Ectopic pregnancy: Surgical treatment
- Togas Tulandi, MD, MHCM
Togas Tulandi, MD, MHCM
- Professor of Obstetrics and Gynecology
- Milton Leong Chair in Reproductive Medicine
- McGill University, Canada
An ectopic pregnancy is an extrauterine pregnancy. Almost all ectopic pregnancies occur in the fallopian tube (98 percent) , but other possible sites include cervical, interstitial (also referred to as cornual; a pregnancy located in the proximal segment of the fallopian tube that is embedded within the muscular wall of the uterus), hysterotomy scar, intramural, ovarian, or abdominal. In addition, in rare cases, a multiple gestation may be heterotopic (include both a uterine and extrauterine pregnancy).
Historically, ectopic pregnancy was managed surgically, but in current practice, treatment with methotrexate is preferred . Some women undergo surgical therapy by choice or by necessity and others are candidates for expectant management.
The surgical treatment of ectopic pregnancy will be reviewed here. Related topics regarding ectopic pregnancy are discussed in detail separately, including:
●Epidemiology, risk factors, and pathology (see "Ectopic pregnancy: Incidence, risk factors, and pathology")
●Clinical manifestations and diagnosis (see "Ectopic pregnancy: Clinical manifestations and diagnosis")
- Bouyer J, Coste J, Fernandez H, et al. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 2002; 17:3224.
- Capmas P, Bouyer J, Fernandez H. Treatment of ectopic pregnancies in 2014: new answers to some old questions. Fertil Steril 2014; 101:615.
- Hajenius PJ, Mol F, Mol BW, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007; :CD000324.
- Fernandez H, Capmas P, Lucot JP, et al. Fertility after ectopic pregnancy: the DEMETER randomized trial. Hum Reprod 2013; 28:1247.
- Mol F, van Mello NM, Strandell A, et al. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet 2014; 383:1483.
- Cheng X, Tian X, Yan Z, et al. Comparison of the Fertility Outcome of Salpingotomy and Salpingectomy in Women with Tubal Pregnancy: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0152343.
- Savaris RF, Cavazzola LT. Ectopic pregnancy: laparoendoscopic single-site surgery--laparoscopic surgery through a single cutaneous incision. Fertil Steril 2009; 92:1170.e5.
- Lee ES, Hahn HS, Park BJ, et al. Single-port laparoscopic cornual resection for a spontaneous cornual ectopic pregnancy following ipsilateral salpingectomy. Fertil Steril 2011; 96:e106.
- Lazard A, Poizac S, Courbiere B, et al. Cornual resection for interstitial pregnancy by laparoendoscopic single-site surgery. Fertil Steril 2011; 95:2432.e5.
- Bedaiwy MA, Escobar PF, Pinkerton J, Hurd W. Laparoendoscopic single-site salpingectomy in isthmic and ampullary ectopic pregnancy: preliminary report and technique. J Minim Invasive Gynecol 2011; 18:230.
- Kim YW, Park BJ, Kim TE, Ro DY. Single-port laparoscopic salpingectomy for surgical treatment of tubal pregnancy: comparison with multi-port laparoscopic salpingectomy. Int J Med Sci 2013; 10:1073.
- Yoon BS, Park H, Seong SJ, et al. Single-port versus conventional laparoscopic salpingectomy in tubal pregnancy: a comparison of surgical outcomes. Eur J Obstet Gynecol Reprod Biol 2011; 159:190.
- Tulandi T, Guralnick M. Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy. Fertil Steril 1991; 55:53.
- Fujishita A, Masuzaki H, Khan KN, et al. Laparoscopic salpingotomy for tubal pregnancy: comparison of linear salpingotomy with and without suturing. Hum Reprod 2004; 19:1195.
- Farquhar CM. Ectopic pregnancy. Lancet 2005; 366:583.
- Spandorfer SD, Sawin SW, Benjamin I, Barnhart KT. Postoperative day 1 serum human chorionic gonadotropin level as a predictor of persistent ectopic pregnancy after conservative surgical management. Fertil Steril 1997; 68:430.
- Gracia CR, Brown HA, Barnhart KT. Prophylactic methotrexate after linear salpingostomy: a decision analysis. Fertil Steril 2001; 76:1191.
- Ego A, Subtil D, Cosson M, et al. Survival analysis of fertility after ectopic pregnancy. Fertil Steril 2001; 75:560.
- Gervaise A, Masson L, de Tayrac R, et al. Reproductive outcome after methotrexate treatment of tubal pregnancies. Fertil Steril 2004; 82:304.
- Tulandi T. Reproductive performance of women after two tubal ectopic pregnancies. Fertil Steril 1988; 50:164.
- Ory SJ, Nnadi E, Herrmann R, et al. Fertility after ectopic pregnancy. Fertil Steril 1993; 60:231.
- Sultana CJ, Easley K, Collins RL. Outcome of laparoscopic versus traditional surgery for ectopic pregnancies. Fertil Steril 1992; 57:285.
- Silva PD, Schaper AM, Rooney B. Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy. Obstet Gynecol 1993; 81:710.
- Pouly JL, Chapron C, Manhes H, et al. Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients. Fertil Steril 1991; 56:453.
- Bernoux A, Job-Spira N, Germain E, et al. Fertility outcome after ectopic pregnancy and use of an intrauterine device at the time of the index ectopic pregnancy. Hum Reprod 2000; 15:1173.
- Dubuisson JB, Aubriot FX, Foulot H, et al. Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy. Fertil Steril 1990; 53:1004.
- Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999; 72:207.
- Habana A, Dokras A, Giraldo JL, Jones EE. Cornual heterotopic pregnancy: contemporary management options. Am J Obstet Gynecol 2000; 182:1264.
- Moon HS, Choi YJ, Park YH, Kim SG. New simple endoscopic operations for interstitial pregnancies. Am J Obstet Gynecol 2000; 182:114.
- Moawad NS, Mahajan ST, Moniz MH, et al. Current diagnosis and treatment of interstitial pregnancy. Am J Obstet Gynecol 2010; 202:15.
- Tulandi T, Al-Jaroudi D. Interstitial pregnancy: results generated from the Society of Reproductive Surgeons Registry. Obstet Gynecol 2004; 103:47.
- Soriano D, Vicus D, Mashiach R, et al. Laparoscopic treatment of cornual pregnancy: a series of 20 consecutive cases. Fertil Steril 2008; 90:839.
- Meyer WR, Mitchell DE. Hysteroscopic removal of an interstitial ectopic gestation. A case report. J Reprod Med 1989; 34:928.
- Budnick SG, Jacobs SL, Nulsen JC, Metzger DA. Conservative management of interstitial pregnancy. Obstet Gynecol Surv 1993; 48:694.
- Weissman A, Fishman A. Uterine rupture following conservative surgery for interstitial pregnancy. Eur J Obstet Gynecol Reprod Biol 1992; 44:237.
- Downey GP, Tuck SM. Spontaneous uterine rupture during subsequent pregnancy following non-excision of an interstitial ectopic gestation. Br J Obstet Gynaecol 1994; 101:162.
- SURGICAL PLANNING
- Salpingostomy versus salpingectomy
- Laparoscopy versus laparotomy
- PREOPERATIVE EVALUATION AND PREPARATION
- OUTCOME AND FOLLOW-UP
- Surgical complications
- Persistent ectopic pregnancy
- - Treatment
- Future pregnancy
- - Interval to conception
- INTERSTITIAL PREGNANCY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS