Diagnosis and Medical Management of Ectopic Pregnancy

## **Chapter 1** Heterotopic Pregnancy

*Bahati Johnson*

### **Abstract**

Spontaneous heterotopic pregnancy is a rare clinical and potentially dangerous condition in which intrauterine (IU) and extra-uterine pregnancies occur at the same time. It can be a life-threatening condition and can be easily missed, with the diagnosis being overlooked. A high index of suspicion is needed in women with risk factors for an ectopic pregnancy and in low-risk women with an IU gestation who have free fluid with or without an adnexal mass or in those presenting acute abdominal pain and shock. The ectopic component is usually treated surgically and the IU one is expected to continue normally. Salpingectomy is the standard surgical approach of a coexistent tubal pregnancy and should be the first line of treatment in patients with hemodynamic instability or other signs of tubal rupture. In expert hands, an unruptured ectopic pregnancy can be treated with local feticidal injection under sonographic guidance.

**Keywords:** heterotopic pregnancy, extrauterine pregnancy, intrauterine pregnancy

### **1. Introduction**

Spontaneous heterotopic pregnancy is a rare clinical but a potentially dangerous phenomenon where intrauterine (IU) and extra-uterine pregnancies occur at the same time. This is a life-threatening condition and can be easily missed, with the diagnosis usually being overlooked. A high index of suspicion is needed in women with risk factors for an ectopic pregnancy and in low-risk women with an intrauterine gestation who have free fluid with or without an adnexal mass or in those presenting acute abdominal pain and shock. The ectopic component is usually treated surgically and the IU one is expected to continue normally if it is live.

*Case: A 20-year-old woman, prime-gravid, was admitted to the gynaecology ward at 10 weeks of amenorrhea, with vaginal bleeding for 2 days, dyspnea and hypotension. Her pregnancy occurred spontaneously. Her past history did not suggest previous history of pelvic inflammatory disease, abortions, infertility or abdominal surgery or trauma. The physical examination revealed a conscious woman however with severe pallor of the palms, conjunctivae, mucous membranes of the buccal cavity and palms. She had hypotension of 75 mmHg systolic blood pressure, respiratory rate of 24 breaths per minute, SPO2 of 92%, cold sweat, and a thin thready rapid pulse of 136 beats per minute. Per abdomen did not suggest intra-abdominal haemorrhage as there was only moderate tenderness and no features of peritonism. Vaginal examination revealed active per vaginal bleeding with visible clots of fresh blood, products of conception hanging in the cervical canal. A clinical diagnosis of an incomplete abortion was made and patient was prepared for an emergency* 

**Figure 1.** *Salpingectomy specimen.*

### *Heterotopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.103145*

*uterine evacuation, which was done with a blunt curettage and curetted plenty of products of conception. Laboratory evaluation showed a normal range white blood cell count, a haematocrit of 18% and haemoglobin concentration of 6.1 g/dL, with a normal blood platelet level (390,000/mm3 ), a blood urea of 44 mg/dL and a creatinine level of 1.09 mg/dL. The patient was admitted to the high dependency unit (HDU) after uterine evacuation with a continuous assessment of her airway, breathing and circulation and administration of 2.0 L of crystalloid fluids over the next 4 h. She was also given 3 units of whole blood. However her haemodynamic observations remained unstable and she developed features of acute abdomen including moderate abdominal distension with positive fluid thrill, severe tenderness with guarding and rigidity. An emergency bedside abdominal ultrasound scan (USS) was done, which demonstrated free intra-peritoneal fluid and an ill-defined right adnexal mass measuring 69.79 mm in diameter. The uterine cavity was however empty following uterine evacuation. These USS findings (free intra-peritoneal fluid and adnexal mass) in a hypovolemic-shocked patient with peritonism but no history of trauma made us think about the presence of a possible concurrent ectopic pregnancy that was not initially thought about. Also, the patient's shock did not respond to fluid resuscitation with increasing abdominal distension. Repeat complete blood count revealed further fall in the patient's haematocrit and haemoglobin concentration. The patient was thus prepared and taken to the operation theatre for an emergency exploratory laparotomy to establish and control the source of intra-abdominal haemorrhage. At laparotomy under general anaesthesia, through a sub-umbilical midline incision, revealed a ruptured right tubal gestation with active bleeding. At least 1.5 L of clots of fresh blood was evacuated from the peritoneal cavity right and left ovaries and the left tube were grossly normal. Total right tubal excision (salpingectomy) as shown in* **Figure 1***, with suction of the haemoperitoneum and peritoneal lavage with saline water. Eight litres of whole blood was transfused to the patient during and after the operation. The patient recovered fully with no recorded complications. Both the tubal pregnancy and intrauterine pregnancy were confirmed at histological analysis of the salpingectomy specimen and endometrial curetting specimens that were sampled. The patient recovered uneventfully and was discharged from the hospital within 4 days*.

### **2. Definition**

Heterotopic pregnancy is defined as the presence of multiple gestations, with one being present in the uterine cavity and the other extra-uterine, commonly in the fallopian tube and uncommonly in the cervix or ovary [1–3].

