Conservative surgery for tubal pregnancy.

Twenty-four conservative surgical procedures for unruptured tubal pregnancies were performed on 23 patients with poor past obstetric performance. All cases were diagnosed preoperatively by laparoscopy. Salpingotomy was performed in 20 cases and fimbrial expression of the ectopic pregnancy was performed in 4 cases. In the group of conservatively treated patients there were 15 live births in 11 women and 28 intrauterine pregnancies in 14 women. No ectopic pregnancies occurred in the operated tube. Early diagnosis and conservative surgical treatment of unruptured tubal pregnancy is appropriate for patients with poor reproductive histories.     

Conservative treatment of ectopic pregnancy with intramuscular administration of methotrexate (MTX/CV).

20 cases of unruptured ectopic pregnancies were studied from August 1990 till May 1991. They were treated according to the Sauers et al. (1987) protocol with Methotrexate and rescuvolin. The treatment was successful in all but one case. Six out of 17 cases had a normal pregnancy in the 12 months following treatment. Seventeen out of 20 cases had tubal patency checked with HSG and laparoscopy. We conclude that conservative management of unruptured pregnancy with MTX must be the treatment of choice.     

Methotrexate treatment of unruptured ectopic pregnancy: a report of 100 cases

In an ongoing clinical trial, 100 patients with an unruptured ectopic pregnancy of 3.5 cm or less in greatest dimension were treated with an outpatient protocol of methotrexate and citrovorum factor chemotherapy. Methotrexate and citrovorum were given on alternating days until the hCG titer had decreased by 15% on 2 consecutive days. The patients ranged in age from 16-40 years, gravidity from 1-8, and parity from 0-5. Twenty-three patients had a previous ectopic pregnancy. Of the 100 patients, 96 (96%) received methotrexate/citrovorum as primary therapy and four (4%) were treated for persistent hCG titers after a conservative surgical procedure. The tubal pregnancies of patient nos. 1-50 were confirmed by laparoscopy, whereas patient nos. 51-100 were diagnosed according to a nonlaparoscopic algorithm. Four patients of 100 failed medical therapy and required surgery. Of these, one had an ectopic pregnancy with cardiac activity, one ruptured after intercourse, and the remaining two cases had no specific identifiable risk factors. Of the ectopic pregnancies with cardiac activity, 80% were successfully treated. Five patients (5%) had methotrexate-related side effects, all after the fourth dose, but none required treatment for these side effects. Hysterosalpingograms done on 58 patients subsequently demonstrated tubal patency in 84.5% on the involved side. To date, 37 pregnancies have occurred in this group, of which 31 (89.2%) were intrauterine and four (10.8%) were recurrent ectopic pregnancies. We conclude that methotrexate/citrovorum is safe, effective, and helps to preserve reproductive performance when used as primary therapy for unruptured ectopic pregnancy and for treatment of persistent disease following a conservative surgical procedure.     

Fertility following conservative surgery for tubal pregnancy

Eighty seven conservative surgical interventions for unruptured tubal pregnancy were performed on 83 patients. Salpingotomy was performed in 66 cases and expression of tubal pregnancy in 21 cases. In this patient group, 76.7% (56 out of 73) experienced intra-uterine pregnancy following surgery and 71.2% (52 out of 73) had a live birth. The recurrence rate of tubal pregnancy was 12.3%. Of the 42 patients with a normal contralateral tube, 36 (85.7%) had an intra-uterine pregnancy, 80.9% had a live birth and 7.1% had a recurrent tubal pregnancy. Sixty percent of the patients who underwent operation on their single tube, had a live birth and 66.6% had an intra-uterine pregnancy; the recurrence of tubal pregnancy in this group was 26.6%. No recurrence of tubal pregnancy was found in the group of patients who underwent expression of tubal gestation. It is suggested that the expression of tubal gestation (milking) is a safe procedure for conserving future fertility, and that the indications for conservative surgical management in patients with unruptured tubal gestation should be broadened to include all patients interested in future pregnancies, regardless of the current state of the contralateral tube.     

