“Lost and Found” Navigating Abdominal Ectopic Pregnancy a Stepwise Approach

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is “Lost and Found” Navigating Abdominal Ectopic Pregnancy a Stepwise Approach?
• What are the Risks of “Lost and Found” Navigating Abdominal Ectopic Pregnancy a Stepwise Approach?
• Video Transcript

Video Description

In this video, we aim to review the incidence and pathophysiology of abdominal ectopic pregnancies, as well as diagnosis and treatment options. We developed a 6-step surgical approach to laparoscopic identification of abdominal ectopic pregnancy.

Presented By

Affiliations

Scarborough General Hospital

Mount Sinai & Women’s College Hospital

University of Toronto

Watch on YouTube

Click here to watch this video on YouTube.

What is “Lost and Found” Navigating Abdominal Ectopic Pregnancy a Stepwise Approach?

Lost and Found: Navigating Abdominal Ectopic Pregnancy, a Stepwise Approach describes a methodical surgical process for managing abdominal ectopic pregnancies, a rare and high-risk form of ectopic pregnancy. The approach emphasizes careful preoperative planning, imaging, and a meticulous, step-by-step surgical technique to safely remove the ectopic pregnancy and minimize complications.

• Definition: Abdominal ectopic pregnancy is an atypical pregnancy occurring outside the uterus, often attaching to abdominal organs or vasculature, making management complex and risky.

• Imaging & Diagnosis: Detailed imaging (ultrasound, CT, or MRI) is crucial to locate the pregnancy and identify its attachment sites, enabling the surgical team to prepare an optimal approach.

• Stepwise Surgical Approach: The approach involves carefully dissecting and separating the pregnancy from surrounding tissues while managing risks of severe bleeding and preserving surrounding organ integrity.

• Multidisciplinary Collaboration: Complex cases may require coordination with specialists, such as vascular or general surgeons, to ensure a safe and successful outcome.

In conclusion, this approach underscores the importance of preoperative preparation, a precise surgical method, and collaborative care for effectively managing abdominal ectopic pregnancies and minimizing risks to the patient.

What are the Risks of “Lost and Found” Navigating Abdominal Ectopic Pregnancy a Stepwise Approach? 

Video Transcript: “Lost and Found” Navigating Abdominal Ectopic Pregnancy a Stepwise Approach

Lost and found. Navigating abdominal ectopic pregnancy, a stepwise approach. In this video, we aim to review the incidence and pathophysiology of abdominal and omental ectopic pregnancies, as well as the diagnostic tools, criteria and treatment options. Here we propose a systematic, surgical approach for identification and management of abdominal ectopic pregnancy.

Abdominal pregnancies occur in the abdominal cavity outside of the reproductive organs. They account for approximately 1% of all ectopic pregnancies. They can occur anywhere in the abdomen, such as the liver, spleen or bowel, with only 9% of these being found in the omentum.

Despite their rarity, they carry a significantly increased maternal mortality rate, up to 20%. This represents a near eightfold increase in comparison to tubal ectopics, and a 90-fold increase in comparison to intrauterine pregnancies. Unlike tubal ectopic pregnancies, there are no specific risk factors associated with abdominal ectopic pregnancies.

Primary abdominal ectopic pregnancies occur when a fertilised ovum implants directly into the peritoneum. This is the rarest form. In order to diagnose a rare primary abdominal ectopic, the following Studdiford’s criteria must be met. Number one, normal appearing tubes and ovaries. Number two, no uteroperitoneal fistula. And number three, the pregnancy is attached solely to the peritoneal surface.

Secondary abdominal ectopic pregnancies, on the other hand, result from secondary abdominal implantation as a result of tubal rupture or tubal abortion. Naturally, this is the most common form.

 Diagnosing abdominal ectopics can be challenging. Ultrasound is the primary modality of choice. However, it only correctly identifies abdominal ectopic pregnancies preoperatively in 50% of cases. MRI and CT scans can be helpful in providing additional information.

Sonographic criteria suggestive of abdominal ectopic include the presence of a foetus and gestational sac outside the uterine cavity, absence of the uterine wall between the bladder and foetus, adherence of the foetus to an abdominal organ and abnormal placental location outside the uterine cavity.

Surgical management remains the treatment method of choice for abdominal ectopic pregnancies. Historically, these pregnancies were managed by laparotomy due to concern for blood loss and difficulty with visualisation and identification of the ectopic. However, laparoscopy is now considered the gold standard.

Medical management is described in rare cases, and is typically reserved for situations where potentially fatal bleeding is anticipated based on the location of the ectopic.

Here we present the case of a 38-year-old G3P1 female, seven weeks and five days gestational age by dates, presenting with mild abdominal pain and nausea. Lab investigations reveal the beta HCG level of 34,000 and transvaginal ultrasound showed a suspected live left adnexal ectopic pregnancy.

She was taken to the OR for laparoscopic unilateral salpingectomy. This was uncomplicated and she was discharged home on the same day. Pathology would ultimately return negative for villous tissue or foetal parts.

One week post-op, she represented with severe abdominal pain and unstable vital signs. Repeat lab investigations revealed a haemoglobin of 56 and a persistently elevated beta HCG level. She was taken to the operating room urgently for diagnostic laparoscopy.

Review of her history and prior imaging raised the suspicion for abdominal ectopic pregnancy. As you can see, upon initial entry into the pelvis, the site of prior salpingectomy is haemostatic. If the fallopian tubes appear normal and no tissue consistent with a tubal ectopic pregnancy is identified, an abdominal ectopic may be suspected.

In this video, we propose a six step approach for identification and excision of abdominal ectopic pregnancy. Step one. While still in Trendelenburg position, turn the laparoscope cephalad and perform initial abdominal sweep. Step two. Now position the patient in reverse Trendelenburg. Inspect the pelvis as the bowel and omentum slide caudally, allowing for completion of thorough upper abdominal survey, including retraction of the liver if necessary.

Step three. Reassume Trendelenburg position slowly, watching the bowel slide cephalad with the aim of identifying ectopic tissue implanted under the bowel or omentum. In this case, the ectopic is easily identified with step three, given the amount of haemorrhage surrounding the pregnancy.

As seen here, the ectopic is implanted directly on the omentum, with a clear margin away from the bowel. Here, the omental ectopic is easily resected with wide local excision using a vessel sealing device. Care is taken to avoid any attempt at blunt dissection or peeling of the pregnancy off the omentum. This is to avoid persistent microscopic trophoblastic tissue, as well as minimise bleeding.

Had the ectopic not been identified in step three, we propose proceeding with step four. Step four. Run the bowel systematically. If these first four steps are unsuccessful, step five suggests considering hysteroscopy for intrauterine evaluation. Finally, if the ectopic pregnancy is still not identified, step six involves aborting the procedure, closing the patient and re-imaging them with close follow-up and serial beta HCG monitoring.

In conclusion, the rarity and high morbidity of abdominal ectopic pregnancies stresses the need for early recognition and intervention. Our surgical approach, including systematic abdominal survey and intraoperative patient repositioning, provides a safe, stepwise method to ensuring an abdominal pregnancy is identified and managed appropriately.