregnancy access surgery in the management of tubal pregnancy and
is now believed to be about 1:4,000 in the general population its management options, and further its effect on future
and 1 to 3% in in vitro fertilization (IVF) pregnancies, much pregnancy.
higher than the originally described prevalence of 1:30,000 MATERIAL AND METHODS
in the late 1940s (Symonds et al 1998, Seeber et al 2006).
Critical review of the relative contributions of these A literature search was performed using the search engines
factors is pertinent. It is widely accepted that when PubMed, Yahoo, Wikipedia, Google, HighWire press, and
pregnancy occurs in a woman using an IUD, there is an SpringerLink. Selected papers were taken for further
increased likelihood of ectopic pregnancy. Indeed, the ratio references. All articles, RCT (randomized controlled trial)
of ectopic pregnancy to intrauterine pregnancy has been following predominantly laparoscopic and open surgical
reported to have increased sevenfold (Lehfold et al 1970, protocol were included for review. The articles, also
Vesset et al 1974, Mol et al 2008). reviewed on the elements like study of follow-up on
subsequent fertility explored in terms of intrauterine
MANAGEMENT pregnancy, recurrence of ectopic pregnancy and sterility
or cumulative intrauterine pregnancy rates, were
For most tubal ectopic pregnancies (EP), surgery is the comparable or superior to that of principle series treated
treatment of choice. Whether surgical treatment should be by laparotomy whether radical or conservative and using
performed conservatively (salpingostomy) or radically or not using microsurgical techniques. Also, comparision
(salpingectomy), and also laparoscopically or by laparotomy between the theurapeutic techniques (laparotomy or
in women wishing to preserve their reproductive capacity, laparoscopy) has been made in view of present and future
it is subject to debate. Salpingostomy preserves the tube pregnancy outcome.
but bears the risks of both persistent trophoblast and repeat The techniques evaluated during the review were:
ipsilateral tubal EP. Salpingectomy avoids these risks, but 1. Laparoscopic
leaves only one tube for reproductive capacity (Mol et al • Linear salpingotomy (tubal aspiration)
2008). • Salpingectomy
In first trimester, ectopic pregnancy is the most • Fimbrial expression.
important cause of maternal mortality and morbidity (Akbar 2. Laparotomy.
et al 2002). Prior to 1883, no woman ever underwent a
deliberate and successful operation for a ruptured ectopic LAPAROTOMY VERSUS LAPAROSCOPY
pregnancy when Trait did it for the first time. Surgical A number of early studies documented the appropriateness
treatment may either be an open laparotomy or laparoscopy of laparoscopic treatment of ectopic pregnancies (Shapiro

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