7.1.1 Diagnosis

In most fertility clinics, early monitoring of serum hCG results in detection of an ectopic pregnancy prior to the development of any symptoms. The diagnosis is more challenging in the gynecologic clinic or emergency medicine department setting. The hallmark of an ectopic pregnancy is the abnormally slow rise of serum levels of beta subunit of hCG. The original proposal of a 53% rise in levels within a 48-hour period to distinguish abnormal from normal intrauterine pregnancy has now been revised to a minimum level of 35% increase in 48 hours [7]. Abnormally rising hCG levels coupled with an empty uterus on ultrasound raises the suspicion for an ectopic pregnancy. Using a discriminatory serum hCG level of 3,000 mIU/mL and an empty uterus on transvaginal ultrasound exam, there is still a 0.5% chance of a viable intrauterine pregnancy. Therefore, unless the patient is unstable, it is prudent to check at least one more hCG level in the next few days with repeat of ultrasound before advocating intervention. The sensitivity of ultrasound markers has been analyzed in a recent meta-analysis. Empty uterus, pseudosac, adnexal mass, and fluid in the cul-de-sac have poor sensitivity but reasonably high specificity. As a result, none of these signs can be used to rule out an ectopic pregnancy [8]. A new set of ultrasound criteria was established by the Society of Radiologists in Ultrasound based on the gestational and yolk sacs, crown-rump length and cardiac activity [9]. Novel markers such as interleukin-6 and activin-A have recently been proposed as adjuncts in the diagnosis of tubal pregnancies but no test is of yet 100% sensitive and specific in diagnosing ectopic pregnancy [10,11].

A dedicated multiprofessional team approach to management has shown to increase ultrasound visualization of ectopic pregnancies from 22% to 61% and decrease negative findings at laparoscopy from 13% to 6% [12]. The possible benefits of such a team approach include improvements in communication, education, patient care, and team cohesion [13].

Nontubal pregnancies are often diagnosed late with life-threatening consequences to the affected women [14]. A high index of suspicion has to be maintained at all times to diagnose and treat them expeditiously.

7.1.2 Treatment Considerations

Nonsurgical management of ectopic pregnancy should always be favored where possible, to decrease surgical and anesthetic risks to the patient. Even with ectopic pregnancies occurring in sites other than the fallopian tube, medical management has been shown to be safe and effective [15]. Despite this, surgical management of ectopic pregnancies remains most popular [16,17]. A recent national survey in the UK revealed that 57% of ectopic pregnancies are managed by laparoscopy, 31% medically, 5% by laparotomy, and 6% expectantly [18]. Similar detailed data is not available for the United States. One report from Maryland examined trends from 1999 to 2004. Comparing data for 1994–1999 with 2000–2004, the rate of surgical management of ectopic pregnancy had increased to 88% in hospitalized patients [19]. In another study, use of data from 200 commercial insurance companies from 2002 to 2007 revealed that Methotrexate treatment increased from 11% to 35% whereas laparotomy rate decreased from 40% to 33%. No data was reported on the use of laparoscopic approach. The failure rate for methotrexate treatment was 14% in this study [20]. Surgical management should be reserved for patients who are not eligible for medical or expectant management. When surgical management is chosen, a laparoscopic approach should be taken. A prospective study covering 10 years from 2003 to 2013 showed that after 4 years, they were consistently able to treat all ectopic surgeries, whether hemodynamically stable or not, by laparoscopy [21].

7.2.1 Diagnosis

The gold standard for the diagnosis of tubal pregnancy is laparoscopy followed by histopathological confirmation after examination of the tissue removed at surgery. Occasionally, a gestational sac with a fetal pole and fetal cardiac activity can be noted outside of the uterine cavity on ultrasound examination. More frequently, a mass is noticed outside of the uterus and the ovaries with or without the presence of free fluid in the cul-de-sac. Most commonly, the suspicion of tubal pregnancy is entertained with the finding of discriminatory levels of hCG (as discussed under the general diagnosis section earlier) and an empty uterus. Ectopic pregnancy has been documented in the stump of the tube that was previously removed and should be considered if symptoms suggest that possibility [30].

