What Is an Ectopic Pregnancy?
When a fertilized egg develops outside of the uterus, it leads to an ectopic pregnancy. Almost more than 90 % of ectopic pregnancies occur in the fallopian tube. The tube may burst (rupture) as the pregnancy progresses. A rupture may result in significant internal bleeding. This could be a life-threatening situation requiring urgent surgery.
What Are Risk Factors for Ectopic Pregnancy?
The following are risk factors for ectopic pregnancy-
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History of previous ectopic pregnancy.
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History of the fallopian tube, pelvic, or abdominal surgery.
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Sexually transmitted infections (STIs).
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Assisted reproductive technology like in vitro fertilization (IVF).
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Older than 35 years of age.
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History of infertility.
What Are the Symptoms of Ectopic Pregnancy?
An ectopic pregnancy may initially exhibit some of the same symptoms as a normal pregnancy, such as a missed period, sore breasts, or an upset stomach.
Other indications include,
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Unexpected vaginal bleeding.
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Lower back ache.
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Mild abdominal or pelvic pain.
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Mild pelvic discomfort on one side.
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More severe symptoms could appear as an ectopic pregnancy progresses, particularly if a fallopian tube bursts. The following symptoms may appear-
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Weakness, dizziness, or fainting.
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Shoulder pain.
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Sudden, excruciating abdominal or pelvic pain.
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A ruptured fallopian tube may result in fatal internal bleeding. Such patients should visit an emergency room if they experience sudden, severe discomfort, shoulder ache, or weakness.
How Is an Ectopic Pregnancy Diagnosed?
When a doctor or other healthcare provider suspects an ectopic pregnancy in a pregnant woman who does not exhibit the signs of a fallopian tube rupture, they may,
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Make a pelvic examination.
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Use ultrasound to determine how the pregnancy is progressing.
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Check for the pregnancy hormone human chorionic gonadotropin (hCG) in the blood.
How Is an Ectopic Pregnancy Treated?
Since an ectopic pregnancy cannot move or be transferred to the uterus, intervention is usually necessary. An ectopic pregnancy can be treated with either medication or surgery. With each therapy, a follow-up period of several weeks is essential.
What Is the Medical Management of Ectopic Pregnancy?
Methotrexate is the most frequently prescribed medication for ectopic pregnancy. This medication ends the pregnancy because it prevents cell growth. Over the next four weeks to six weeks, the body gradually absorbs the pregnancy. Fallopian tube removal is not necessary in this case.
What Is the Surgical Management of Ectopic Pregnancy?
An urgent surgical procedure is required if the ectopic pregnancy has ruptured a tube. Even when the fallopian tube is intact, surgery is occasionally necessary. In certain situations, it is possible to either remove the ectopic pregnancy from the tube or to remove the entire tube along with it.
What Are the Indications for Surgical Intervention of Ectopic Pregnancy?
The following are some indications for surgical treatment of ectopic pregnancy,
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Medical treatment is not appropriate for the patient.
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Medical treatment has not worked.
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The patient is pregnant heterotopically, and the pregnancy is still alive inside the uterus.
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The patient needs emergency care because their hemodynamics are unstable.
What Are the Contraindications for Surgical Intervention of Ectopic Pregnancy?
The following are the only limitations to surgical management,
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The patient has an ectopic pregnancy that is manageable medically.
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The patient has additional medical issues that would make the risks of surgery unacceptable.
Surgical Management of Ectopic Pregnancy:
Preoperative Evaluation:
The following factors affect how an ectopic pregnancy is surgically managed optimally-
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Patient's age, past medical history, and future childbearing options.
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Condition of the ruptured tube.
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Condition of the non-ruptured tube (on the other side of the body).
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Location of ectopic pregnancy (ampulla, isthmus, or interstitium).
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History of previous ectopic pregnancy.
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History of pelvic inflammatory disease (PID).
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Size of the pregnancy.
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Presence of any complicating factors.
Surgical Techniques:
Radical (complete surgical removal) has been replaced by conservative surgery thanks to breakthroughs in microsurgical techniques and the capacity to diagnose diseases earlier. In the last few decades, a less invasive procedure called minimally invasive surgery has been recommended to treat unruptured ectopic pregnancies and maintain tubal function.
1. Salpingectomy - In a salpingectomy, a woman's fallopian tubes are surgically removed, either one or both. It is done to treat ectopic pregnancies and some fallopian tube disorders, as well as as a preventative step for women who are more likely to develop ovarian cancer. A salpingectomy can be carried out laparoscopically to speed up the recovery.
