Laparoscopy superior to laparotomy for managing ruptured tubal ectopic pregnancy: IJOGR study
Ectopic pregnancy is one of the most emergency condition during the pregnancy period in which the fertilized egg implanted outside the uterine cavity. The occurrence of ectopic pregnancy accounts for approximately 2% of total pregnancy in 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 of the ectopic pregnancies are fallopian tube pregnancy and generally, the diagnosis happens after seven weeks of amenorrhoea with or without symptoms. Tubal rupture is sudden and life threatening emergency, which needs immediate attention.
Laparoscopy and Laparotomy both are established in gynaecology for several years. In the developed countries laparoscopy is widely used for management of ruptured ectopic pregnancy because of the availability of skilled manpower, logistics, improved anaesthesia and cardiovascular monitoring, well organised surgical care and good healthcare insurance. For ruptured tubal ectopic pregnancy management, Laparoscopic procedures implemented with an aim to reduce intra operative blood loss, analgesic requirements, hospital stay and higher recovery as well as it's effectiveness in patients with massive haemoperitonium. However, Laparotomy is still preferred surgery in low resource set ups.
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 in the period of three years by Mishra et al.
A total of 90 confirmed case of ruptured tubal ectopic pregnancies were divided into 2 groups, laparoscopy(n=68) and laparotomy (n=22). The main outcome measures the demographic features like age, gravida, parity, previous spontaneous loss, previous MTP, Hb at admission, period of gestation, total blood loss and haemoperitonium and postoperative parameters blood loss, blood requirement and duration of hospital stay.
- No significant differences observed in age, gravida, parity, previous history of spontaneous loss and previous MTP in both laparoscopy and laparotomy procedure.
- Common demographic features were age (30 to 32 years), gravida (2-3) and parity (1).
- Patients with heavy blood loss >1000ml and massive hemoperitoneum were also undergone for laparoscopic procedure.
- Hospital stay and PRBC blood transfusion were less in patient undergone laparoscopic surgery.
Laparoscopic approach for management of ectopic pregnancy has largely replaced laparotomy. In the present study ruptured tubal ectopic pregnancy was managed with laparoscopic approach in 75.5% cases. All the ruptured tubal ectopic pregnancy cases (90) were taken for emergency operative procedures either laparoscopy or laparotomy.
In the laparoscopic group, haemoperitonium with estimated with blood loss more than 1000ml was observed in 68% patients and were successfully operated with laparoscopic procedure. Laparoscopic procedure is not only safe for early ectopic pregnancy but also appropriate for tubal rupture with haemoperitonium.
In the present study, laparoscopic procedure was applied successfully in tubal ectopic pregnancy of different location. An ampullary pregnancy was managed in a better way through laparoscopic procedure than other locations. Hospital stay was 4 days in case of laparoscopic procedures, whereas in case of laparotomy it was 7 days. Shorter hospital stay can help patients for faster recovery, decreased need of analgesic and better quality of life.
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 laparosopic surgery cost effective. This will have positive impact on outcomes of ruptured ectopic pregnancies in periphery and low cost set ups."
Author Dr Sudhanshu Kumar Rath also gave an insight for further research, "I would like to add that we are coming across number of ruptured ectopics after self administration of MTP pills. In the unregulated over the counter availability of strong abortifacient 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