7.2.2 Treatment Considerations

There is no difference in subsequent intrauterine or repeat ectopic pregnancy rates between salpingectomy and salpingostomy (see Video 7.1). The intrauterine pregnancy rate was 56% in salpingectomy vs 61% in salpingostomy and the repeat ectopic pregnancy rate was 5% vs 8%, respectively, neither of which was statistically significant [31]. Concerns have been raised about the effect of salpingectomy on ovarian reserve. A retrospective study of 118 women who underwent IVF after salpingectomy or salpingostomy showed no difference in the number of eggs retrieved [32].

In standard three-port laparoscopic salpingostomy, the uterus is laterally deviated to the contralateral side of the ectopic pregnancy while the distal part of the affected tube is grasped with atraumatic graspers and pulled to the ipsilateral side. Dilute vasopressin (20–30 units in 100 ml of saline) can be injected into the mesosalpinx beneath the ectopic (Figure 7.1). A monopolar needle or scissors is then used to incise the tube on the anti-mesenteric border over the ectopic bulge (Figure 7.2). The products of conception will often spontaneously extrude out. Manual compression on the exterior of the tube beneath the ectopic can facilitate expressing the products of conception through the salpingostomy incision (Figure 7.3). The products may also be flushed out using hydrodissection. In any case, it is important to avoid placing graspers in the incision to extract the tissue as it tends to cause more bleeding, which can be difficult to control, leading to excessive thermal injury from electrocautery or even the need for salpingectomy. The products of conception must be meticulously removed from the pelvis to avoid persistence of the trophoblastic tissue (Figure 7.4). Salpingostomy is left open to heal by secondary intention (Figure 7.5).

Figure 7.1 Dilute vasopressin is injected in the mesosalpinx beneath an unruptured isthmic ectopic.

Figure 7.2 The antimesenteric surface of the ectopic bulge is incised with scissors.

Figure 7.3 External compression is used to express the products of conception through the salpingostomy incision.

Figure 7.4 The products of conception are removed from the peritoneal cavity.

Figure 7.5 Hemostasis is assured and the salpingostomy incision is left open.

Salpingectomy can be started at the cornual or fimbriated end. The mesosalpinx, as well as the proximal tube, are coagulated with bipolar cautery then divided with scissors (Figures 7.6–7.9). Care must be taken to stay as close to the mesenteric border of the fallopian tube as possible to prevent possible compromise of the blood supply to the ovary. Advanced sealing devices can be used instead of the bipolar graspers and scissors. A single-port approach can also be used for both salpingostomy as well as salpingectomy and the principles are similar to multiport approach [33,34]. Regardless of the approach, the products of conception should be carefully removed, preferably after placing them in a tissue removal bag.

Figure 7.6 This is a ruptured ampullary ectopic pregnancy.

Figure 7.7 The proximal tube is coagulated and divided.

Figure 7.8 The mesosalpinx is coagulated close to the tube to avoid compromising the ovarian vascular supply.

Figure 7.9 The tube has been removed through the 10 mm umbilical port, taking care not to leave any products of conception behind.

7.3.1 Diagnosis

A triad of ultrasound signs was proposed by Timor-Titsch including an empty uterine cavity, an eccentrically placed gestational sac, and a thin myometrium surrounding the gestational sac that is < 5 mm. Ackerman added a fourth sign of a bright echogenic line extending from the uterine cavity to the cornua running to one side of the gestational sac called the “interstitial line.” Use of all four criteria results in 80% sensitivity and 98% specificity for the diagnosis of ectopic pregnancy [37].

7.3.2 Treatment Considerations

Compared with laparotomy, laparoscopic management of the cornual pregnancy has the advantages of faster recovery and decreased morbidity. However, effective hemostasis is a prime concern and surgeons must possess the requisite laparoscopic suturing skills. As a result, many patients undergo laparotomy with resection of the affected cornua. Others have advocated a hysteroscopic approach with either resection, use of urologic stone retriever forceps, or injection of methotrexate to treat the gestational sac [38,39]. Most surgeons favor a laparoscopic approach and in experienced hands, the outcome is as good as with other tubal pregnancies managed by laparoscopy [40].

