The form of therapy, wait-and-see – hoping for resorption (“imbibition”) -, drug (systemic or local), or surgical (pelviscopic/abdominal endoscopy, by laparotomy/abdominal incision, or in the case of cervical gravidity/pregnancy by cervical curettage) remains a case-by-case decision and depends on the clinical situation. The exception at present seems to be cervical gravidity. Recent studies suggest that, because of the risk of extreme bleeding, drug therapy should be sought before surgery by curettage (scraping) to denature the gravidity.
Indications for surgical therapy:
- Rupture (“bursting of the fallopian tube”).
- Hemodynamic instability (acute abdomen, circulatory instability, acute signs of rupture, or peritoneal hemorrhage) → immediate surgical intervention
- Complaints (e.g., pain)
- Suspicion of heterotopic gravidity
1st order
- Diagnostic-therapeutic pelviscopy (surgery to view the lower abdomen and pelvis; gold standard); depending on the size of the pregnancy (eg, mass: < 4 cm without cardiac action or < 3.5 cm with cardiac action) and desire to have children.
- Organ (tubal/fallopian tube) preservation:
- Antimesenteric longitudinal salpingotomy (tubal opening), milking out gravidity, optional closure of the tube (fallopian tube) by suturing.
- Segmental partial resection (partial salpingotomy).
- Transampullary expression (“milk out”).
- Resection of the tube (surgical removal of the fallopian tube):
- As ultima ratio in case of non-stoppable bleeding.
- Wg. pronounced tubal destruction (“tubal destruction”).
- Wg. ipsilateral (“on the same half of the body”) recurrence.
- Wg. previous ipsilateral sterilization.
- For recurrence prophylaxis with completed family planning.
- Organ (tubal/fallopian tube) preservation:
- Laparotomy (abdominal incision) when pelviscopic surgery is not possible.
- Curettage of the cervix in cervical pregnancy:
- Wg. strong bleeding risk preoperatively always inform about a hysterectomy (surgical removal of the uterus).
- If clinically possible, systemic methotrexate treatment should be given preoperatively (systemic preferred over local application because of risk of bleeding from manipulation)
Note: Rh-negative patients always require Rh-D immunoglobulin administration.
Caveat.
- After minimally invasive salpingotomy, trophoblast persistence (persistence of the outer cell layer of a blastocyst) may occur in up to 20%.
- Follow-up: weekly checks until normalization of HCG levels!
- If persistent extrauterine pregnancy/trophoblastic tissue, re-laparoscopy or initiation of drug therapy if necessary.
