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Ectopic Pregnancy, Diagnosis and Management

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Topics

Management:

Many randomized controlled trials have shown that laparoscopic management of ectopic pregnancy has advantages over laparotomy. There is quick recovery, less requirement of analgesia, and less adhesions with laparoscopy. But many gynecologists avoid laparoscopic management in clinically unstable ectopic pregnancy. Facilities like laparoscopic equipments and expertise are essential and persistent trophoblastic tissues with slow regression of HCG levels are added disadvantages with laparoscopy.

Laprotomy still remains the main management option in unstable women with ectopic and where the facility and expertise are lacking.

If contralateral tube is unhealthy , salpingostomy is advised with the explanation of risk of future ectopic and subfertility. Salpingostomy can be again through laparoscopy or laparotomy.

Medical management is indicated in women who are clinically stable and available for follow up. Other criteria for medical management with Methotrexate are Pregnancy sac size of < 3 – 3.5 cms , Serum Beta HCG < 3500 IU, and no fetal heart activity. Some gynaecologists have given Methotrexate where BHCG levels are up 5000 IU.

Dilemma continues in pregnancy of unknown location where BHCG values are less than 1000 IU and no intra or extra uterine sac is noticed. If the patient is stable and available for follow up, either the medical management with Methotrexate or only observation can be considered. But, clear explanation and counseling of patient is of paramount important.

Serial BHCG and Transvaginal scans are done till the BHCG values are declined to < 20 IU in medical management and in observation group.

EVIDENCE BASED: LAPAROSCOPIC MANAGEMENT IS PREFERRED METHOD OF MANAGEMENT OF ECTOPIC PREGNANCY IN CLINICALLY STABLE WOMEN WHERE EXPERTISE AND FACILITIES ARE AVAILABLE.

References:

  1. Lewis G, Drife J, editors.Why Mothers Die 1997-1999.The Fifth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press;2001.
  2. Royal College of Obstetricians and Gynaecologists. Searching for evidence. Clinical Governance Advice No 3. London: RCOG Press; 2001.
  3. Parker J, Bisits A. Laparoscopic surgical treatment of ectopic pregnancy: salpingectomy or salpingostomy? Aust N Z J4. Vermesh M,Silva P,Rosen G,Stein AL,Fossum GT,Sauer MV.
  4. Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy. Obstet Gynecol 1989;73:400-4.
  5. Lundorff P, Thorburn J, Hahlin M, Kallfelt B, Lindblom B. Laparoscopic surgery in ectopic pregnancy: a randomized trial versus laparoscopy. Acta Obstet Gynecol Scand1991;70:343-8. Obstet Gynaecol 1997;37:115-7
  6. Gray D,Thorburn J, Lundorff P, Strandell A, Lindblom B.A cost-effectiveness study of a randomised trial of laparoscopy versus laparotomy for ectopic pregnancy. Lancet 1995;345:1139-43.


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