الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
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Abstract
Ectopic pregnancy ( E.P. ) has became a surgical epidemic during the last decade. There is a five folds increase in hospitalization for E.P between 1970 to 1989 all over the world. E.P. remains an important direct cause of maternal deaths accounting for 1 in 10 of all direct maternal deaths. The reasons for this internationally observed increase in E.P. are multiple, but can be attributed to better reporting, improved diagnostic tools and acquired risks for this disease in the reproductive population of women, the most important risk factor is scarring of the pelvic viscera from previous infections.
The classical therapy for tubal pregnancy has been the laparotomy and salpingectomy for decades. Because of infertility problem caused by previous ectopic management and the organ new preserving philosophy. The treatment of E.P. no longer necessarily requires laparotomy. And the laparoscopic management is an efficacious, safe and cost effective approach for the resolution of E.P. problem.
The standard history and physical examination remain insensitive methods for detecting E.P.; And there is no pathognomonic findings on examination that are diagnostic for E.P., So the diagnosis of E.P. as early as of 6-7 postmentrual weeks by screening of all suspected pregnancies may be the key for optimal use of new therapeutic concepts. V/S and Follow up of serum B-hCG levels are highly successful in early detection of intrauterine and ectopic pregnancy.
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summary
This study aimed to assess the conservative role of laparoscopic surgery in the treatment of ectopic pregnancy and its value in preservation of fertility potentiality during the childbearing period. For this reason a 30 cases diagnosed early as E.P. by history taking, clinical examination, B-hCG tittering and ’TVS. The diagnosis of the studied cases required more than one visit , more than one B-hCG titre and ’TVS to establish a complete solid diagnosis.
Conservative laparoscopic surgery is the treatment of choice in the treatment of ectopic pregnancy. So the cases of this study were managed conservatively by laparoscopic linear salpingostomy and removal of the pregnancy products from the tube, prefect hemostasis. Conservative procedure was done successfully in 30 cases , Follow up for more than 2 years by spontaneous pregnancy or tubal patency dying.
Salpingostomy was the procedure of choice during this study and done successfully for 30 cases,. 7 cases were complicated intraoperativly by persistent bleeding from the tube and ended by salpingectomy by diathermy or triple loop technique with no further bleeding.
The duration of the operation during this study was ranging from 45 minutes to 2 hours. But there is much improvement in the laparoscopic technique and operative time with experience.
The hematologic findings of the studied group showed that, there is no significant changes in the pre and postoperative values,
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there is a significant reduction in the estimated intraoperative blood loss and no one case needed blood transfusion.
The present study recorded no persistent ectopic pregnancy (PEP) after laparoscopic salpingostomy at any of the cases. A single IM injection of 50 mg/m2 body surface area of MTX is a simple, efficacious and successful therapy in suspicious cases.
During this study, No maternal mortality or major anesthetic complications recorded. No major complications (i.e needs laparotomy or relaparoscopy) as urinary tract or bowel injuries recorded. 7 cases were complicated by bleeding from the tube and ended by failure of the conservative procedures and salpingectomy was done successfully by laparoscopy in all cases. Two cases were complicated by inferior epigastric vessel trauma and bleeding (incidence 5.41%). The bleeding was controlled by compression sutures. Two cases were complicated by umbilical sepsis and require no more than frequent dressing. One cases was complicated by mild bleeding from the drain for 24 hours postoperativly, and stopped spontaneously with no further
intervention.
Reproductive outcome after E.P. is evaluated by determining tubal patency by Hysterosalpigography (HSG) or second look laparoscopy, the subsequent intrauterine pregnancy rates and the recurrent E.P. rates. The results of the present study showed that, The incidence of intrauterine pregnancy after a follow up period of 2 years was 36.66% (11 patients) in the conservative laparoscopic patients. These results are lower than the previous recorded studies, but may be due to small number of cases and short period
of follow up.
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The results of evaluating the tubal patency in this study was in agreement with the previous studies inspite of the small number of cases. 5 cases were followed by HSG proving tubal patency in 4 of them. Laparoscopic dye testing was done for 4 cases, proving tubal patency in 3 of them. One of these cases was having a solitary tube and got pregnant from that only tube.
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Conclusions
from the present study, we can conclude that:-
There is no pathognomonic pain or findings on examination that are diagnostic for E.P.. Also the diagnosis of E.P. as early as 6-7 postmenstrual weeks by screening of all suspected pregnancies may be the key for optimal use of new therapeutic concepts. TVS and serial serum B-hCG are highly successful in early detection of intrauterine and ectopic pregnancies.
The treatment of E.P. no longer necessarily requires laparotomy. And the laparoscopic management is an efficacious, safe and cost effective approach for the resolution of E.P. problem.
Conservative laparoscopic surgery is the treatment of choice in E.P.. Salpingectomy may be necessary if hemostasis cannot be obtained by conservative surgery, or if the tube cannot be salvaged.
Methorexate (MTX) is used in the treatment of very early undisturbed and carefully selected ectopic pregnancy. MTX ism, specially useful when the pregnancy is located in a site ( cervix, ovary or cornue ) where surgical treatment carries a significant risk. MTX therapy is an option when an E.P. in the interstitial portion of the tube, growing in the wall of the uterus. MTX is also used in the treatment of persistent trophoblast after a failure of conservative surgery.