Persistent Ectopic Pregnancy After Laparoscopic Linear Salpingostomy for Tubal Pregnancy: Prevention and Early Detection

Persistent ectopic pregnancy (PEP) is a condition that occurs due to incomplete removal of trophoblastic tissue during fallopian tube-preservation surgery for tubal pregnancy. According to several studies, the incidence has been reported to be approximately 3%-20%,1 and the incidence appears to be rising due to the increase in treatment of tubal pregnancies via laparoscopic surgery.2-4 If treatment for PEP is delayed, tubal rupture and intraabdominal hemorrhage can occur and may be accompanied by significant morbidity and mortality. Therefore, prevention and early detection of PEP is of great importance. Methotrexate (MTX), a cytostatic agent with proven anti-trophoblastic activity, has been used for the treatment of ectopic pregnancies, and has also been reported to be useful for treating PEPs.5-6 Therefore, combined use of MTX following conservative tubal surgery may facilitate prevention of PEP. Indeed, MTX has thus far been reported to significantly decrease the occurrence of PEP when systemically-administered in a single dose within 24 hours after laparoscopic linear salpingostomy.7 However, systemic MTX administration has been reported to cause side effects and must be used with caution.8,9 In contrast, local MTX administration into the tube, either laparoscopically10,11 or through transvaginal ultrasonography12,13, has been associated with few side effects, and may be useful as a prophylactic for PEP. Therefore, local MTX administration after linear salpingostomy could prevent PEP without serious side effects. In this chapter, we examined the efficacy of local MTX administration after linear salpingostomy for tubal pregnancies in preventing PEP, and evaluated the usefulness of postoperative serum human chorionic gonadotropin (hCG) decline (percentage of the preoperative hCG level) for early detection and ruling out of PEP.