Techniques described for hemostasis can be broadly classified into chemical vasoconstrictive agents (dilute vasopressin), securing of the ascending branch of the uterine artery using suture (endoloop, encircling suture around the base of the ectopic, square suture that is carried through and through the anterior and posterior walls of the uterus), automatic stapler, electro-cautery, fibrin glue, and uterine artery ligation [41].

A standard, three-port laparotomy approach is sufficient to manage the condition. A single-port approach has also been reported. If the ascending branch of the uterine artery is to be suture ligated, the double-impact devascularization technique can be used [41]. A 0-Proline or similar suture can be used to take a first bite along the medial border of the cornual ectopic after infiltrating with dilute vasopressin solution (20–30 units of vasopressin in 100 ml of normal saline) traversing from the superior to the inferior margin of the ectopic. The needle should then be reversed and the bite taken in the posterior to the anterior direction underneath the ectopic, through the mesosalpinx. The knot is then tied over the fundus, thus constricting the ectopic as well as the ascending branch of the uterine artery. More than two bites can be employed to achieve a good purse-string effect. An alternative method is to use an endoloop device to encircle the base of the ectopic gestation. This does not quite secure the ascending branch of the uterine artery but does not require any suturing skills [42].

The cornual ectopic may be treated by cornuostomy or wedge resection. Monopolar cautery or harmonic scalpel can be used to create a linear cornuostomy to allow evacuation of the contents with laparoscopic suction irrigator and/or graspers. Once the contents have been evacuated, the defect should be closed in one or two layers using interrupted or running sutures. If bidirectional barbed suture is available, all the above steps requiring suture can be achieved without any knot-tying skills. It has been reported that removal of the contents of the gestational sac alone is sufficient and it is not necessary to remove the sac. This reportedly decreases the risk of excessive bleeding and does not increase the risk of persistent ectopic tissue after the surgery [43,44].

Wedge resection of the cornua is the classic treatment for the condition. This is more likely to result in higher blood loss. After injection of dilute vasopressin, a monopolar needle or harmonic scalpel is used to resect the cornual ectopic before closing the defect using standard or bidirectional barbed suture. Reports of rupture and dehiscence in subsequent pregnancies have been published for patients with wedge resection but the safety of cornuostomy remains to be established [45].

7.5.1 Diagnosis

The classic sign of cervical pregnancy on ultrasound is an hourglass uterus. The uterus appears narrow with an enlarged cervix narrowing at the internal os. The differential diagnosis is a pregnancy in the process of miscarrying. Fetal cardiac activity may be present and Doppler ultrasonography may reveal increased vascularity surrounding a true ectopic pregnancy [48]. Both of these features will be absent with an aborting pregnancy.

7.5.2 Treatment Considerations

Due to its rarity and variable presentation, a standard treatment for cervical pregnancy has not been established. Options include medical treatment with methotrexate, systemically or by ultrasound-guided local instillation [49]. Surgical treatment with curettage may be performed followed by Foley balloon tamponade to limit bleeding from the placental bed [50]. Alternatively, or in addition, uterine artery embolization may be performed prior to curettage [48].

7.6.1 Diagnosis

The cesarean scar pregnancy can be mistaken for a cervical pregnancy, pregnancy implanted in the lower uterine segment, or a miscarriage in progress. On ultrasound examination, these pregnancies will be located within the anterior myometrium with little or no myometrium between the gestational sac and the bladder [48].

7.6.2 Treatment Considerations

Treatment options include local injection of methotrexate, suction evacuation of the gestational sac, hysterotomy, and hysterectomy [52,53].

Suction curettage, with the additional use of a Foley balloon for tamponade in case of profuse bleeding, was shown to be safe and effective in a series of 19 patients, of whom 16 were successfully treated [53].

7.7.1 Diagnosis

Preoperative diagnosis by ultrasonography has reasonable accuracy [56]. However, distal tubal pregnancies, ruptured ovarian pregnancies with absence of yolk sac or fetal pole and normal corpus luteum, make the diagnosis challenging [47].