Tubal Pregnancy: Relationship of Conservative and Radical Management and Follicular Salpingitis Upon Reproductive Outcome
Authors: Hochstein Eva R. , Baranyai Judith 
Published: February 2008

EDITORIAL COMMENT: In former years the treatment of tubal ectopic pregnancy was resuscitation when indicated, followed by partial salpingectomy to control haemorrhage and remove the affected tube ‐ the principle was to prevent death from haemorrhage rather than the preservation of fertility; conservative surgery was practised only when the patient had already had one tube removed, or when the unaffected tube was macroscopically abnormal (evidence of chronic inflammatory disease). In recent years the availability of beta unit HCG assay and vaginal probe ultrasonography has resulted in earlier diagnosis of tubal pregnancy in an increasingly high proportion of patients ‐ hence the greater opportunity for conservative treatment because the tube has not been damaged by rupture and the patient's life has not been threatened by haemorrhage. Treatment, often by laparoscopic technique, has become increasingly conservative. The most modern regimen is treatment of unruptured tubal pregnancies with methotrexate, either systemically or by injection in small doses (4mg) into the tube at the site of the ectopic implantation, with resolution of the pregnancy (serial assays of beta unit HCG) and preservation of tubal patency (subsequent hysterosalpingography or chromotubation). However, the series reported here showed a higher recurrence rate of ectopic pregnancy in conservatively treated patients and questions whether modern techniques are superior to radical treatment (partial salpingectomy). There are recent reports where tubal rupture has occurred following conservative surgery. Moreover, readers should be aware that ectopic pregnancy, in Australia and elsewhere, remains a leading cause of maternal death from haemorrhage. Has the pendulum swung too far? Are gynaecologists becoming captive to the new technology? Is it relevant to recall that in vitro fertilization and embryo transfer remains an option for the patient who has nonfunctional or absent tubes and wishes to reproduce? What evidence is there that preservation of a Fallopian tube containing an ectopic pregnancy is indicated, when the other tube appears macroscopically normal? It is suggested that readers ponder these questions in the light of the data contained in this paper.

Summary: Eight‐four patients with tubal pregnancy presenting between January, 1981 and December, 1982 to National Women's Hospital, Auckland, New Zealand, were identified from medical records and pathology files; 64 had radical surgery, 20 had conservative surgery performed. The 2 groups were analysed for reproductive outcome over a 5‐year follow‐up period. Subsequent viable pregnancy rates of 53 % for the group with radical surgery, and 50% for the group with conservative surgery, are similar to those quoted in the world literature, as is a recurrent tubal pregnancy rate of 14% for the radically treated group. However a recurrent tubal pregnancy rate of 45% for the conservatively treated group in our study is significantly higher than that reported elsewhere.

The relationship between recurrent tubal pregnancy and histological evidence of follicular salpingitis was examined. An unexpected finding was that no correlation exists between salpingitis diagnosed at the time of the initial tubal pregnancy, and an increased risk of subsequent tubal pregnancy.