February 1995, Vol. 2, No. 2 The Journal of the American Association of Gynecologic Laparoscopists

Diagnosis of Early Tubal Pregnancy by Salpingoscopy

Timur Gurgan, M.D., Hakan Yarali, M.D., and Bulent Urman, M.D.

Abstract

Salpingoscopy was performed to diagnose any early tubal pregnancy that could not be identified at laparos- copy. The procedure may prove to be a valuable tool in such cases not only for diagnosis but also as a guide to proper endoscopic treatment by determining the site of the gestation.

The development of sensitive human chorionic gonadotropin (hCG) assays and high-resolution vagi- nal ultrasonography have contributed to early diagnosis of ectopic pregnancy. However, in some patients tubal pregnancy can be suspected so early that it cannot be visualized at laparoscopy or laparotomy.1 To our knowl- edge, this is the first report of salpingoscopy during laparoscopy to diagnose an early tubal pregnancy that could not be identified externally. Localization of the pregnancy by salpingoscopy was also helpful in guid- ing endoscopic treatment by laparoscopy.

Case Report

A 29-year-old gravida 0 woman experienced vagi- nal spotting 33 days after her last menstrual period. Her medical history was not contributory. Physical and pelvic examinations were normal. The initial serum

level of hCG was 80 mIU/ml; repeat measurements failed to demonstrate normal doubling, and the max- imum hCG level reached was 150 mIU/ml. Vaginal ultrasonography using a 7.5-MHz probe was normal. Dilatation and curettage yielded secretory endometrium without any chorionic villi. Laparoscopy was per- formed with a presumptive diagnosis of ectopic preg- nancy. During laparoscopy, however, both fallopian tubes appeared normal. We therefore decided to per- form salpingoscopy to visualize the tubal lumina and localize an early tubal pregnancy, if present.

The fimbrial end of the fallopian tube was initially stabilized. A rigid salpingoscope (Karl Storz, Tuttlingen, Germany) with 2.8-mm outer diameter was then intro- duced through its sheath into the tubal lumen through a 5-mm cannula and gently forwarded up to the level of the ampullary-isthmic junction. The tube was dis- tended with Ringer's lactate solution (Haver Chemical

From Hacettepe University, Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Ankara, Turkey (all authors).

Address reprint requests to Timur Gurgan, M.D., Hacettepe University, Tip Fakultesi, Kadin Hastaliklari ve Dogum Anabilim Dali, Sihhiye-Ankara 06100, Ankara, Turkey; fax 011 90 4 312 310 7632.

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Diagnosis of Early Tubal Pregnancy by Salpingoscopy Gurgan et aJ

products, Beykoz, Istanbul, Turkey) through the lat- eral stopcock of the sheath, and the endosalpinx was visualized as the salpingoscope was slowly withdrawn toward the fimbrial end. A pregnancy bulging into the tubal lumen at the midampullary level was encountered in the right fallopian tube.

The surface of the ectopic pregnancy was pink, and small blood clots were detached from the gestational products when irrigated with Ringer's lactate solution. Salpingoscopic findings in the contralateral tube were normal.

After diagnosing and localizing the tubal preg- nancy, linear salpingotomy was performed with sharp- tipped unipolar electrosurgery. After the lumen was entered, the products of conception were gently dis- lodged from the tubal wall with a suction irrigator, and removed with a grasper forceps. The procedure was uncomplicated. Histologic examination confirmed the diagnosis of ectopic pregnancy. Follow-up hCG titers reached normal limits within 2 weeks.

Discussion

Laparoscopy is a very valuable diagnostic proce- dure to identify and localize an ectopic pregnancy. Occasionally a tubal pregnancy may be suspected so early that it may not be visualized during laparos- copy. 1 In such cases, salpingoscopy may be performed to identify and localize the implantation site within the lumen. Once the site of the pregnancy is identified by salpingoscopy, appropriate endoscopic treatment may be undertaken.

Salpingoscopy allows endoscopic visualization of the inner architecture of the fallopian tube from the fimbriated end up to the ampullary-isthmic junction. However, with falloposcopy, using a transvaginal approach, it is possible to explore the tube from the uterotubal ostium to the fimbriae. Early isthmic or intramural ectopic pregnancies may therefore be iden- tified only by falloposcopy. However, as the inner diameter of lumen is much narrower in the isthmic and intramural portions than in the ampulla and infundibu- lum, early ectopic pregnancies in the former segments may be externally visible during laparoscopy much ear- lier than in the latter segments.

It may be argued that expectant management with serial serum hCG measurements or medical treatment

with methotrexate might have been tried in our patient. In the natural history of early tubal pregnancies, some resorb spontaneously. IfhCG titers are declining from an initial level of below 1000 mIU/ml, the volume of ectopic trophoblastic tissue is probably small and the tubal pregnancy unruptured, and a period of observa- tion may be justified, l' 2 However, some cases may progress, and surgical or medical treatment would be mandatory. Obviously, it is not possible to predict either course in advance.

Medical management is gaining widespead accep- tance as the primary treatment of ectopic pregnancy? Although the results appear promising with proper selection of patients, toxicity remains a potential side effect. Furthermore, a diagnostic laparoscopy may still have to be performed before implementing med- ical treatment.

Tubal pregnancy was visualized by transcervical tubal cannulation and falloposcopy in two patients. 4 Laparoscopy was also undertaken at the same ses- sion. Ectopic pregnancy was externally visible in both patients at laparoscopy and salpingectomy was performed.

To our knowledge, this is the first reported patient in whom an early tubal pregnancy was visualized by salpingoscopy that could otherwise not be identified externally at laparoscopy. We conclude that salpin- goscopy may prove to be a valuable tool in such cases not only for diagnosis but also to guide proper endo- scopic treatment by determining the site of the preg- nancy. This approach also avoids a second laparoscopy if salpingoscopy is not performed.

References

1. American College of Obstetricians and Gynecologists: Ectopic Pregnancy. Technical bulletin 150. Washington, DC, Author, 1990

2. Vermesh M: Conservative management of ectopic ges- tation. Fertil Steril 51:559-567, 1989

3. Goldenberg M, Bider D, Admon D, et al: Methotrexate therapy of tubal pregnancy. Hum Reprod 8:660-666, 1993

4. Risquez F, Pennehouat G, Foulot H, et al: Transcervical tubal cannulation and falloposcopy for the management of tubal pregnancy. Hum Reprod 7:274-275, 1992

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