Surgical intervention in ectopic pregnancy is indicated in several scenarios, depending on the type and location of the ectopic pregnancy, as well as the patient's clinical status:
General indications
- Surgery is recommended in patients with ectopic pregnancy exhibiting hemodynamic instability, symptoms of an ongoing ruptured ectopic mass (such as pelvic pain), or signs of intraperitoneal bleeding
- Both laparoscopic surgery and intramuscular methotrexate are safe and effective treatment options in clinically stable patients with non-ruptured ectopic pregnancy. The decision between surgical and medical management should be based on the initial clinical, laboratory, and radiologic data as well as patient-informed choice
Tubal pregnancy
- The decision to perform a salpingostomy or salpingectomy should be guided by the patient's clinical status, desire for future fertility, and the extent of fallopian tube damage
- A laparoscopic approach is preferred over open surgery in patients with tubal pregnancy
- Salpingotomy should be considered in patients with tubal pregnancy with a history of fertility-reducing factors (previous ectopic pregnancy, contralateral tubal damage, previous abdominal surgery, previous pelvic inflammatory disease)
Ovarian pregnancy
- Laparoscopic ovarian wedge resection should be considered rather than oophorectomy in patients with ovarian ectopic pregnancy, if clinically appropriate
- Definitive surgical treatment should be performed if laparoscopy is required to make the diagnosis of ovarian ectopic pregnancy
Interstitial pregnancy
- Laparoscopic cornual resection or salpingotomy should be considered as an effective option in patients with interstitial pregnancy
- Hysteroscopic resection under laparoscopic or ultrasound guidance should be considered as an alternative surgical technique in patients with interstitial pregnancy
Cornual pregnancy
- Either laparoscopic cornuotomy or cornual wedge resection should be considered if surgery is required for the treatment of patients with interstitial or cornual pregnancy, as both procedures have comparable results
Cervical pregnancy
- Surgical methods of management for cervical pregnancy should be reserved only for patients with life-threatening bleeding, because of the associated high failure rate
Heterotopic pregnancy
- Surgical removal of ectopic pregnancy should be considered as the method of choice in hemodynamically unstable patients with heterotopic pregnancy and as an option in hemodynamically stable patients with heterotopic pregnancy
Cesarean scar pregnancy
- Surgical management should be considered in patients with cesarean scar pregnancy, recognizing that there is insufficient evidence to recommend any one specific intervention over another
In conclusion, the decision to perform surgery in ectopic pregnancy is multifactorial and should be individualized based on the patient's clinical status, the location of the ectopic pregnancy, and the patient's desire for future fertility.