There are two primary varieties of salpingectomy,
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Total Salpingectomy - Complete removal of the fallopian tube.
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Partial Salpingectomy - Only a part of the fallopian tube is removed.
There are two different surgical techniques for salpingectomy,
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Laparoscopic Salpingectomy - It comprises the use of a laparoscope, a narrow instrument having a light and camera at the end, during a minimally invasive procedure. Tiny abdominal incisions are used to insert surgical instruments to remove the fallopian tubes. After removing extra blood and fluid, the surgeon will close the wounds with stitches or medical glue.
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Open Abdominal Salpingectomy - The abdomen is cut with a single, big incision (called a laparotomy). Through this incision, the surgeon will have access to the fallopian tubes. After removing the fallopian tube, the incision is closed with stitches or staples.
The preferred method is laparoscopic because it is less intrusive, has a quicker recovery period, and carries a lesser risk of complications. However, based on additional considerations, an open strategy can be required.
2. Salpingostomy (Neosalpingostomy) - The fallopian tube is opened during a salpingostomy procedure, but the tube itself is not removed. Salpingostomy should be considered in individuals with an ectopic pregnancy that has not ruptured, who desire future fertility but have damaged the contralateral fallopian tube, and in whom removal of the fallopian tube would need assisted reproduction for future childbearing.
A suction-irrigator is used to drain away the byproducts of conception. The salpingostomy site does not require suturing because it will naturally heal. Keeping an eye on the patient's serial beta hCG levels after a salpingostomy is crucial.
3. Salpingotomy - Salpingotomy, a conservative method, preserves the tube but carries the danger of not completely removing the pregnancy tissue (permanent trophoblast), which requires additional treatment and the possibility of a subsequent ectopic pregnancy in the same tube. Numerous studies have found little evidence to support the benefits of tubal incision closure (salpingotomy) over secondary intention healing (salpingostomy).
4. Segmental Resection - When the ends of the tubes (the fimbriae) look healthy and the ectopic pregnancy is small, a segment of the tube may be removed using a surgical procedure called a segmental resection. If only a small part of the tube is cut away, microsurgery can later be used to reattach the tube. A total salpingectomy is carried out if the fallopian tube is severely damaged, the ectopic pregnancy is large, or the patient is bleeding profusely.
5. Milking or Fimbria Expression- When the product of conception is situated at the fimbrial end, or very close to the fimbria, it is removed by gripping the tubal segment and gradually milking the gestational product out of the tube's fimbriae. However, there is a higher risk of bleeding while using this method. Patients with ectopic or tubal pregnancies who want to maintain their reproductive potential can benefit from the well-established fimbrial milking procedure.
Postoperative Care:
Important postoperative issues include maintaining hemodynamic stability and effective pain management. The majority of laparoscopic patients are released the same day as surgery, but in some cases, an overnight stay may be required to monitor postoperative bleeding and ensure acceptable pain control. Laparotomy patients typically spend a few days in the hospital after their procedure.
Once the ectopic pregnancy has been surgically removed, quantitative hCG levels must be checked every week until they are zero to confirm that treatment has been successful. Until their hCG levels have returned to normal levels, patients should use some reliable contraception.
What Is the Prognosis After Surgery for Ectopic Pregnancy?
Patients with an ectopic pregnancy have an excellent prognosis if they receive an early diagnosis. Fertility conservation is frequently possible. The likelihood of subsequent fertility is higher the earlier the diagnosis is made, and treatment is started.
Conclusion:
Ectopic pregnancy is a term used to describe extrauterine pregnancy. Most ectopic pregnancies develop and grow in the fallopian tube, but they can also develop in the cervix, interstitial area of the fallopian tube, hysterotomy or cesarean scar, myometrium, ovary, or abdomen.
In the first trimester of pregnancy, ectopic pregnancy continues to be the most significant cause of death. Most ectopic pregnancies may now be identified early with serial serum hCG readings and transvaginal ultrasound screening, allowing for methotrexate therapy. The type of surgical procedure needed to manage ectopic pregnancy depends on the clinical condition of the patient and the location of the pregnancy in people who need it.
The majority of cases can and must be handled by laparoscopy. The laparoscopic method has many benefits over laparotomy, including a shorter hospital stay, lower costs, and less adhesion formation. If a woman has an unruptured tubal pregnancy and wants to keep her fertility, she should have a linear salpingostomy; otherwise, a salpingectomy is performed.
