Page 34 - WALS Journal

Role of Minimally Invasive Surgery in the Treatment of Ectopic Pregnancy
• Pelvic inflammatory disease considered presumptive evidence of an ectopic pregnancy. With
• Infertility the evolution in ultrasound technology, the discriminatory
• Induced abortion, adhesions threshold has dropped form 6500 IU/L with a transabdominal
• Myomata approach to between 1000 and 2000 IU/L with transvaginal
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• Progestin only oral pill imaging. The spectrum of sonographic findings in ectopic
pregnancy is broad. Identifiation of an extrauteine gestational
2. Use of Beta Human Chorionic Gonadotropin sac containing a yolk sac (with or without an embryo) confirms
Measurement the diagnosis. Suggestive finding include an empty uterus,
In the emergency department, pregnancy is diagnosed by cystic or solid adnexal or tubal masses (including the tubal-ring
determining the urine or serum concentration of B human sign, representing a tubal gestational sac), hematosalpinx and
chorionic gonadotropin (β -hCG). This hormone is detectable echogenic or sonolucent cul-de-sac fluid. It is therefore found
in urine and blood as early as 1 week before an expected that the proportion of patients with the tubal rupture, heavy
menstrual period. Serum testing detects levels as low as 5 IU/L, intra-abdominal bleed and pre-shock/shock have decrease
whereas urine testing detects levels as low as 20-50 IT/L. 13, 14 owing to early diagnosis.
In most cases, screening is done with a urine test, since obtaining Thorough physical and clinical examination with
the result of a serum test is time-consuming and is not always preanesthetic checkup was performed. Surgical intervention
possible in the evening and at night. was done under general anesthesia, on an in-patients basis.
A single serum measurement of the β-hCG concentration,
however, cannot identify the location of the gestation sac. If a Four different operative techniques were used:
low serum β-hCG level (< 1000 IU/L) is associated with a higher 1. Laparoscopic linear salpingiotomy (tubal aspiration)
relative risk of ectopic pregnancy, then can very low levels 2. Laparoscopic salpingectomy
predict a benign clinical course? A single serum β-hCG 3. Laparoscopic fimbrial expression
measurement cannot exclude ectopic pregnancy or predict the 4. Laparotomy
risk of rupture unless it is less than 5 IU/L. 14
In a normal pregnancy, the first trimester β-hCG Laparoscopic Linear Salpingiotomy
concentation rapidly increases, doubling about every 2 days. Used as method of choice in patients with unruptured ampullary
An increase over 48 hours of at least 66% has been used as a pregnancy. A linear incision was made over antimesenteric
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cutoff point for viability. Ectopic pregnancy may present with border of tubal segment containing pregnancy with point needle
rising, falling or plateau β -hCG levels; thus, serial measurement monopolar diathermy. Prior injection of 5-8 ml of diluted solution
is most useful to confirm fetal viability rather than to identify containing 5 units of vasopressin in 20 ml normal saline is made
ectopic pregnancy.
with 20 gauge spinal needle into the mesosalpinx. Product of
conception extrudes itself, if not this can be completed by using
3. Use of Progesterone Measurement
hydrodessection or gentle traction with laparoscopic forceps.
Measurement of the serum concentration of progesterone has Copious irrigation is used to dislodge trophoblast. The opening
been investigated as a potentially useful adjunct to serum β- of fallopian tube was left to heal by secondary intention.
hCG measurement, since progesterone levels are stable and
independent of gestational age in the first trimester. A Meta Laparoscopic Salpingectomy
analysis, published in 1998, of studies assessing a single
progesterone level demonstrated good capacity of low levels This method is chosen for treatment of isthmic pregnancy, with
(≤ 5 ng/mL) to correctly diagnose pregnancy failure, but this tubal distriction, hydrosalpinx, recurrent ectopic in the same
cutoff was unable to discriminate between ectopic pregnancy tube, severe adhesions or patients choice. This procedure
and intrauterine pregnancy. Both high (≥ 22 ng/mL) and low involves resection of segment of tube containing pregnancy in
(≤ 5 ng/mL) cutoff points have since been studied for their several ways including laser, stapling devices, endoloops, or
ability to correctly identify nonviable pregnancy and ectopic progressive biopolar coagulation and cutting the mesosalpinx
pregnancy. 16, 17 Invasive diagnostic testing (e.g. D and C) could begins at proximal isthmus of tube, progressed to fimbriated
be postponed in the former patients but offered to the latter, as end.
could treatment with methotrexate, without fear of interrupting
a potentially viable intrauterine pregnancy. Laparoscopic Fimbrial Expression
Milking of the tube was done for the patients with fimbrial
4. Ultrasound Imaging
ectopic pregnancy. Trophoblastic tissue either sucked out by
A β−hCG level that has risen above the discriminatory threshold suction, or retrieved through 10 mm ports and sent for
in the absence of sonographic signs of early pregnancy is histopathological examination.
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