### **3. Incidence and risk factors**

Initially described in 1708 as a postmortem discovery [4]. Under normal circumstances, with natural conception cycles, heterotopic pregnancy is an unusual occurrence with an incidence of <1/30,000 pregnancies [2, 4–6]. It accounts for 0.08% of all pregnancies [7]. The frequency of heterotopic pregnancy has increased to between 1/100 and 1/500 with assisted reproduction techniques [5, 8]. Its occurrence is 5% of conception achieved after in vitro fertilisation (IVF) [4]. Triplet heterotopic pregnancy has also been seen following natural conceptions [9]. A case, of ectopic gestation in both tubes bilaterally with an intra-uterine pregnancy has also been reported [10]. The diagnoses of heterotopic gestations are frequently made at gestation age of 5–34 weeks with 70% at 5–8 weeks, 20% at 9–10 weeks and only 10% >11 weeks of gestation [8, 11, 12].

### **4. Clinical presentation and diagnosis**

The early detection of heterotopic pregnancy is usually very problematic due to non-specific clinical symptoms as signs of the intra-uterine pregnancy always predominate [11]. Mainly, the four cardinal clinical features common in most literature are: abdominal pain, adnexal mass, features of peritonism and an enlarged uterus [1, 11]. About 83% of heterotopic pregnancies report abdominal pain alone while 13% present with hypovolemic shock together with abdominal tenderness. More than half of the pregnant patients with heterotopic gestations do not present with

### **Figure 2.**

*Image of a trans-vaginal sonography of the uterus (transverse section) showing an intrauterine gestation (black arrow) coexisting with an ectopic cornual pregnancy (\*) with a sac of 25 mm in diameter, containing an embryo with a crown rump length of 13 mm.*

### *Heterotopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.103145*

vaginal bleeding though it may be retrograde from the extra-uterine pregnancy due to intact endometrium of the intrauterine pregnancy [8, 13]. Increasing knowledge and skills in trans-vaginal ultrasound scanning has eased early and timely detection of heterotopic gestations. Trans-vaginal ultrasound scanning is an important tool in timely and accurate detection of heterotopic gestations. However its sensitivity in detecting heterotopic gestation is as low as 56% at 5–6 weeks [14]. Diagnosis a heterotopic gestation is confirmed at trans-vaginal sonography if there is an intra-uterine pregnancy together with an ectopic gestation (**Figure 2**) [14]. In a retrospective review of ultra-sonographic findings it was discovered that a fallopian tubal ring (an adnexal mass with a concentric echogenic rim of tissue, a gestational sac, surrounding a hypo-echoic empty center) was present in 68% of the ectopic pregnancies in which the tube had not ruptured [15]. If the pregnancy is >6 weeks, confirmation of the diagnosis is made on the presence of a cardiac activity. Sometimes, even with transvaginal ultrasonography, the adnexal mass is mistaken for a hemorrhagic corpus luteum or ovarian cyst, especially in ovarian hyper-stimulation [16]. In these cases, a heterotopic gestation becomes unnoticed in the presence of intra-uterine gestation. Therefore, when the levels of human chorionic gonadotropin (β-hCG) are higher for the period of gestation with an intra-uterine pregnancy, one has to find out for a possible coexistence of a tubal gestation. Occasionally, there are no concrete adnexal

### **Figure 3.**

*Ultrasonography demonstrating free fluid adjacent to the kidney, consistent with a large amount of hemoperitoneum in a patient with ruptured ectopic pregnancy.*

findings and the diagnosis of ectopic gestation is then based on other sonographic findings like haemoperitoneum, haematosalpinx which present as free fluid in the peritoneal cavity or the pelvis; e.g., in the pouch of Douglas (**Figure 3**). Usually, the identification of an intra-uterine gestation causes shift of attention from the possibility of a concurrent ectopic gestation. Even on suspicion of its existence, identification of ectopic component of heterotopic gestation at ultrasonography is usually much more difficult with the presence of a big haemoperitoneum. In a patient with even a confirmed intra-uterine gestation and presents with acute lower abdominal pain, the likelihood of an ectopic component of a heterotopic gestation must be seriously thought about. Heterotopic gestation is uncommon in natural cycles but it still happen. With the increasing application of assisted reproductive techniques, clinicians must be aware of the fact that identifying an intra-uterine or ectopic gestation clinically or sonographically does not exclude a concurrent existence of ectopic or intrauterine gestation pregnancy, respectively [17, 18].

### **5. Differential diagnosis**

In a patient with an intrauterine pregnancy, the differential diagnosis of uterine bleeding and/or abdominal pain includes threatened abortion, ruptured corpus luteum cyst, and heterotopic pregnancy. The correct diagnosis depends on careful sonographic assessment. Free fluid in the abdomen is a nonspecific finding as it could reflect cyst rupture, tubal pregnancy rupture, or ascites associated with ovarian hyper-stimulation syndrome during ART [16]. Patients with an intrauterine pregnancy may also develop abdominal pain from appendicitis, nephrolithiasis, or urinary tract infection, but these disorders can be distinguished from ectopic pregnancy by history, physical examination, and imaging and laboratory results. In unstable pregnant patients with abdominal pain and bleeding, surgical evaluation continues to play a key role in the diagnosis of heterotopic pregnancies.

### **6. Treatment**

As soon as the diagnosis is made, the extra-uterine pregnancy is always managed surgically especially with features of rupture and the intrauterine component is left to continue normally. With unruptured extra-uterine pregnancy, other treatment options like expectant management with aspiration and installation of potassium chloride or prostaglandin into the ectopic gestational sac can be tried. Methotrexate (MTX) (systemic or local injection) is avoided in heterotopic pregnancy due to its toxicity. Laparoscopic technique is another feasible approach for both cases without disruption to the progression of an intra-uterine pregnancy.

