Surgical Management Of Tubal Pregnancy Research Articles

Use of FloSeal Sealant in the Surgical Management of Tubal Ectopic Pregnancy

Background. Surgery is sometimes required for the management of tubal ectopic pregnancies. Historically, surgeons used electrosurgery to obtain hemostasis. Topical hemostatic sealants, such as FloSeal, may decrease the reliance on electrosurgery and reduce thermal injury to the tissue. Case. A 33-year-old G1 P0 received methotrexate for a right tubal pregnancy. The patient became symptomatic six days later and underwent a laparoscopic right salpingotomy. After multiple unsuccessful attempts to obtain hemostasis with electrocoagulation, FloSeal was used and hemostasis was obtained. Six weeks later, a hysterosalpingogram (HSG) confirmed tubal patency. The patient subsequently had an intrauterine pregnancy. Conclusion. FloSeal helped to achieve hemostasis during a laparoscopic salpingotomy and preserve tubal patency. FloSeal is an effective alternative and adjunct to electrosurgery in the surgical management of tubal pregnancy.

Recurrent Ectopic Pregnancy After Ipsilateral Salpingectomy: Report of a Rare Case

Abstract Background: Ectopic pregnancy occurs in 1.3%–2% of all pregnancies, and women with a history of prior ectopic pregnancy have an approximately eightfold increased risk of further episodes. The most common site for implantation of an ectopic pregnancy is the fallopian tube, with an incidence of up to 95%. Current surgical management of tubal pregnancy includes conservative (usually salpingostomy) and radical (total or partial salpingectomy) methods. However, in some cases, these methods may not solve the problem. Case: A 23-year-old woman underwent a right salpingectomy because she had a right tubal pregnancy. She returned 2 years later with a positive pregnancy test and lower abdominal pain. Transvaginal sonography and serum s-hCG testing suggested that she had another tubal pregnancy. Because she had hemodynamic instability, she was prepared for a laparotomy. This procedure revealed that she had a right adnexal mass just adjacent to her ovary on that side of her body, and a remnant fallopian tube...

Current status of endoscopic surgical management of tubal pregnancy

A worldwide increase in the incidence of ectopic pregnancy has been reported in the last two decades. Recently developed diagnostic tools markedly improved the early diagnosis capability. These include: 1, rapid and sensitive beta hCG and progesterone assays; 2, improved ultrasonogaphic visualization of the pelvic organs; 3, the wide application of diagnostic laparoscopy. Today, most cases are diagnosed before a rupture occurs. Accordingly, treatment has shifted from an immediate, life-saving intervention to conservative methods of management, directed at preserving fertility and reducing morbidity. Endoscopic surgical tecniques have also rapidly improved in the last decade, thus, this treatment option apparently became the treatment of choice in most centers. Laparoscopic conservative treatment of tubal pregnancy is as effective and safe as treatment with laparotomy and has the advantage of decrease in hospital stay, cost, and delay in return to normal activity. This review will focus on the endoscopic surgical procedures and their place in view of the other surgical and non-surgical options.

Persistent Tubal Pregnancy

Persistent tubal pregnancy may be manifest by either acute symptoms or a persistent or rising beta-hCG titer following conservative surgery. This condition is a relatively new complication, related to the recent practice of conservative surgical management of tubal pregnancy. Much has been written on the identification and possible therapy for this condition but little is known about its pathophysiology. Eight cases of persistence were studied, as well as three cases of failed conservative procedures. In nine instances, the surgeon had concentrated appropriately on the maximally dilated portion of the tube, which contained the blood clot and aborted products of conception. Unfortunately, the implantation site was located medially, toward the uterus. Ways of avoiding this complication include medial exploration or possibly the use of mesosalpingeal injection of vasopressin. An understanding of the natural history of the pathologic process might also be valuable in the management of cases of "persistence" identified solely by a continuing beta-hCG titer.

Ectopic Pregnancy

The diagnosis of ectopic pregnancy has become precise and reliable. Consequently, the management of ectopic pregnancy has progressed to the point where the physician is often able to preserve fertility. Therefore, conservative surgery is indicated if the patient desires future fertility and conditions are appropriate. The combination of ultrasound, beta-hCG pregnancy testing, and laparoscopy has led to a rising incidence of diagnosed ectopic pregnancy prior to rupture. This has greatly facilitated the use of the conservative approach to the management of tubal pregnancy. Although ectopic pregnancy can be diagnosed early and managed conservatively, it is, and will remain a potentially life-threatening disease and must be approached as such. Table 3 summarizes our proposed surgical management of tubal pregnancy. Table 4 summarizes the results of conservative surgery for tubal pregnancy.

