Surgical treatments are indicated whenever diagnosis requires laparoscopy or if the mass is larger than 4 cm.
They include:
- laparoscopy - is the preferred method in a haemodynamically stable patients (1), can be either
- salpingostomy
- should be considered as the primary treatment method in patients with contralateral tubal disease and with desire for future fertility (1)
- with products of conception removed with forceps or by suction; or
- salpingectomy - if the mother does not wish a subsequent pregnancy
- laparotomy -
- if the patient is haemodynamically unstable and/or there are no staff trained in operative laparoscopy
NICE state with respect to choice between salpingectomy and salpingotomy (2)
- offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility
- women having a salpingotomy that up to 1 in 5 women may need further treatment. This treatment may include methotrexate and/or a salpingectomy
- for women who have had a salpingotomy, take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained
- advise women who have had a salpingectomy that they should take a urine pregnancy test after 3 weeks. Advise women to return for further assessment if the test is positive
Observational studies have identified that rates of subsequent intrauterine pregnancy (73% vs. 57%) and ectopic pregnancy (15% vs. 10%) was higher in salpingotomy when compared to salpingectomy
Complications occur in 5-20% of laparoscopic procedures and include postoperative bleeding, elevated beta hCG levels indicative of a persistent viable pregnancy, and other persistent symptoms.
Postoperative serial hCG monitoring should be done in women who undergo salpingotomy due to the persistence of trophoblastic cells in the fallopian tube (3).
- persistence of trophoblasts were seen in around 8% of women after laparoscopic salpingotomy and in about 4% of women after open salpingotomy
- risk of developing persistent trophoblasts is increased in women
- who have a higher serum hCG levels (>3000 iu/l) preoperatively
- with rapid preoperative rise in serum hCG
- active tubal bleeding (1)
- a single dose of intramuscular Methotrexate (at a dose of 50 mg/m2) has been used for treatment of persistent trophoblasts instead of repeated surgery (3)
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