### **7. Outcome**

There appears to be a higher risk of spontaneous abortion of the intrauterine pregnancy of a heterotopic pregnancy than in an isolated intrauterine pregnancy [19]. In a literature review of 11 cases of heterotopic tubal and intrauterine pregnancy treated with Potassium chloride injection, 6 of 11 cases (55%) failed this therapy and required surgical intervention.

### **8. Conclusion**

Clinicians should be aware that the presence of an intra-uterine pregnancy sonographically or clinically should not and does not necessarily exclude the possibility of an ectopic pregnancy which should be thought about in any pregnant patient presents with abdominal pain plus unexplained hypovolemic shock.

### **9. Summary**

Heterotopic pregnancy refers to simultaneous pregnancies at two different implantation sites: an intrauterine and an extra-uterine pregnancy. Heterotopic intrauterine and tubal pregnancies should be suspected when ultrasound examination shows an intrauterine pregnancy and a complex adnexal mass, especially after assisted reproduction technology (ART) is used for conception. The diagnosis is confirmed when the adnexal mass contains a yolk sac or embryo/fetal pole. The clinical presentation closely mimics the symptoms of threatened abortion and isolated ectopic pregnancy. The uterus is enlarged consistent with gestational age and there may be abdominal pain, vaginal bleeding, and/or an adnexal mass. Patients are usually diagnosed late after becoming symptomatic and are often diagnosed at a more advanced gestational age than isolated tubal pregnancy. Rupture can result in acute abdomen and hemodynamic shock. The ectopic pregnancy should be terminated. Treatment of the ectopic pregnancy is tailored to the site of implantation and should utilise the least invasive therapy in order to preserve the concomitant intrauterine pregnancy. Salpingectomy is the standard surgical approach of a coexistent tubal pregnancy and should be the first line of treatment in patients with hemodynamic instability or other signs of tubal rupture. In expert hands, an unruptured ectopic pregnancy can be treated with local feticidal injection under sonographic guidance.

### **Author details**

Bahati Johnson Obstetrician and Gynaecologist at St. Francis Hospital Mutolere, Kisoro, Southwest Uganda

\*Address all correspondence to: johnsonbahati@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Reece EA et al. Combined intrauterine and extrauterine gestations: A review. American Journal of Obstetrics and Gynecology. 1983;**146**(3):323-330

[2] Govindarajan M, Rajan R. Heterotopic pregnancy in natural conception. Journal of Human Reproductive Sciences. 2008;**1**(1):37

[3] Gruber I et al. Heterotopic pregnancy: Report of three cases. Wiener Klinische Wochenschrift. 2002;**114**(5-6):229-232

[4] Pisarska MD, Carson SA. Incidence and risk factors for ectopic pregnancy. Clinical Obstetrics and Gynecology. 1999;**42**(1):2-8

[5] Luo X et al. Heterotopic pregnancy following in vitro fertilization and embryo transfer: 12 cases report. Archives of Gynecology and Obstetrics. 2009;**280**(2):325-329

[6] Xiao S et al. Study on the incidence and influences on heterotopic pregnancy from embryo transfer of fresh cycles and frozen-thawed cycles. Journal of Assisted Reproduction and Genetics. 2018;**35**(4):677-681

[7] Jerrard D et al. Unsuspected heterotopic pregnancy in a woman without risk factors. The American Journal of Emergency Medicine. 1992;**10**(1):58-60

[8] Barrenetxea G et al. Heterotopic pregnancy: Two cases and a comparative review. Fertility and Sterility. 2007;**87**(2):417

[9] Alsunaidi MI. An unexpected spontaneous triplet heterotopic pregnancy. Saudi Medical Journal. 2005;**26**(1):136-138

[10] Jeong HC et al. Heterotopic triplet pregnancy with bilateral tubal and intrauterine pregnancy after spontaneous conception. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2009;**142**(2):161-162

[11] Varras M et al. Heterotopic pregnancy in a natural conception cycle presenting with tubal rupture: A case report and review of the literature. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2003;**106**(1):79-82

[12] Wallach EE et al. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: A literature review from 1971 to 1993. Fertility and Sterility. 1996;**66**(1):1-12

[13] Wu Z et al. Clinical analysis of 50 patients with heterotopic pregnancy after ovulation induction or embryo transfer. European Journal of Medical Research. 2018;**23**(1):17

[14] Tandon R et al. Spontaneous heterotopic pregnancy with tubal rupture: A case report and review of the literature. Journal of Medical Case Reports. 2009;**3**(1):1-3

[15] Fleischer A et al. Ectopic pregnancy: Features at transvaginal sonography. Radiology. 1990;**174**(2):375-378

[16] Louis-Sylvestre C et al. The role of laparoscopy in the diagnosis and management of heterotopic pregnancies. Human Reproduction (Oxford, England). 1997;**12**(5):1100-1102

[17] Hassani K et al. Heterotopic pregnancy: A diagnosis we should suspect more often. Journal of Emergency Trauma Shock. 2010;**3**(3):304 *Heterotopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.103145*

[18] Saha E et al. Laparoscopic management of tubal ectopic of heterotopic pregnancy. Journal of Bangladesh College of Physicians and Surgeons. 2016;**34**(4):218-221

