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| Laparoscopic Ectopic Pregnancy
Evacuation |
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 What
is Ectopic pregnancy? |
| What
are the causes? |
| What
are the symptoms? |
| How
is it diagnosed? |
| What
are the treatment options? |
| What
is the prognosis? |
| Benefits
and drawbacks |
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| What
is Ectopic pregnancy? |
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| Once the egg gets fertilized, it travels
down the fallopian tube to uterus. But when the tubes
are damaged or blocked and fail to propel the egg toward
the womb, the egg may become implanted in the tube and
continue to develop there. Because almost all Ectopic
pregnancies occur in one of the fallopian tubes, they
are often called "tubal" pregnancies. Much less
often, an egg implants in an ovary, in the cervix, directly
in the abdomen, or even in a c-section scar. In rare cases,
a woman has a normal pregnancy in her uterus and an Ectopic
pregnancy at the same time. This is called a heterotopic
pregnancy and it's more likely to happen if one has had
fertility treatments, such as in-vitro fertilization.
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| There's no way to transplant an Ectopic
(literally, "out of place") pregnancy into the
uterus, so ending the pregnancy is the only option. In
fact, if an Ectopic pregnancy is not recognized and treated,
the embryo will grow until the fallopian tube ruptures,
resulting in severe abdominal pain and bleeding. It can
cause permanent damage to the tube or loss of the tube,
and if it involves very heavy internal bleeding that's
not treated promptly, it can even lead to death. Fortunately,
the vast majority of Ectopic pregnancies are caught in
time. |
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| What
are the causes? |
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| Many factors are known to increase
the risk of having an Ectopic pregnancy. Anything that
alters the tubal function may affect further pregnancies.
Fallopian tubes are not like a hollow pipe that sits there
with the egg rolling down. They have little hairs on the
inside (cilia) which move with a wave-like motion to encourage
the egg toward the womb. If the tube becomes blocked or
the cilia damaged then ectopic is more likely. Besides
this, there are some risk factors, like: |
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- Advancing age
- Pelvic inflammatory disease - eg. previous Chlamydia
or gonorrhoea. Infection causes scar tissue adhesions
in the tube and may damage the cilia. PID is one of
the main causes of the increase seen in Ectopic pregnancies
in recent years. Risk of an Ectopic pregnancy increases
about 7-fold after a woman suffers acute pelvic infection.
- Tubal surgery - women who have had operations on
their tubes are more at risk of Ectopic. This includes
tubal ligation, reversal of sterilisation or tubal
surgery for a previous Ectopic.
- Previous Ectopic - about 10-20% of those attempting
pregnancy after one Ectopic will have another.
- DES exposure - this is a drug that was once used
during pregnancy, until it was found that female babies
of women who used it were at risk of developmental
abnormalities of the genital system. Their tubes are
more likely to be abnormal and predisposed to Ectopic
pregnancy. This is a very rare problem.
- Previous termination of pregnancy - the risk of
ectopic increases among those who have had two or
more terminations, particularly if there was infection
afterwards.
- IVF (test-tube baby) and ovulation induction - both
these techniques of assisted reproduction are associated
with increased chances of Ectopic pregnancy.
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| What
are the symptoms? |
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| Ectopic pregnancy can be difficult
to diagnose because symptoms often mirror those of a normal
early pregnancy. These can include missed periods, breast
tenderness, nausea, vomiting, or frequent urination. Ectopic
pregnancy can exhibit any of the following symptoms: |
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- Abdominal or pelvic pain or tenderness. It can
be sudden, persistent, and severe but may also be
mild and intermittent early on. You may feel it only
on one side, but the pain can be anywhere in the abdomen
or pelvis and is sometimes accompanied by nausea and
vomiting.
- Vaginal spotting or bleeding. If you're not sure
you're pregnant yet, you may think you're getting
a light period at first. The blood may look red or
brown like the colour of dried blood, and may be continuous
or intermittent, heavy or light.
- Pain that gets worse when you're active or while
moving your bowels or coughing.
It's a medical emergency when:
- There is severe shoulder pain. Cramping and bleeding
can mean many things, but pain in the shoulder, particularly
when one is lying down, is a red flag for a ruptured
Ectopic pregnancy. The cause of the pain is internal
bleeding, which irritates nerves that go to the shoulder
area.
- There are signs of shock, such as a weak, racing
pulse; pale, clammy skin; and dizziness or fainting.
This generally indicates that a fallopian tube has
ruptured.
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| How
is it diagnosed? |
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| Ectopic pregnancy can be tricky to
diagnose. If your symptoms suggest this type of pregnancy,
your caregiver will do several tests to try to confirm
the diagnosis: |
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| A blood test- to check level
of the pregnancy hormone human chorionic gonadotropin
(hCG). If it's high enough to suggest pregnancy, but not
as high as it should be at your stage, the pregnancy may
be ectopic. If you're not in pain and there's still some
question about the diagnosis, the test may be repeated
in two to three days. If your hCG level doesn't increase
as it's supposed to, this probably indicates either an
Ectopic pregnancy or a miscarriage. |
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| A vaginal exam- If the vaginal
area is very tender or your caregiver detects a mass or
an enlarged fallopian tube, an Ectopic is likely the cause.