Operative laparoscopy for the management of tubal pregnancy

Laparoscopic management of selected cases of tubal pregnancy may be an alternative to the conventional approach, laparotomy. Twenty-seven patients were managed with this technique; each had a readily accessible unruptured ampullary pregnancy less than 4 cm in diameter. All but one went home by the second hospital day. One suffered an immediate postoperative hemorrhage that required laparotomy to control. Six of eight patients tested from three to ten months after the operation had tubal patency. Five of eight patients attempting conception have become pregnant, with one repeat ipsilateral tubal pregnancy. In five patients, serum beta-human chorionic gonadotropin remained elevated for more than 30 days after laparoscopy with no untoward effect. Although insufficient data exist to compare reproductive outcome after this technique with that after laparotomy, in properly selected cases operative laparoscopy seems to be safe and effective conservative therapy, decreasing the need for laparotomy and the duration of hospitalization.     

Re-evaluation of the indication for and limitation of laparoscopic salpingotomy for tubal pregnancy

OBJECTIVE: We investigated the outcome of laparoscopic salpingotomy for tubal pregnancy by follow-up hysterosalpingography (HSG) or second-look laparoscopy (SLL) and reexamined the indication for and limitation of this conservative surgery. STUDY DESIGN: From April 1991 to December 2003, we treated 181 cases of tubal pregnancy using laparoscopic salpingotomy. The tubal patency was assessed by either HSG or SLL performed at 3 months post-surgery. The patients with a successful initial operation and confirmed ipsilateral patent tubes at follow-up were classified as truly successful cases (group I). Even after successful operation, if the treated tubes were found to be occluded, they were considered as unsuccessful cases. Therefore, those cases that were unsuccessful at initial surgery as well as at follow-up were categorized as group II. RESULTS: One hundred and thirty-four cases (74%) were successfully treated by salpingotomy at initial laparoscopy and 85 of them (63.4%) were found to be truly successful at follow-up (group I). The remaining 47 cases (26.0%) were unsuccessful at initial surgery and 18 (13.4%) cases at follow-up (group II). Thirty-one other patients refused to accept a tubal patency test or were not examined for personal reasons or were lost to follow-up. No difference in surgical outcome was observed between these two groups of patients with regard to gestational age, intra-operative hemorrhage, size or anatomic location of the pregnancy mass, and pre-operative adhesions of the fallopian tube. However, pre-operative serum levels of hCG were significantly higher in group II than in group I. In addition, the unsuccessful cases were more frequently associated with positive fetal heart beat (FHB), tubal rupture, and pre-operative serum levels of hCG of more than 10,000 IU/l (p<0.05, chi2 test). The log-rank test indicated a higher pregnancy success rate in group I (p<0.05) than in group II in those who desired future pregnancy. CONCLUSION: Laparoscopic salpingotomy may be practised as conservative surgery for proximal ectopic pregnancy, and gestational mass size is not as important and is not a relative contraindication for conservative laparoscopic surgery, as previously reported. Low pre-operative HCG levels, absence of FHB, absence of tubal rupture initially or minimal rupture may be considered suitable parameters for successful surgery and for achieving future pregnancy.     

Characteristics of indigent women with ruptured and unruptured tubal pregnancies.

The diagnosis of tubal pregnancy, whether ruptured or unruptured, often requires a surgical procedure, such as laparoscopy or laparotomy, for confirmation. We compared women with ruptured and unruptured tubal pregnancies to determine whether the clinical presentations, morbidity and surgical complications in the two groups were significantly different. We compared the demographic characteristics, clinical presentations, laboratory findings, morbidity and complications from surgical management in the two groups. Women with ruptured tubal pregnancies had a higher incidence of abdominal pain lasting less than 24 hours, adnexal tenderness and positive culdocentesis from hemoperitoneum as compared to women with unruptured tubal gestations. Abnormal uterine bleeding was observed less frequently in women with ruptured tubal pregnancies as compared to women with unruptured ones despite similar gestational ages at presentation. All the patients with a tubal pregnancy were managed surgically. The morbidity and surgical complication rates in the two groups were not significantly different.     

Ectopic tubal pregnancy treated by operative laparoscopy

Between July 1986 and May 1988, all 23 patients with ectopic tubal pregnancies of 5 to 10 1/2 weeks' gestation and with serum beta-human chorionic gonadotropin levels between 51 and 92,610 mIU/ml (first international reference preparation) were treated by operative laparoscopy. Twenty-two (96%) of the ectopic pregnancies were unruptured or leaking and one (4%) was ruptured. Fifteen patients (65%) were treated with electrosurgical linear salpingotomy, and three of these patients (20%) later needed subsequent operative procedures. Six patients (26%) were treated with laparoscopic partial or total salpingectomy, and two patients were treated with either fimbrial expression of the pregnancy or completion of a partial abortion. Twenty patients (87%) spent less than 24 hours in the hospital for successful treatment of the ectopic pregnancy. It is concluded that operative laparoscopy should be considered an alternative to laparotomy or minilaparotomy for the treatment of ectopic pregnancy.     