[19] Goldstein JS et al. Risk of surgery after use of potassium chloride for treatment of tubal heterotopic pregnancy. Obstetrics & Gynecology. 2006;**107**(2):506-508

### **Chapter 2**

## Endoscopic Approach to Ectopic Pregnancy

*Sergio Rosales-Ortiz, Tammy Na Shieli Barrón Martínez, Carlos Augusto De La Cruz Vázquez, José Fugarolas Marín, Alejandra Vega León, Janeth Márquez-Acosta, Smarth Santacruz Baez and Rogelio Apolo Aguado Pérez*

### **Abstract**

Minimally invasive surgery is an option in the management of ectopic pregnancy, it may be rupture, not rupture, or complement of medical treatment. In addition to the known advantages of endoscopic surgery in the field of obstetrics, it allows better conservative management of the fallopian tube and ovaries, allowing a better reproductive prognosis. The surgical technique to be performed of the clinical findings, the hemodynamic status, and the anatomical location of the ectopic pregnancy. Salpingectomy is performed in the ruptured ectopic pregnancy, assessing the integrity of the contralateral salpinge. Linear salpingostomy is performed on unbroken ectopic pregnancy preserving the fallopian tube, in the literature, this technique has reported maintenance of the fertility rate. In case of a cervical or niche ectopic pregnancy, resectoscopy is recommended.

**Keywords:** ectopic pregnancy, laparoscopic surgery, hysterocopic procedures

### **1. Introduction**

Ectopic pregnancy occurs in 0.6–2.1% of all pregnancies. Its prevalence in emergency services is 18%, and it is associated with abdominal pain and transvaginal bleeding. It leads to 2.7–5% of maternal deaths in developed countries, and it is also the main cause of death in the first trimester. Death results mainly from ectopic pregnancy rupture. The frequency of ectopic pregnancy is 90–97% in the uterine tube, 1–3% in the ovary, the same percentage is in the niche or cesarean section scar, 1% are abdominal, and 1% are interstitial or located in the horn, as well as cervical, post-hysterectomy, in the rudimentary horn due to Müllerian malformation, and heterotopic or atypical implantation is present in less than 1% of cases. Ectopic pregnancies in atypical locations are a surgical challenge, associated with a high risk of hemorrhage and death, and should be managed in a tertiary care medical center with experience in the treatment of this entity.

Management by laparoscopy and hysteroscopy is currently the most recommended approach; these minimally invasive procedures aid in the preservation of reproductive function, allowing an intrauterine pregnancy within 2 years after conservative surgery in 70% of cases.

### **2. Endoscopy in gynecology**

The implementation of endoscopic surgery in surgical practice is one of the most successful innovations in the history of medicine. The first laparoscopy in a human being was performed by Hans Christian Jacobaeus, who coined the term "laparoscopy," and in 1910 he described the technique to inspect peritoneal, thoracic, and pericardial cavities in humans [1].

Over the following four decades, gynecological laparoscopy was greatly promoted and developed by Raoul Palmer and Hans Frangenheim, who routinely performed the procedure, and the first book on surgical techniques in laparoscopy was published by Patrick Steptoe in 1967. Initially, gynecological laparoscopy was mainly used to establish diagnoses, and its only surgical applications were uterine tubal ligation and fenestration of benign ovarian cysts. Its progressive development, particularly in the last two decades, has placed this surgical technique as the first-line therapeutic approach in gynecological surgery since the same procedures as in open surgery can be performed to manage uterine tubes, ovaries, and corpus uteri pathology; it is also of use in pregnant patients with appendicular, gallbladder, and adnexal disease and in all variants of ectopic pregnancy. It is also the diagnostic and therapeutic gold standard in the management of endometrial pathology [1–6].

Minimally invasive surgery has many advantages in gynecology since it can be performed in girls, adolescents, women of reproductive age, pre and postmenopausal females, including those with obesity; postoperative results include less pain, shorter hospital stays, faster recovery, a decrease in the risk of developing adhesions, a superior esthetic outcome, greater fertility preservation, and the ability of the patient to engage more rapidly in their work and daily activities with less labor disability periods than cases who undergo open surgery. In-office and surgical hysteroscopy is one of the most significant advances in gynecology and has revolutionized the management of intracavitary uterine pathology [7, 8].

Complications of endoscopic surgery in gynecology occur in 3 to 6 cases per 1000 procedures. Half of them appear when introducing the trochars or the hysteroscope, followed by events derived from the use of energy. New entry techniques, materials, and endoscopic equipment have not modified this frequency in the last two decades, but it varies in accordance with the surgical group's experience [1].

### **3. Endoscopic management of ectopic pregnancy**

Surgical management of ectopic pregnancy is the option in patients that are not candidates for expectant or pharmacologic management. The choice between laparoscopy and laparotomy depends on the patient's clinical features, the physician's experience in endoscopic techniques, and the available hospital resources. When possible, an endoscopic approach in the management of this pathology is preferable since there is sufficient evidence of its feasibility and greater preservation of organ function [9–11].

Ectopic pregnancy is specifically managed according to the implantation site that may be: tubal, interstitial, ovarian, abdominal, cervical, or heterotopic.

### **4. Tubal pregnancy**

Ectopic pregnancy in the uterine tube is located in the ampulla in 70–80% of cases, in the fimbriae in 11%, and 10–12% are implanted in the isthmic portion. The intramural or interstitial portion is considered a separate entity [9, 11, 12]. In any of these clinical presentations, women prefer conservative surgical management, and preservation of the uterine tube, despite an increased risk of ectopic pregnancy recurrence, or its persistence [9–11].