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| An ultrasound- If the sonographer
can see an embryo in the fallopian tube, you definitely
have an Ectopic pregnancy. But in most cases, the embryo
will have died early in the process and be too small for
the sonographer to find. Instead, she may notice that
a fallopian tube is swollen, and may see blood clots as
well as tissue that remain from the embryo. |
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| If the diagnosis remains unclear,
your tubes may be examined more closely by using laparoscopic
surgery, a procedure that may also be used to treat an
Ectopic pregnancy and remove the embryo (see below). |
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| What
are the treatment options? |
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| Once an Ectopic is diagnosed, there
are several different treatments. It is not possible to
take the pregnancy from the tube and put it into the womb.
The options are as follows: |
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| Expectant management |
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| A proportion of all Ectopic will not
progress to tubal rupture, but will regress spontaneously
and be slowly absorbed. This may be appropriate if the
level of hCG is falling and a woman is clinically well.
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| Medical treatment |
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| This is done with a drug, which is
given by injection. The drug is injected into a muscle
and reaches the embryo through your bloodstream, where
it ends the pregnancy by stopping the cells of the placenta
from growing. Only a few Ectopic can be treated this way,
which is the least invasive. Certain criteria must be
fulfilled, such as small diameter of the Ectopic and low
level of hCG. Close follow-up with further scans and blood
tests is also necessary. |
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| Open surgery or Laparotomy |
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| This involves a 5cm incision at the
top of the pubic hairline. The affected tube is brought
out and either salpingotomy or salpingectomy performed.
This is a major surgery and since the incisions are bigger
compared to laparoscopic ones, it takes more time to heal.
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| Laparoscopic surgery |
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| This is also called 'keyhole' surgery.
Previously, salpingectomy by Laparotomy was the gold standard
for the treatment of Ectopic pregnancy. The laparoscope
has virtually eliminated the need for Laparotomy. Currently,
Laparotomy is the preferred technique when the patient
is hemodynamically unstable. Ofcourse it also depends
on how clear the diagnosis is, how big the embryo is. |
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| The surgeon will examine your tubes
with a tiny camera inserted through a small cut in your
navel and can often remove the embryo or remaining tissue
while preserving your tube. (However, if there's extensive
damage to the tube or you're bleeding profusely, the tube
may need to be removed.) Laparoscopic surgery requires
general anaesthesia, special equipment, and a surgeon
experienced in the technique, and you'll need about a
week to recuperate. |
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| It may be possible to either open
the tube and remove the pregnancy (salpingotomy), or remove
the tube altogether (salpingectomy). The decision on which
of these options is taken is very specific to each patient.
In some cases - for example, if you have extensive scar
tissue in the abdomen or heavy bleeding, or the embryo
is too large - it may not be possible or expedient to
use laparoscopic technology. If this is the case, you'll
need major abdominal surgery.
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By using a suction irrigator, the
products of conception are flushed out
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| What
is the prognosis? |
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| The earlier you end an Ectopic pregnancy,
the less damage you'll have in that tube and the greater
your chances will be of carrying another baby to term.
And even if you do lose one of your tubes, you can still
have a normal pregnancy as long as your other tube is
normal. If and when you do conceive again, call your health
practitioner as soon as you suspect that you might be
pregnant so that she can schedule you for an early sonogram
and monitor you closely. Overall, your chances of having
another Ectopic pregnancy are about 10 to 15 percent,
depending on what caused the first one and what type of
treatment you had. That means that your overall chances
of having a normal pregnancy next time are still very
high - about 85 to 90 percent. |
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| If, on the other hand, you're unable
to conceive because of Ectopic pregnancies or damaged
tubes, the good news is that you're likely to be an excellent
candidate for fertility treatments such as in
vitro fertilization (IVF), in which your healthy
embryos are implanted directly in your uterus. |
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| Benefits
and drawbacks |
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| So Laparoscopic hysterectomy has many
advantages like: |
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- Less postoperative pain
- May shorten hospital stay
- May result in a quicker return to bowel function
- Quicker return to normal activity
- Better cosmetic results
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| So, if we were to compare an open
surgery with a laparoscopic surgery, we can display it
in a nutshell as under: |
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LAPAROSCOPIC
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OPEN
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Small Incisions (less than ½ an inch)
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Large Incision
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Hospital stay is 1 to 3 days
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Hospital stay of about 5 days
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Patients usually return to work in 5 to 10 days
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Return to work in about 4 weeks
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Lesser risk of Infection
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Greater risk of infection
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Less pain
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More painful
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Less chance of hernias
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More chance of hernias
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