レーザー内視鏡法による子宮外妊娠の手術

レーザー内視鏡法による子宮外妊娠の手術

Surgical Management of Tubal Pregnancy

Surgical Management of Tubal Pregnancy

New concepts in the surgical management of tubal pregnancy and the consequent postoperative results

The success following reconstructive tubal pregnancy can only be measured in terms of live births. Because the fallopian tube is not a simple conduit and has numerous complex functions, many women fail to conceive despite successful reconstructive surgery. The most effective way to prevent reocclusion or peritubal adhesion is to minimize tissue trauma. Magnification permits accurate excision and hemostasis. In this review, it has been demonstrated that tubal conservation is technically possible and safe. It is effective in increasing the number of live births postoperatively in women interested in fertility and does not increase the risk of the repaired tube for a repeat tubal gestation more than the uninvolved tube, although one of five subsequent pregnancies are again ectopic. They seem to occur equally as often in the contralateral tube as in the repaired tube. It has been shown that salpingotomy can restore tubal patency and maintain fertility. The second question was whether the number of viable pregnancies increase after conservative surgery. This question can be answered only if the repaired tube remains and the patient subsequently delivers at term. Such data have already demonstrated this outcome. Conservative operations in selected cases of tubal pregnancy seem feasible and safe and do not further impair tubal function. Because intrauterine pregnancy is more apt to occur than is repeat ectopic pregnancy, it seems logical that the involved tube should be saved whenever fertility is desired (Fig. 2). In unruptured isthmic pregnancy, Stangel and Gomel prefer segmental excision and end-to-end anastomosis during the same intervention. Gomel advocates segmental excision of the conceptus whether ruptured or not when the pregnancy is located in the isthmus or proximal half of the ampulla, and end-to-end anastomosis undertaken later as an elective procedure if necessary (Fig. 2). An ampullary gestation may be successfully treated by salpingotomy; and in the case of distal ampullary location, a tubal abortion may be performed (Fig. 2). When extensive destruction of the tube occurs, salpingectomy becomes necessary. In cases of early diagnosis of tubal gestation, conservative surgical management may be carried out via laparoscopy (Fig. 1).

Human chorionic gonadotropin regression following conservative surgical management of tubal pregnancy

Human chorionic gonadotropin regression following conservative surgical management of tubal pregnancy

Tubal Pregnancy Subsequent to Transperitoneal Migration of Spermatozoa

All available English, French, and German literature published prior to January 1978 in which post-sterilization tubal pregnancy was reported was surveyed. From 1957 on, the Index Medicus or Current List of Medical Literature was surveyed for reported sterilization failures. Additional references cited in the literature on tubal pregnancy not associated with prior sterilization were evaluated. A total of 127 pregnancies was collected. Among the 91 specifically mentioned as being tubal, the incidence of pregnancy distal to the site of sterilization was 5 times that in the segment proximal to the site of sterilization. Among the 41 distally located pregnancies, a morphologic description of the site of sterilization was not reported in 30 cases. In these, recanalization of the pregnant tube could have occurred and, therefore, transperitoneal migration of the fertilizing spermatozoon could neither be established nor excluded. In 15 of the 30 cases, recanalization of the pregnant tube was the only etiology considered, and a stenotic area of the site of sterilization, sufficiently wide to permit the passage of sperm but not the passage of ova, was postulated; in 7 cases, the possibility of a fistula as well as recanalization was suggested and in the remaining 8, the etiology was not considered at all. Among the remaining 11 distally located pregnancies, in only one was the site of sterilization evaluated with both patency-testing and microscopic study. In this case, luminal continuity of the pregnant tube was demonstrated, which could have allowed normal sperm transport on that side. A total of 1528 reported tubal pregnancies were selected from the literature for analysis. The presence of complete luminal obliteration proximal to the site of implantation was definitely stated in only 3 cases, while the lumen was found almost completely occluded in 18. In addition to the 3 cases of isthmic obliteration, a pregnancy within a rudimental ampulla and 1 in an ectopically located tube establish that ectopic pregnancy can in fact occur within a tubal segment which does not communicate with the uterus in the absence of previous sterilization. Practical implications in regard to the practice of sterilization, conservative surgical management of tubal pregnancy, and tubal surgery for sterilization reversal are considered, including the advantages of the use of the Irving or Uchida method over the Pomeroy method.