According to the ACOG and NICE guidelines, an ectopic pregnancy with a detectable heart rate by ultrasound, an adnexal mass larger than 35 millimeters, a β-hCG fraction of 5000 IU/L, severe abdominal pain, signs and symptoms suggesting ectopic pregnancy rupture, hemodynamic instability, intra-abdominal bleeding, and/or medical treatment failure are all obligate indications of surgery [11].

The laparoscopic surgical techniques in the uterine tube include:

Salpingotomy: This refers to a linear incision on the uterine tube exactly over the ectopic pregnancy on the anti-mesosalpinx border. The uterine tube wall is previously injected with diluted vasopressin (0.2 UI/ml of saline), the longitudinal incision is created with scissors or bipolar energy, and should measure 10–20 millimeters; the embryo and trophoblastic tissue are extracted through the incision by hydrodissection and/or blunt dissection, the surgical site should then be thoroughly washed with antiadherent solutions, hemostasis should be carefully performed, and the incision closed with absorbable 4/0 sutures [12].

Linear salpingostomy: This is the same procedure as salpingotomy but without suturing the incision.

Salpingectomy: This is the only radical or nonconservative management of the uterine tube and implies the removal of a segment or the entire uterine tube; it is warranted if the uterine tube ruptures, a complication of the previously mentioned techniques, or if further pregnancies are unwanted. This technique may be converted into conservative management if complemented with anastomosis of the uterine tube segments, to preserve function.

Fimbrial milking refers to the nontraumatic compression of the fimbriae to promote trophoblastic expulsion.

Regardless of location, the success of conservative management will be greater if the diagnosis is timely and precedes rupture symptoms [10, 13].

Salpingotomy is recommended in patients wishing to preserve their fertility butare at risk of infertility due to injury in the contralateral tube secondary to pelvic inflammatory disease, or recurrent ectopic pregnancy in the same salpinx; the procedure is feasible in 96% of cases, it is safe, with almost a zero percentage of complications [10]. Its disadvantages include: it requires β-hCG follow-up after surgery to ensure the resolution of the ectopic pregnancy, it carries a greater risk of ectopic pregnancy persistence that may require postoperative treatment in 7% vs. <1% after salpingectomy (RR 15.0; 95% CI 2.0–113.4), and a possible increase in the risk of ectopic recurrence that in the literature, varies between a RR of 2.27 (95% CI 1.12–4.58; p = 0.02) to 1.04 (95% CI 0.89–1.21; p = 0.61) [9, 14].

Salpingectomy is recommended when there is an extensive injury to the involved salpinx while the contralateral salpinx is intact, and the patient wishes to remain

fertile [11]; it carries a lower risk of ectopic persistence, surgical reintervention, and recurrence. Its disadvantage is a decrease in fertility in women with a contralateral injured tube or the presence of pelvic adhesions (40 vs. 75%; p < 0.005) [9, 15].

Segmental resection with anastomosis is the recommended procedure in isthmic pregnancy (12% of ectopic pregnancies), since the muscular portion is compact and rapidly invaded by the trophoblast, leading to two significant risks: early rupture and persistence of the trophoblast, as well as sequelae due to structural injury upon removal. This approach requires microsurgical techniques and experienced surgeons [13].

Fimbrial milking or expression is a procedure used in pregnancies implanted in the distal portion of the uterine tube (fimbriae). It is evacuated by compressing the fimbriae with nontraumatic instruments, in the direction of the uterus toward the fimbriae, even with tempered glass atraumatic mobilizers. This technique requires follow-up to exclude the persistence of trophoblastic tissue [10].

In daily practice, the choice between a salpingectomy and a salpingostomy entails patient and physician factors. The patient factors include age, the desire to remain fertile, the obstetric history, previous surgeries, the condition of the involved, and the contralateral tubes. From a medical perspective, the physician's experience in endoscopic surgery and his/her preference, are pivotal.

When conservatively managing the uterine tube, hemorrhage control at the implantation site resulting from the removed tissue is a key, as well as control of postincision bleeding, for if persistent, a salpingectomy will be required; for this reason, 20% of salpingostomies require conversion into a salpingectomy.

The recommended hemostatic techniques are: direct compression over the surgical site with endoscopic forceps, cauterization with bipolar energy, ligation of the mesosalpinx and bleeding vessels with 6/0 polyglactin, application of hemostatic sealants, and segmental resection with anastomosis of the compromised segment [10, 12].

Direct compression tends to be insufficient while electric energy must be cautiously used to avoid desiccation of the surgical site, since the thermal injury of the mesosalpinx may be permanent and irreversible. If choosing bleeding blood vessel ligation, one must avoid the involvement of the collateral vasculature. Hemostatic sealants must not be used in excess since they may compromise the healing process, and alter the functionality of the tubal epithelium. One must remember that the milder the injury to the tissue, the less formation of adhesions.

When following conservative management, the risk of persistence of trophoblastic tissue may reach 20% but can be decreased with 2% intramuscular prophylactic methotrexate (RR 0.89, 95% CI 0.82, 0.98) [16].

Although there is a tendency to follow conservative management to improve future fertility, no statistical difference has been reported using a particular technique, especially when attempting a subsequent intrauterine pregnancy.

