Page 32 - WJOLS - World Journal of Laparoscopic Surgery

Laparoscopic Conservative Treatment and Laparoscopic Salpingotomy
The sonographic absence of an intrauterine gestational sac The greatest risk factor for an ectopic pregnancy and loss of
with a serum β-hCG level above the discriminatory zone is highly fertility is a history of previous ectopic pregnancy. The recurrent
12,13
suggestive of an ectopic pregnancy. ectopic rate is 10–15% after the first ectopic pregnancy, and 30%
23
The diagnosis is less evident when the β-hCG level is below after the second. This risk is related to both the underlying tubal
the discriminatory level and when the adnexal ultrasonographic disorder that led to the initial ectopic pregnancy and to the choice
14
findings are inconclusive. of treatment procedure.
Promising tools to achieve an early diagnosis of ectopic pregnancy Sexually transmitted infections or tubal surgery are responsible
are ultrasonographic endometrial patterns and the endometrial for the majority of the tubal damage seen in ectopic pregnancies.
thickness. Several endometrial patterns have been correlated with Postabortal or puerperal infection, appendicitis, and endometriosis
the presence of an ectopic pregnancy, which include the endometrial are additional etiologies for tubal pathology. One episode of
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trilaminar pattern. Regardless of the location, the endometrium salpingitis results in subsequent ectopic pregnancy in up to 9% of
often responds to ovarian and placental production of pregnancy- women. Smoking is also a risk factor but may be a surrogate marker
1
related hormones. The most common types of endometrium as it coincides with other high-risk behaviors. As an example,
associated with ectopic pregnancy are decidual reaction (42%), a study of surgical and medical therapy of ectopic pregnancy
secretory endometrium (22%), and proliferative endometrium reported the rates of recurrent ectopic pregnancy after single dose
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(12%). The trilaminar pattern is specific for the diagnosis of ectopic methotrexate, salpingectomy, and linear salpingostomy were 8,
17
pregnancy, but it is associated with low sensitivity. 9.8, and 15.4 percent, respectively, among patients who attempted
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The endometrial thickness tends to be lesser in patients with an to conceive.
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ectopic pregnancy. However, there was no endometrial thickness Despite remarkable advances made in both diagnosis and
value that was adequately specific and sensitive for the diagnosis treatment, ectopic pregnancies continue to account for up to
25
17
of ectopic pregnancy. 9% of all maternal deaths in developed countries. The ability
Over the last decades, transvaginal ultrasound (TVUS) has to make diagnoses early and accurately has led to the significant
become the first step in the diagnosis of ectopic pregnancy expansion of treatment options and the development of innovative
and the most useful imaging test for determining the location surgical and nonsurgical treatment approaches. Today, ectopic
of a pregnancy. TVUS should be performed as part of the initial pregnancies continue to make up approximately 2% of all
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evaluation and may need to be repeated, depending upon the hCG recognized pregnancies. Less than 5% of ectopic pregnancies are
level or a suspicion of rupture. Sensitivity of TVUS as a single test in found outside the tube in locations including the ovary or other
the diagnosis of ectopic pregnancy is 74% (95% CI: 65.1–81.6) with intraabdominal structures, the cervix, or defects in the myometrium
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a specificity of 99.9% (95% CI: 99.8–100). Between 87% and 99% (e.g., cesarean scar pregnancy). The diagnostic and treatment
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of tubal pregnancies can now be diagnosed reliably using TVUS. approaches to these unusual ectopic pregnancies vary greatly
Approximately 60% of ectopic pregnancies are seen as an depending on their location.
inhomogeneous mass (“blob sign”) adjacent to the ovary, 20% The diagnosis of an ectopic pregnancy is made on the basis
appear as a hyperechoic ring (bagel sign), and 13% have an obvious of history including physical examination, the assessment of risk
gestational sac with a fetal pole, with or without fetal cardiac factors, vaginal ultrasonography, and serum hCG levels.
19
activity. The concept of a “discriminatory zone” which is the hCG level
The diagnosis of ectopic pregnancy (EP) relies on the above which we expect to see an intrauterine gestational sac has
interpretation of serial hCG levels in conjunction with TVUS and been an important addition to the early diagnosis of an ectopic
27–30
clinical history. Transvaginal sonography is sensitive and specific pregnancy. In most institutions, the discriminatory zone is a serum
for distinguishing an intrauterine pregnancy (IUP) from an EP when hCG level of 1,500 or 2,000 IU/L with TVUS. The reported sensitivity
13,20
the presenting hCG is above the discriminatory zone. and specificity of hCG of >1,500 IU/L are 15.2 and 93.4%, and for an
31
Measurement of hCG is performed initially to diagnose hCG level of >2,000 IU/L, they are 10.9 and 95.2%, respectively.
pregnancy and then followed to assess for ectopic pregnancy. For The level is higher for transabdominal ultrasound (approximately
follow-up, hCG is measured serially (every 48–72 hours). A single 6,500 IU/L), but TVUS is the standard modality used to evaluate
hCG measurement alone cannot confirm the diagnosis of ectopic ectopic pregnancy.
or normal pregnancy. However, the correct level to use for the discriminatory zone
Clinical interpretation of TVUS in patients with hCG levels close is controversial. A number of factors (e.g., prostaglandins, integrin,
to, or below, the discriminatory zone is challenging, and initial TVUS growth factors, cytokines, lectin, matrix-degrading cumulus,
18
alone cannot detect 26% of ectopic pregnancies. Additional and modulator proteins) may cause premature implantation in
21,22
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factors may impact the diagnostic utility of TVUS. Medical and/ the tube. Pelvic infection may alter tubal function, in addition
or surgical management is often appropriate once the diagnosis to causing tubal obstruction and pelvic adhesive disease. Some
has been confirmed. data suggest that a history of chlamydial infection results in the
Although surgical intervention has long been the gold standard production of a protein (PROKR2) that makes a pregnancy more
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of ectopic treatment, medical management of unruptured ectopic likely to implant in the tubes.
pregnancy has emerged as a safe and effective alternative. Of interest is the fact that unusual forms of ectopic pregnancies,
Regardless of the treatment strategy used, the primary goal is such as interstitial and heterotopic pregnancies, are encountered
the avoidance of catastrophic outcomes including tubal rupture. more often. This is partly because of the more frequent use of
4,34,35
Fertility preservation should also be a variable in the decision- assisted reproductive techniques. Very rarely it is found
36–40
making process for unruptured ectopic pregnancies. retroperitoneally or after a hysterectomy.
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Unfortunately, there is no consensus in the literature regarding Bassil et al. reported advanced heterotopic pregnancy after
the optimal treatment of tubal pregnancy for the maintenance of IVF and embryo transfer, with survival of both the baby and the
fertility. mother.
140 World Journal of Laparoscopic Surgery, Volume 11 Issue 3 (September–December 2018)