eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery

Surgical Management of Ectopic Pregnancy

Author: Allahyar Jazayeri, MD, PhD, Medical Director of Perinatal Services, Bellin Health Hospital Center
Coauthor(s): Herbert S Coussons, MD, FACOG, Private Practice in Obstetrics and Gynecology, Women's Specialty Care
Contributor Information and Disclosures

Updated: Jan 7, 2008

Introduction

Ectopic pregnancy is defined as implantation of a fertilized egg outside the endometrial cavity. Ectopic pregnancy is estimated to occur in 2% of all pregnancies. It remains a major cause of maternal morbidity and mortality when misdiagnosed or left untreated and accounts for as much as 9% of maternal death in this country. Quantitative measurements of the beta subunit of human chorionic gonadotropin (β -hCG) and transvaginal ultrasonography have improved the accuracy of diagnosis and allow earlier detection of ectopic pregnancies. Although deaths associated with ectopic pregnancy have declined, more than three quarters of deaths in the first trimester and about 10% of all pregnancy-related deaths are associated with pregnancies outside of the womb.

History of the Procedure

Ectopic pregnancy was described by Charles Dickens in Nicholas Nickelby, in which he refers to "a disease in which death and life are so strangely blended." This is an accurate description since implanting outside the endometrial cavity results in the loss of pregnancy and the mother is also exposed to significant morbidity and potential mortality. 

In the past 30 years the ability to diagnose and treat ectopic pregnancies has significantly improved, thereby reducing the maternal risks.

Robert Lawson Tait, a British surgeon, is credited with performing the first successful laparotomy for ruptured tubal pregnancy in 1883. In 1881, Tait was consulted in the case of a patient who had been diagnosed with intraperitoneal hemorrhage secondary to a ruptured tubal pregnancy. The patient's physician suggested that Tait open the abdomen and remove the ruptured tube. Tait rejected the idea. After the woman died, Tait injected the specimen and determined that if he had operated and tied the broad ligament, he would have arrested the hemorrhage and probably would have saved the woman's life. In April of 1883, he operated on another woman and ligated the ruptured tube and broad ligament. This was the first successful surgical management of ruptured tubal pregnancy. At a time when ectopic pregnancy was associated with a greater than 60% mortality rate, Tait lost only 2 patients of the first 42 on which he operated.

By the 1920s, laparotomy and ligation of the bleeding vessels with removal of the affected tube was the standard of care and remained so until operative laparoscopy and salpingostomy replaced laparotomy and salpingectomy in the late 1970s.

In the 1980s and 1990s, medical therapy of ectopic pregnancy has been implemented and has replaced surgical treatment in many cases. Thus, in less than 3 decades, treatment has evolved from a surgical emergency to conservative medical management.

Problem

An ectopic pregnancy occurs outside of the uterus. Approximately 97.7% of all ectopic pregnancies occur in the fallopian tubes, with the rest occurring in the ovary, abdomen, or cervix.

Of tubal pregnancies, the ampulla is the most common site of implantation (80%), followed by the isthmus (11%), fimbria (4%), cornua (2%), and interstitia (3%).

Frequency

The incidence of ectopic pregnancy is reported most commonly as the number of ectopic pregnancies per 1000 conceptions. The incidence varies among populations. Over the last 40 years, the incidence has been increasing steadily.

In 1970, the reported rate in the United States was 4.5 cases per 1000 pregnancies. By 1987, this was reported as 16.8 cases per 1000 pregnancies. These statistics are based on US Centers for Disease Control and Prevention data that use hospitalizations for ectopic pregnancy to determine the total number of ectopic pregnancies. Looking at raw data, 17,800 hospitalizations for ectopic pregnancies were reported in 1970. This number rose to 88,000 in 1989 but fell to 30,000 in 1998. This raises the question of whether the number of ectopic pregnancies is declining or whether many ectopic pregnancies are now treated in ambulatory surgical centers and even using medical therapy without admission. The author and many others believe the latter is true, but truly accurate statistics are lacking. The prevalence is estimated at 1 in 40 pregnancies or approximately 25 cases per 1000 pregnancies.

Approximately 85-90% of ectopic pregnancies occur in multigravid women. In the United States, rates are nearly twice as high for women of other races compared with white women.

Etiology

Risk factors for ectopic pregnancy include tubal damage, smoking, and altered motility in the fallopian tube.

• Tubal damage can be the result of infections such as pelvic inflammatory disease or salpingitis or can also result from abdominal surgery or tubal ligation.
• Smoking is a risk factor in about one third of ectopic pregnancies and may contribute to decreased tubal motility by damage to the ciliated cells in the fallopian tubes.
• Altered tubal motility can also occur as the result of hormonal contraception. Both progesterone only contraception and progesterone intrauterine devices (IUDs) have been associated with increased risk of an ectopic pregnancy. 

One third of ectopic pregnancies occur in women with no known risk factors.

Pathophysiology

Delay or prevention of passage of the fertilized ovum (blastocyst) to the uterine cavity by the factors mentioned or by factors inherent in the embryo result in premature implantation.

Presentation

The typical triad includes bleeding and abdominal pain and a positive pregnancy test result. The clinical presentation can therefore be confusing, since symptoms overlap with miscarriage. A third of women have no clinical signs and 9% have no symptoms of ectopic pregnancy. As a result, almost half of cases are not diagnosed at the first prenatal visit.

The signs of ectopic pregnancy on examination include lower abdominal tenderness with or without rebound and pelvic tenderness usually much worse on the affected side. Abdominal rigidity, involuntary guarding, and severe tenderness as well as evidence of hypovolemic shock, such as orthostatic blood pressure changes and tachycardia, should alert the clinician to a surgical emergency; this may occur in up to 20% of cases.

On pelvic examination, the uterus may be slightly enlarged and soft, and uterine or cervical motion tenderness may suggest peritoneal inflammation. An adnexal mass may be palpated but is usually difficult to differentiate from the ipsilateral ovary.

Indications

Indications for surgery in ectopic pregnancy include women with the following criteria:

• Not suitable candidate for medical therapy
• Failed medical therapy
• Heterotopic pregnancy with a viable intrauterine pregnancy
• Hemodynamically unstable and need immediate treatment

Relevant Anatomy

The illustration below shows the anatomy of an ectopic pregnancy and the frequency distribution for this phenomenon.

Contraindications

The only contraindication to surgical management is a patient with a medically treatable ectopic pregnancy and other medical conditions that would make the risk of surgery unacceptable.

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