### **5. Interstitial or horn pregnancy**

The terms interstitial pregnancy or horn pregnancy are used indistinctly in the literature to refer to the implantation of the gestational sac in the uterine horns or the proximal portion of the uterine tube (intramural); however, some authors consider that the term "horn pregnancy" should be reserved for gestation in the horn of a bicornuate uterus. The interstitial portion of the uterine tube is that crossing the

### *Endoscopic Approach to Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.101917*

myometrium to the endometrial cavity; its diameter is 0.7 millimeters and measures 1–2 centimeters in length [17, 18].

The frequency of interstitial pregnancy ranges between 2 and 4% of all ectopic pregnancies, and carries a seven-fold increase in morbimortality compared with other types of tubal pregnancies; this results from the pregnancy's asymptomatic nature until weeks 7 to 16, and that is later suddenly manifested as a massive intraperitoneal hemorrhage, pain, and shock. Its incidence has increased in the past two decades as a result of pelvic inflammatory disease, assisted reproduction techniques, the use of intrauterine devices, adhesions, and previous tubal surgeries [19, 20].

Three therapeutic approaches have been described: close surveillance of the ectopic pregnancy if not associated with hemodynamic instability, medical management, and surgical management. The choice hinges on various factors such as the patient's clinical status, the gestational age at the time of diagnosis, the presence of contraindications of medical treatment, and the patient's preference [21].

An expectant approach (surveillance) is reserved for patients with decreasing β-hCG levels and that remain clinically stable. Medical treatment with local and/ or systemic methotrexate is indicated in young nulliparous women wishing to preserve their future fertility if the interstitial pregnancy has not ruptured, if the gestational sac measures 35 mm or more in diameter, a β-hCG level of 5000 mUI/ mL or below, and the absence of embryonic cardiac activity; the rate of success is 80% [21–24].

Surgical approaches include: hysteroscopy, laparoscopy, and laparotomy. Surgery is recommended in symptomatic cases that are hemodynamically unstable, and at risk of rupture of the ectopic mass; also, in pregnancies over 7 weeks, gestational sacs ≥35 mm in diameter, when the use of methotrexate is contraindicated or has failed, and according to the patient's preference and the surgeons' expertise [19, 24].

The most frequent approach used to be a laparotomy with horn resection and/or hysterectomy, due to delayed diagnoses, in patients with uterine rupture, hemorrhage, and instability. Currently, this remains an option in the absence of a surgeon with laparoscopic training. Now, the first option is conservative laparoscopy since it is associated with lower blood volume loss, a shorter operative duration, shorter hospital stays, faster recovery, and preservation of the anatomy, even in cases of uterine rupture and hemoperitoneum [23–25].

The endoscopic options are: laparoscopic horn resection, wedge horn resection (in combination with an ipsilateral salpingectomy), hornostomy/salpingostomy (incision in the horn region, and removal of the gestational sac or horn evacuation), and mini-horn excision. The most frequently used and described techniques are laparoscopic horn excision and hornostomy [21, 24, 26].

Less radical techniques that conserve the anatomy such as hornostomy, salpingostomy, and horn mini-excision are performed when the tumor formed by the ectopic implantation of the gestational sac is smaller than 40 millimeters in diameter, there is no rupture nor embryonic cardiac activity, the patient wishes to preserve her future fertility, or the contralateral tube is absent or injured. There is no evidence of subsequent successful pregnancies, but there is a risk of persistent ectopic pregnancy in 5–15% of cases [19, 24].

More radical techniques are preferred such as wedge horn resection with salpingectomy in cases of tumors formed by the ectopic implantation of the gestational sac greater than 40 millimeters in diameter, and in the presence of rupture or embryonic cardiac activity [24]. Between horn resection and laparoscopic hornostomy, there are no significant differences in postoperative hemoglobin level,

persistence of the ectopic pregnancy, complications, but only in the duration of surgery, favoring hornostomy [27].

Despite the different laparoscopic techniques, there is no consensus on which is superior, and the most frequent injury is intestinal, due to electrocautery. Vasopressin or a myometrium vasoconstrictor can be injected around the ectopic site to minimize bleeding and obtain hemostasis [24, 28].

There are case reports of hysteroscopic extraction of horn pregnancies, with or without previous methotrexate administration. To evacuate the gestational sac, graspers or forceps are used. Follow-up is based on ultrasound, hysteroscopy, and β-hCG determinations for 3 months [29, 30]. Hysteroscopic management is recommended in horn pregnancies measuring less than 40 millimeters in diameter; if the embryo has no cardiac activity, this approach has greater chances of success with average blood loss of 30 milliliters, but the technique should be limited to groups with expertise in the field [31].

### **6. Ovarian pregnancy**

Ovarian pregnancies account for 0.5–3% of all ectopic processes. Seventy-five percent end in the first trimester and they are often mistaken for a corpus luteum or a tubal ectopic pregnancy by ultrasound.

The clinical presentation is abdominal pain (93%) with scant transvaginal bleeding, and the diagnosis is corroborated at the time of laparoscopy. Management options include wedge resection, sac resection from the ovarian tissue, blunt dissection of trophoblastic tissue (with bipolar energy), and in extreme cases, oophorectomy [9].

Ovarian wedge resection consists in removing the ovarian portion fixed to the ectopic pregnancy; bipolar energy is recommended without suturing the ovarian edges. Hemostasis is obtained with bipolar energy, but in cases of persistent bleeding, an absorbable 2/0 suture should be used.

The gestational sac may be removed from the ovarian surface by hydrosection, or blunt dissection, and complemented with bipolar energy to release trophoblastic tissue or control bleeding on the ovarian surface.

Oophorectomy is reserved for cases in which there is ovarian parenchymal rupture and massive hemorrhage, advanced pregnancies, or a ruptured ectopic pregnancy with infiltration into the ovarian parenchyma.

A laparoscopic approach is recommended over an open technique since it permits greater preservation of the ovarian tissue [11, 32].

### **7. Abdominal pregnancy**

It accounts for 0.1 to 1.3% of all ectopic pregnancies; implantation may occur anywhere in the abdominal cavity, although it is more frequent in the posterior cul-de-sac (approximately 50%), followed by the mesosalpinx (27%). They have also been reported on the omentum, intestine, mesentery, pelvic peritoneum, anterior cul-de-sac, liver, spleen, diaphragm, retroperitoneum, abdominal wall, inferior vena cava, and aorta; however, the entire cavity is at risk of implantation [13, 33].

This type of pregnancy has an eight-fold increased risk of leading to death than tubal pregnancies since it is difficult to diagnose and treat. It is frequently a transoperative finding triggered by clinical signs of an acute abdomen, there is free blood in

### *Endoscopic Approach to Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.101917*

the abdominal cavity, the presence of an abdominal tumor, or even a fetus associated with an empty uterus on ultrasound.

For study purposes, it can be divided into primary and secondary: primary refers to pregnancies that from the beginning are implanted in the abdominal cavity, while the secondary types are implanted in the abdominal cavity after an extraction procedure or detachment from the site of origin in the genital tract. It has also been divided according to the moment of interruption: early, if it occurs before week 20, or late if the pregnancy culminates after that week [11, 32].

Trophoblastreimplantation after removal of a primary ectopic pregnancy by laparoscopy or laparotomy has a frequency of 1–1.9%. To prevent this, it is important to remove all pathological tissue during surgery as well as clots, to decrease the possibility of leaving reimplantation tissue behind. The Trendelenburg position is recommended as well as the complementary administration of methotrexate [34].

When an early pregnancy is suspected, the recommended treatment is methotrexate, even if the implantation site has not been established; this is followed by laparoscopic excision.

In pregnancies beyond 8–10 weeks of gestation, and at imminent risk of hemorrhage, the decision to perform open or laparoscopic surgery will depend on the time of diagnosis and the patient's clinical status. Manipulation of the placenta and/or placental bed tends to be lethal so the cord must be ligated as close to its insertion as possible and its management should be expectant. The risk of bleeding due to removal must be well evaluated since hemorrhaging of the placental bed results from its location in a tissue that does not contract like the uterus to staunch the bleeding. Within the expectant management, also consider the risk of infection, the possibility of bleeding, and the need for reintervention; the approach should be multidisciplinary [9].

### **8. Heterotopic pregnancy**

It is defined as the simultaneous presence of an intrauterine and an extrauterine pregnancy; it is a very unusual variant with a frequency of approximately 1 in 30,000 spontaneous pregnancies, or 1 in 1111 pregnancies, and tends to result from fertility issues. The most frequent location is the uterine tube but it may also be located in the horn, cervix, niche, or the abdomen [9].

Management of the uterine tube will be the same as in tubal single pregnancy, but salpingectomy is the most frequently reported approach. In other sites, instead of using methotrexate that is contraindicated due to the intrauterine pregnancy, an intracardiac injection of potassium chloride is administered. Management options will depend on the patient's preferences, her clinical conditions, and the physician group's experience. After resolution, the patient requires close follow-up [9, 11].

A complication of laparoscopic treatment is the persistence of trophoblast tissue so β-hCG levels must be followed from day 5 to 10, and if they decrease ≥93.1%, the possibility of persistence is extremely low [35].

### **9. Cervical pregnancy**

Cervical pregnancy has a frequency of 0.1% of all ectopic pregnancies, but its incidence varies from 1 in 1000 to 1 in 18,000 in the literature. Since its etiology is unknown, consider risk factors such as previous dilation and curettage in a previous pregnancy (70% of cases), a previous cesarean section, cervical surgery, and endometritis. Its most common symptom is usually profuse vaginal bleeding, and the diagnostic suspicion should be corroborated by high-resolution ultrasound [36–38].

This type of ectopic pregnancy carries a high risk of massive hemorrhage during abortion labor or during attempts at surgical evacuation; it may even lead to definitive treatment such as an emergency hysterectomy.

Conservative management of the cervical ectopic pregnancy with hysteroscopy was first described in 1996 by Ash and Farrel. It must be performed before the 8th week, there must be no embryonic vitality, and it warrants the use of methotrexate [36, 39, 40].

Hysteroscopic treatment is effective and safe but requires two conditions: if the embryo is alive, the uterine arteries must first be ligated or embolized. If it is alive in an early pregnancy, saline (KCl) or 50% glucose solution or methotrexate can be injected, leading to embryonic death. Once either premise is fulfilled and in accordance with the medical group's experience, hysteroscopy can be performed with local vasopressors and a resectoscope or bipolar miniresectoscope in one or two surgical attempts, with roller ball coagulation [41–44].

With a coagulation intensity of 80 watts and a cut of 60 watts, the implantation site is located and coagulated from the periphery and advanced concentrically until it decreases completely or as far as the implantation site allows blood flow. The cutting and extraction of the gestational sac and trophoblastic tissue can be complemented with Forester's clamp or uterine clamp. Hemostasis is corroborated and supplemented with roller handle selectively. If bleeding occurs, a Foley catheter can be placed, filling the balloon with 5–7 cc of solution and removing it after 7 days.

Postsurgical monitoring should include a determination of β-hCG level every 48 hours until it is negative and a hysterosonography or hysterosalpingography 3 months after the procedure is performed.

### **10. Niche, cesarean scar pregnancy**

This ectopic pregnancy variant is also known as "cesarean" scar, and previously, as isthmocele. The first report of this type of ectopic pregnancy appeared in 1978, and to date, its incidence is 0.15%, with a described frequency of 1 in 1800 to 2216 ectopic pregnancies [45].

It is important to emphasize that the gestational sac may become implanted in a cesarean scar, after a myomectomy, placental removal, or dilation and curettage, even after *in vitro* fertilization.

The diagnosis is difficult to establish whereby the differential diagnoses include cervical ectopic pregnancy and intrauterine pregnancy in abortion labor. Ultrasound findings include the absence of an intrauterine gestational sac, location in the endocervical canal or isthmus surrounded by cesarean scar tissue, with or without myometrium contiguous to the bladder or abdominal cavity; a Doppler image with a gestational sac within the scar defect and surrounded by high-speed vascular flow has also been described.

Niche pregnancies may be divided into two types: type I or endogenic in which the pregnancy grows toward the isthmo-cervical space or uterine cavity, and there is myometrium between it and the bladder; this pregnancy may cause transvaginal bleeding originating in the placental bed. Type II or exogenic invades the bladder or the abdominal cavity, there is no myometrium, and it is usually complicated by uterine rupture and profuse bleeding in an early pregnancy [46].

*Endoscopic Approach to Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.101917*

Before hysteroscopy, 4 milliliters of 50% glucose solution may be injected into the gestational sac, followed by 2.5 mg orally administered methotrexate, 3 times daily for 5 days, or the injection of methotrexate 50 mg/m2 directly into the gestational sac. Once the embryo's death is corroborated, the niche pregnancy can be removed with a 5Fr resectoscope or a miniresectoscope and bipolar energy, or a mechanical resector (True Clear); note that only type I niche ectopic pregnancies can be treated hysteroscopically [47].

The technique of hysteroscopic surgical resection was mentioned in cervical pregnancy, remembering that if the thickness of the myometrium is less than 3 mm it is dangerous to perform the hysteroscopic technique due to the risk of perforation and bladder injury.

Type II must be treated with an abdominal approach by laparotomy or laparoscopy dissecting or even a vaginal approach. The bladder and resecting uterine and vesical tissue can be performed wit bipolar energy, scalpel, or scissors. The uterus is treated with revival and hemostasis of surgical edges and myography in 2 planes with absorbable 4/0 suture, and a Foley catheter for hemostasis control. Laparoscopy is recommended.

Niche pregnancy can be removed by resectoscopy after the administration of methotrexate, saline solution or ethanol, to provoke embryonic and trophoblastic cell death if there is intercalated myometrium [47].

### **11. Fertility and ectopic pregnancy**

Ectopic pregnancy is a problem with consequences in women of reproductive age, and its resolution requires consideration of the patient's reproductive future. Based on this principle, laparoscopic surgery and hysteroscopy, following the previously described techniques, are part of its conservative management.

The choice of a surgical technique should consider preservation of the patient's life, preservation of the organ and its function, the possibility of persistent trophoblastic tissue or ectopic pregnancy recurrence, the possibility of requiring surgical reintervention, and/or the development of hemorrhage. An important factor to take into account in any conservative management setting is that the contralateral side (uterine and ovarian tubes) must be healthy or without apparent pathology [48].

Other points to consider to preserve the fertility rate with conservative techniques are: the decrease in trophoblastic tissue persistence (5–20%), a single 1 mg/kg intramuscular and/or local dose [49], and an increase in ectopic pregnancy recurrence resulting from the loss of uterine tube function due to scarring, inflammation, and injury caused by bipolar energy during hemostasis, all promoting the implantation of the blastocyst at the scar site [50, 51].

Despite the tendency to follow conservative management protocols, there is no significant difference after a 24–36-month follow-up with either radical treatment or removal of the involved segment, in terms of the frequency of intrauterine pregnancy (HR 1.06 (0.69–1.63; P1/4.78); the recurrence rate is 6–10% [50, 52].

Regardless of whether management is conservative or radical, we must be aware that the spontaneous fertility rate at 2 years is similar as long as there are no risk factors favoring another ectopic pregnancy; if present, radical treatment may certainly compromise spontaneous fertility.

*Ectopic Pregnancy and Prenatal Diagnosis*

### **Author details**

Sergio Rosales-Ortiz\*, Tammy Na Shieli Barrón Martínez, Carlos Augusto De La Cruz Vázquez, José Fugarolas Marín, Alejandra Vega León, Janeth Márquez-Acosta, Smarth Santacruz Baez and Rogelio Apolo Aguado Pérez Hospital de Gineco Obstetricia No. 4 "Luis Castelazo Ayala," Institution MexicanodelSeguro Social, Mexico City, Mexico

\*Address all correspondence to: dr.sergiorosalesortiz@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 3**
