Video-laparoscopy in the Management of Ectopic Pregnancy

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Ectopic Pregnancy
Why not a prospective study in EP?
Shocked patients will need immediate interference
Tendency towards conservative surgery
The need to develop experience with the laparoscope

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Diagnosis
Medical history
Physical examination
Abdominal examination
Vaginal digital examination
Speculum examination
Transvaginal US
Serum β-hCG

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Diagnosis
Transvaginal US (mandatory)
Serum β-hCG (mandatory)
Abdominal examination (helpful)
Speculum examination (vaginal bleeding)

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Diagnosis
Vaginal digital examination for patients with suspected EP is unnecessary as it could potentially cause tubal rupture
Mol et al., 1999 Amsterdam

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Diagnosis
Inability to detect a sac when levels of β-hCG
are as low as 1.025 IU/L indicates either a miscarriage or an EP
A repeat test will confirm either diagnosis.

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Diagnosis
Suggestive picture by TVS:
Pelvic fluid
Ring like structure in the fallopian tube
Absent intrauterine sac

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Definitions
Persistent EP is defined as a postoperative elevation of hCG or detection of persistent trophoblastic tissue in the ipsilateral tube
Di Marchi et al., 1987

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Definitions
A day-1 postoperative hCG value of >50% is predictive of persistent EP
Spandorfer et al., 1997

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Definitions
Continued growth of trophoblastic tissue resulting in additional surgical or medical treatment
Seifer et al., 1993

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Persistent EP after linear salpingostomy has been reported to be 4% to 20% of cases
Di Marchi et al., 1987; Thorton et al., 1991

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Tubal patency after laparoscopic salpingostomy was sent at 80%
Vernesh et al., 1987; Lundorff et al., 1991

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Medical
Rate of spontaneous resolution of EP is as high as 77%, the efficacy of medical treatment may often be biased toward overestimation
Korhonen et al., 1996

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Medical
Combination of mifepristone (action 48h optimum) and methotrexate (action 3-7days optimum) decreased the risk of failure of medical treatment of EP
Perdu et al., 1998

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Medical
Transvaginal injection of hyperosmolar glucose (3 ml, 33% dextrose) may be an effective conservative treatment for intact ectopic pregnancies
Strohmer et al., 1988

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Medical
Universal agreement that methotrexate can be used when hCG <2000 IU/ml and sac <2 cm

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Medical
Systemic methotrexate therapy consistently had a more negative impact on patient’s health quality of life than did laparoscopic salpingostomy
Nieuwkerek, 1998

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Medical
Methotrexate is given to a selected group of patients, where as surgical treatment is more universal for all patients with EP
Yao & Tulandi, 1997

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Patients with 6 weeks (amenorrhea) pregnancy in the tubes can be successfully treated with MTX single dose. For patients with longer amenorrhea, the therapy remains alternative
Gobellis, 1998

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Methotrexate
Four doses: administered IM (1 mg/kg, days 0, 2, 4 & 6) alternated with four doses of folinic orally (0.1 mg/kg, days 1, 3, 5 & 7)
Nieuwkerk et al., 1998
Single dose: 50 mg/m2 IM may be repeated after one week if β-hCG did not drop by >15% between day 4 & day 7
Yao & Tulandi, 1997

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Surgery
There is no difference in the reproductive outcome after treatment of EP by laparotomy or laparoscopy
Yao & Tulandi, 1997

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Surgery
The incidence of tubal rupture is 32% if the initial serum β-hCG is >10,000 IU/ml
Kao & Kock, 1992

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Surgery
Against conservative tubal surgery in EP is persistent trophoblastic activity, the major argument with it is increasing chance of IUP (compared to salpingectomy)
Yao & Tulandi, 1997

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Frequency of Risk Factors in Choice of Surgery
(Conservative versus Radical)
The only case of heterotropic pregnancy that also had a previous ectopic pregnancy in the contralateral tube and then got pregnant with an outcome of a healthy baby

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Operative Details of 47 Cases of Ectopic Pregnancy
Total number of patients is 47 from which 1 case was extraction by expression.
*Salpingo-oophorectomy

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Postoperative Complications & Recovery

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Operative Laparoscopy in 47 Cases of Ectopic Pregnancy from November 1995 to December 1999
7 cases were defaulters and one case, that was extracted by expression, is now pregnant at 30 weeks

09/05/2023
Prof. Dr. Mounir M. F. El-Hao
Conclusions
Operative Laparoscopy can be used successfully to treat ectopic pregnancy.
Routine use of single preoperative MTX may be useful in controlling bleeding prior to and postoperative.
Fertility after salpingostomy with or without MTX seems to be satisfactory.
Operative laparoscopy has the advantage of short operative time, fast recovery and low cost.