Concurrent tubal ectopic pregnancy and acute appendicitis

A 25-year-old woman had signs of an acute surgical abdomen. Differential diagnoses were ectopic pregnancy and acute appendicitis. Diagnostic laparoscopy revealed an apparent inflamed appendix and left-sided unruptured tubal ectopic pregnancy. This case illustrates the importance of considering multiple pathologic disorders in a patient with an acute surgical abdomen, especially in pregnancy. Furthermore, it shows that laparoscopy constitutes the optimal treatment modality in patients with multiple diagnoses, because it combines multifocal diagnosis and treatment without additional postoperative morbidity.     

Local methotrexate injection: a nonsurgical treatment of ectopic pregnancy

Twenty seven patients with unruptured tubal pregnancy were selected for nonsurgical treatment with the use of one injection of 12.5 mg of methotrexate into the ectopic site at laparoscopy. No adverse reactions were observed. In three patients (11%), a laparotomy was performed because of rising beta-human chorionic gonadotropin titers. In the other patients, serum beta-human chorionic gonadotropin levels decreased to the nonpregnant range with no further intervention, and the patients recovered uneventfully. This method is suggested as an alternative to surgery in selected cases of early unruptured tubal pregnancy.     

Medical treatment of ectopic pregnancy.

Methotrexate is an alternative to surgical treatment of unruptured tubal pregnancy. Among 39 women with the diagnosis of tubal pregnancy there were ten10 cases without rupture of salpinx. Nine9 out of these treated with Methotrexate. In one1 case there was rupture immediately after the termination of the treatment. There were no experiences of major side effects from the treatment with Methotrexate. The passage through the tubes was examined laparoscopically 3 months after the treatment. There was passage through all affected tubes.     

Methotrexate local injection for unruptured tubal pregnancy: an alternative to laparotomy?

Fifty-nine women with early unruptured tubal pregnancy were treated by a single local injection of methotrexate at laparoscopy. All 59 patients underwent the procedure without any adverse reaction, 47 (80%) of them needing no laparotomy. Twelve patients required a laparotomy for reasons such as rising beta-hCG levels and abdominal pain with or without rising levels of beta-hCG. Only one patient ruptured the tube. None of the women needed a blood transfusion. We found tubal patency in 19 out of 21 patients at follow up hysterosalpingography. Eleven pregnancies were subsequently reported, one of them tubal. The appearance of the injected tube was absolutely normal in three patients, one at cesarean section and two at repeated laparoscopy. No peritubal adhesions were observed. We suggest that this new technique is a safe and effective alternative to laparotomy in a patient with an early unruptured tubal pregnancy.     

Persistent ectopic pregnancy following conservative surgery for tubal pregnancy

Objective To audit the incidence and management of persistent ectopic pregnancy following conservative tubal surgery performed at laparotomy and via the laparoscope.
Design A retrospective analysis of the case records. Setting The Birmingham and Midland Hospital for Women.
Participants Two hundred and fourteen women who received surgical treatment for ectopic pregnancy between October 1991 and December 1994.
Results Of the 85 women who underwent conservative tubal surgery, nine were diagnosed as having persistent ectopic pregnancy on the basis of hCG values. The incidence after laparoscopy was no higher than after laparotomy. A second surgical procedure was indicated in only four cases.
Conclusions Post-operative surveillance of serum hCG remains mandatory. Patients who remain symptom free may be managed conservatively The threshold for a second-look laparoscopy should be relatively high and be based on the presence of symptoms rather than changes in hCG values.     

Contemporary management of ectopic pregnancy

Over the five years 1975-79 at Yale-New Haven Hospital, ectopic pregnancy changed from a disease requiring acute emergency are utilizing radical surgery for a ruptured ectopic to a disease requiring chronic, observant care utilizing conservative treatment for the unruptured ectopic. One hundred ninety-five cases of ectopic pregnancy have been retrospectively reviewed to determine how laparoscopy, ultrasound and beta pregnancy testing have affected this change. Over the reviewed period of time, the rate of diagnosed and treated unruptured ectopic pregnancies increased from 8% to 35%. Those patients with ectopic pregnancies having laparoscopy prior to laparotomy rose from 11% to 29.5%. Ultrasound diagnosed intrauterine pregnancy in 13% of those patients suspected of having an ectopic pregnancy by defining an intrauterine gestational sac and demonstrated a mass in 85% of patients diagnosed as having an ectopic pregnancy, although the mass was not always the ectopic pregnancy. Beta pregnancy testing, available only over the past two years, was positive in 99%, with only one false negative. One hundred twenty-eight culdocenteses were done, with 85% positive, and was the most important factor in deciding on emergency versus expectant care. These factors have allowed us to treat ectopic pregnancy expectantly, making the diagnosis sooner and more accurately, leading to an increase in conservative treatment and employing salpingostomy as opposed to salpingectomy as the rate of unruptured ectopic pregnancy increases.     

New concepts in the surgical management of tubal pregnancy and the consequent postoperative results

The success following reconstructive tubal pregnancy can only be measured in terms of live births. Because the fallopian tube is not a simple conduit and has numerous complex functions, many women fail to conceive despite successful reconstructive surgery. The most effective way to prevent reocclusion or peritubal adhesion is to minimize tissue trauma. Magnification permits accurate excision and hemostasis. In this review, it has been demonstrated that tubal conservation is technically possible and safe. It is effective in increasing the number of live births postoperatively in women interested in fertility and does not increase the risk of the repaired tube for a repeat tubal gestation more than the uninvolved tube, although one of five subsequent pregnancies are again ectopic. They seem to occur equally as often in the contralateral tube as in the repaired tube. It has been shown that salpingotomy can restore tubal patency and maintain fertility. The second question was whether the number of viable pregnancies increase after conservative surgery. This question can be answered only if the repaired tube remains and the patient subsequently delivers at term. Such data have already demonstrated this outcome. Conservative operations in selected cases of tubal pregnancy seem feasible and safe and do not further impair tubal function. Because intrauterine pregnancy is more apt to occur than is repeat ectopic pregnancy, it seems logical that the involved tube should be saved whenever fertility is desired (Fig. 2). In unruptured isthmic pregnancy, Stangel and Gomel prefer segmental excision and end-to-end anastomosis during the same intervention. Gomel advocates segmental excision of the conceptus whether ruptured or not when the pregnancy is located in the isthmus or proximal half of the ampulla, and end-to-end anastomosis undertaken later as an elective procedure if necessary (Fig. 2). An ampullary gestation may be successfully treated by salpingotomy; and in the case of distal ampullary location, a tubal abortion may be performed (Fig. 2). When extensive destruction of the tube occurs, salpingectomy becomes necessary. In cases of early diagnosis of tubal gestation, conservative surgical management may be carried out via laparoscopy (Fig. 1).     

A review of the literature on nonsurgical treatment in tubal pregnancies.

In some cases tubal pregnancy resolves spontaneously. The risk of subsequent surgical intervention due to either tubal rupture or the entry criteria of the study varies from 0 per cent to 31 per cent. The major problem in nonsurgical treatment of tubal pregnancy is the absence of a parameter that reveals the threat of tubal rupture. In addition, data on the functional recovery of the fallopian tube are controversial. The scarcity of data on medical treatment with RU486, glucose 50 per cent, KCL, and actinomycin-D make proper evaluation impossible. Both MTX and prostaglandin treatment should be investigated further. Compiled data on prostaglandin treatment in cases of unruptured tubal pregnancy do not show better results than data on expectant management only. If, however, patients with initial serum hCG levels greater than 1000 mIU/ml or greater than 2500 mIU/ml are excluded from this therapy, the risk of tubal rupture diminishes. Side effects are minimal, especially if injection into the corpus luteum is omitted. Compiled data on MTX treatment in cases of unruptured tubal pregnancy show a crude risk of subsequent surgical intervention of 5 per cent. If patients with an initial serum hCG level exceeding 10,000 mIU/ml are excluded, the risk of tubal rupture is limited to 3 per cent. (The estimated risk of persistent trophoblastic activity after conservative surgical therapy is also 5 per cent.) Studies on the optimum MTX dosage, treatment scheme, and method of administration are still going on. Side effects are reversible and minimal. Theoretically, the local injection of MTX is more effective. Although often used to propagate a new way of treatment, fertility in the future is a questionable parameter in the evaluation of therapy. Fertility is influenced by so many factors other than the method of treatment that it can only be used for treatment evaluation in a case control or a randomized prospective study. Such a study has yet to be published. Besides the influence on future fertility, other results of treatment, such as morbidity, cost, and length of hospital stay should be taken into account.     

Use of laparoscopy in gynecology]

Paper concerns 1822 performed laparoscopies. The most frequent indications to laparoscopy were: sterility, adnexal mass, tubal pregnancy and pelvic pain syndrome. In 80% cases of sterility we found pathologic findings, which could be the cause of sterility. adnexal mass, tubal pregnancy and pelvic pain syndrome. In 80% cases of sterility we found pathologic findings, which could be the cause of sterility. In 75% of cases we confirmed adnexal mass, which were operated by laparoscopy or by laparotomy. In 17 cases we confirmed unruptured tubal pregnancy, which were conservatively operated by laparoscopy or by laparotomy. Laparoscopy is useful method in gynecology, especially in diagnostically difficult cases of gynecologic disease.     

The use of carbon dioxide laser laparoscopy in the treatment of tubal ectopic pregnancies.

OBJECTIVE: The purpose of this study was to assess the efficacy of the treatment of unruptured tubal ectopic pregnancies by the use of carbon dioxide laser laparoscopy. STUDY DESIGN: A series of 125 consecutive ectopic pregnancies were treated laparoscopically; the tubal pregnancy was removed by a laparoscopic laser technique. Preoperative assessment included monitoring beta-human chorionic gonadotropin levels, use of vaginal ultrasonography, and preoperative and postoperative hematocrit levels. RESULTS: Laparoscopic laser surgery was successful for removal of tubal ectopic pregnancies in all but four patients, in whom a laparotomy was required. Hematocrit levels before and after surgery were similar. The time necessary for beta-human chorionic gonadotropin to fall to nondetectable levels averaged between 3 and 4 weeks. There were five patients who had complications requiring additional surgery and/or medical treatment. CONCLUSION: The techniques are easy to learn, and the use of laparoscopic laser surgery in the treatment of tubal ectopic pregnancies appears to be a safe procedure with definite advantages for both the patient and the physician. There are decreased operating times, shorter hospital stays, and lower medical costs compared with those for major surgery. Subsequent successful intrauterine pregnancy rates are comparable to those of conservative methods previously reported.     

输卵管妊娠治疗现状与趋势

由于定量测定 HCG水平和阴道超声的应用 ,大约 80 %异位妊娠可以在破裂前得到早期诊断 ,因此 ,治疗倾向于保守性。甲氨蝶呤 (MTX) 1mg/ m2 单次肌内注射总成功率达 88% ,对大约 4 0 %患者可作为首选方案。多次注射方案成功率略高于单次注射 ,但副反应发生率明显升高。腹腔镜下输卵管线形切开造口术 (开窗术 )已成为治疗输卵管妊娠的标准保守性手术。若对侧输卵管异常 ,患侧输卵管行保守性治疗虽稍增加重复异位妊娠的发病率 ,但在一定程度上也能提高宫内孕率     

A Pragmatic and Evidence-Based Management of Ectopic Pregnancy

The incidence of ectopic pregnancy is approximately 2% of all pregnancies, and it remains the leading cause of death in early pregnancy. Over 95% of ectopic pregnancies are tubal pregnancies, and the remainders are nontubal pregnancies. The highest risk factor for ectopic pregnancy is a previous tubal pregnancy followed by previous tubal surgery, tubal sterilization, tubal pathology, and current intrauterine device use. The apparent increase in the incidence of nontubal ectopic pregnancy including heterotopic pregnancy may be attributed to the increasing number of pregnancies because of in vitro fertilization treatment. In most cases, an ectopic pregnancy can be treated medically with a single dose of methotrexate. Surgical treatment is still needed in women who are hemodynamically unstable and in those who do not fulfill the criteria for methotrexate treatment. Usually surgical treatment can be performed by laparoscopy and in some cases by hysteroscopy. Laparotomy is rarely needed even in women with intraperitoneal bleeding.