Presented by:
Caroline Desbiens
Affiliations:
Université laval
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What Is Improving Outcomes in Non-Tubal Ectopic Pregnancy?
Surgical management of a non-tubal ectopic pregnancy can be particularly challenging when the pregnancy is implanted near major pelvic blood vessels, the cervix, ureters, or other vital structures. In high-risk cases, adjunctive techniques such as Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and ureteral indocyanine green (ICG) can be used to improve vascular control and identification of the urinary tract during surgery. Here’s what it involves:
- Preoperative Assessment: Imaging is used to determine the location of the ectopic pregnancy, its relationship to surrounding organs and blood vessels, and the presence of internal bleeding.
- Multidisciplinary Planning: Gynecology, interventional radiology, anesthesia, and nursing teams may coordinate care when there is a significant risk of hemorrhage or injury to surrounding structures.
- REBOA Placement: A balloon catheter is positioned within the aorta, typically through arterial access, so it can be temporarily inflated if needed to reduce blood flow to the pelvis and help control severe bleeding.
- Ureteral ICG Instillation: Indocyanine green is introduced into the urinary tract to allow enhanced visualization of the ureters during laparoscopic surgery.
- Laparoscopic Assessment: The pelvis and abdomen are inspected to identify the ectopic pregnancy, hemoperitoneum, and its relationship to surrounding structures.
- Ectopic Pregnancy Removal: The pregnancy tissue is carefully dissected and removed while protecting the ureters, bowel, bladder, cervix, and major blood vessels.
- Hemorrhage Control: REBOA can provide temporary vascular control while bleeding vessels are identified and definitively managed.
- Final Assessment: The operative field is inspected for residual bleeding, ureteral integrity, and injury to surrounding structures before completing the procedure.
Combining enhanced ureteral visualization with temporary vascular control can provide surgeons with additional safeguards when treating complex non-tubal ectopic pregnancies at particularly high risk for hemorrhage and urinary tract injury.
What are the risks of Improving Outcomes in Non-Tubal Ectopic Pregnancy?
Non-tubal ectopic pregnancies can carry substantial surgical risk because implantation may occur close to highly vascular tissues and critical pelvic or abdominal structures. REBOA and ureteral ICG also introduce their own procedure-specific risks.
- Severe Hemorrhage: Separation of ectopic pregnancy tissue from its implantation site can cause rapid and potentially life-threatening bleeding.
- Ureteral Injury: Distorted anatomy or implantation near the ureters can increase the risk of ureteral damage despite enhanced visualization.
- Bowel or Bladder Injury: Abdominal or deep pelvic ectopic pregnancies may adhere to surrounding organs, creating a risk of injury during dissection.
- Vascular Injury: Both the ectopic pregnancy and placement of the REBOA catheter involve major blood vessels, creating risks of bleeding, vessel injury, thrombosis, or other vascular complications.
- Ischemic Injury: Prolonged REBOA inflation reduces blood flow below the balloon and can potentially cause ischemic injury, making careful monitoring and limited occlusion time important.
- ICG-Related Complications: Adverse reactions to indocyanine green are uncommon but can occur, and ureteral catheterization itself may cause trauma, bleeding, or urinary tract infection.
- Incomplete Removal: Residual pregnancy tissue may result in persistent symptoms, bleeding, or the need for additional treatment.
- General Surgical Risks: Infection, blood clots, anesthesia-related complications, and conversion to open surgery may occur during complex ectopic pregnancy surgery.
Careful multidisciplinary planning, precise localization of the pregnancy, controlled use of REBOA, and real-time identification of the ureters can help reduce risk when managing complex non-tubal ectopic pregnancies.