Ectopic Pregnancy: A Clinical Study

Ectopic pregnancy is one of the most emergency conditions during the pregnancy period in which the fertilized egg is implanted outside the uterine cavity. The occurrence of ectopic pregnancy accounts for approximately 2% of total pregnancies worldwide, whereas in India the incidence is 3.5 to 7.1% and is a major cause of maternal morbidity and mortality with pregnancy loss. Most ectopic pregnancies are fallopian tube pregnancies and generally, the diagnosis happens after seven weeks of amenorrhoea with or without symptoms. Tubal rupture is a sudden and life-threatening emergency, which needs immediate attention.

Laparoscopy and Laparotomy both have been established in gynaecology for several years. In developed countries, laparoscopy is widely used for the management of ruptured ectopic pregnancy because of the availability of skilled manpower, logistics, improved anaesthesia and cardiovascular monitoring, well-organized surgical care, and good healthcare insurance. For ruptured tubal ectopic pregnancy management, laparoscopic procedures are implemented with the aim to reduce intraoperative blood loss, analgesic requirements, hospital stay, and higher recovery as well as its effectiveness in patients with massive haemoperitoneum. However, laparotomy is still the preferred surgery in low-resource setups.

Study Overview

A clinical retrospective study in an academic tertiary obstetrics and Gynaecology department of Pradyumna Bal Memorial Hospital, Kalinga Institute of Medical Science (KIMS), Bhubaneswar, Odisha was conducted over a period of three years by Mishra et al.

Study Details

A total of 90 confirmed cases of ruptured tubal ectopic pregnancies were divided into 2 groups: laparoscopy (n=68) and laparotomy (n=22). The main outcome measures included demographic features like age, gravida, parity, previous spontaneous loss, previous MTP, Hb at admission, period of gestation, total blood loss, and haemoperitoneum, as well as postoperative parameters such as blood loss, blood requirement, and duration of hospital stay.

• No significant differences were observed in age, gravida, parity, previous history of spontaneous loss, and previous MTP in both laparoscopy and laparotomy procedures.
• Common demographic features were age (30 to 32 years), gravida (2-3), and parity (1).
• Patients with heavy blood loss >1000ml and massive hemoperitoneum also underwent laparoscopic procedures.
• Hospital stay and PRBC blood transfusion were less in patients who underwent laparoscopic surgery.

Findings

The laparoscopic approach for the management of ectopic pregnancy has largely replaced laparotomy. In the present study, ruptured tubal ectopic pregnancy was managed with a laparoscopic approach in 75.5% of cases. All the ruptured tubal ectopic pregnancy cases (90) were taken for emergency operative procedures either laparoscopy or laparotomy.

In the laparoscopic group, haemoperitoneum with estimated blood loss more than 1000ml was observed in 68% of patients and was successfully operated on with a laparoscopic procedure. The laparoscopic procedure is not only safe for early ectopic pregnancy but also appropriate for tubal rupture with haemoperitoneum.

In the present study, the laparoscopic procedure was applied successfully in tubal ectopic pregnancies of different locations. An ampullary pregnancy was managed in a better way through the laparoscopic procedure than other locations. Hospital stay was 4 days in the case of laparoscopic procedures, whereas in the case of laparotomy it was 7 days. A shorter hospital stay can help patients with faster recovery, decreased need for analgesics, and a better quality of life.

Conclusion

Authors concluded, "In our study, laparoscopy is found to be advantageous over laparotomy in terms of shorter hospital stay and speedy recovery. Even, massive haemoperitoneum is not a contraindication for minimal invasive surgery. Generalised availability of logistics and skilled team will make laparoscopic surgery cost-effective. This will have a positive impact on outcomes of ruptured ectopic pregnancies in periphery and low-cost setups."

Author Dr. Sudhanshu Kumar Rath also gave an insight for further research, "I would like to add that we are coming across a number of ruptured ectopics after self-administration of MTP pills. The unregulated over-the-counter availability of strong abortifacients is a menace. We are studying this aspect currently."

Source: Mishra et al. / Indian Journal of Obstetrics and Gynecology Research 2021;8(3):301–304

https://doi.org/10.18231/j.ijogr.2021.064