Conservative management may not be possible owing to lack of methotrexate, lack of familiarity with medications by health-care staff, inability to immediately assess blood count, kidney and liver functions via laboratory studies, and patient’s remoteness from the hospital.

Patients often have limited or no transport, limited ability to communicate with the hospital, and there are often no emergency systems (i.e., 911) in place. Therefore, medical management can only be considered in select patients.

With advances in the ability to make the diagnosis earlier and improvements in microsurgical techniques in high-resource settings, conservative surgery has replaced the once-standard laparotomy with salpingectomy.

In low-resource settings, ectopic pregnancies are often diagnosed late as most patients delay initiation of antenatal care to 16 weeks’ gestation or later. The reasons for this are multifactorial and include cultural beliefs, access, and health systems limitations.

Owing to this, laparotomy with salpingectomy is still widely practiced as the standard of care. Many women present hemodynamically unstable with large, ruptured ectopic pregnancies.

Interstitial cornual ectopic and abdominal pregnancies are probably more common in this setting (5).

Salpingostomy is often contraindicated because of lack of beta-human chorionic gonadotropin testing, poor follow-up, lack of reliable transport and emergency services, and so on.

Laparotomy and salpingectomy are also preferred for surgeons inexperienced in laparoscopy and for women in whom a laparoscopic approach is difficult (e.g., secondary to the presence of multiple prior surgeries with a risk of dense adhesions, obesity, or in the unstable patient with massive hemoperitoneum).

If disseminated intravascular coagulation is not suspected, all surgical patients should receive tranexamic acid preoperatively to possibly limit blood loss (6,7).

Surgical steps

Elective abortion may not be available in many areas owing to local or national statutes.

For spontaneous abortions, conservative management with expectant management can be considered, as can the use of misoprostol. Dilation and curettage or MVA can also be used for spontaneous abortions, particularly when there is heavy bleeding, when patients live remote from the health-care facility, or per patient preference when appropriately counseled.

MVA may be more readily available, can usually be performed outside of an operating room, and can have a higher likelihood of success compared to misoprostol (8).

Cerclage use is potentially controversial in all settings, but particularly so in low-resource settings. It is often difficult or impossible to get an accurate history to ensure cervical incompetence because of incomplete record keeping and patient knowledge about past medical encounters. This should be taken into account before performing cervical cerclage in low-resource settings.

If there is any suspicion of preterm labor/infection as a cause for cervical dilation, a cerclage should not be performed as the risk to the woman will be magnified considerably.

The McDonald cerclage technique is associated with less operative time, expertise, blood loss, and less anesthesia compared to the Shirodkar technique.

Steps of a cerclage are not affected by resource limitations. Suture choice, however, may be limited. Prolene (polypropylene), Mersilene suture or Mersilene tape (polyethylene terephthalate), or Ethibond (polyethylene terephthalate) are typically described as the sutures for cerclage (9). These sutures are chosen for the availability of a larger caliber and for their nonabsorbable nature. The use of silk and nylon has been described in the literature and can be considered for use for cerclage (10).