Ectopic pregnancy is a condition in which a fertilized ovum implants outside the uterine cavity, most commonly in the fallopian tube. It remains a leading cause of maternal morbidity and mortality during the first trimester of pregnancy. Among its most serious complications is rupture, which can result in life-threatening intraperitoneal hemorrhage. Prompt diagnosis and management are crucial to preserve maternal life and, when possible, future fertility. With advances in minimally invasive surgery, laparoscopy has emerged as a highly effective approach even in cases of ruptured ectopic pregnancy, offering both diagnostic accuracy and therapeutic benefits.

Pathophysiology and Clinical Presentation

Ruptured ectopic pregnancy occurs when the trophoblastic tissue erodes through the tubal wall, causing bleeding into the peritoneal cavity. The rupture is most often associated with tubal pregnancies in the ampullary or isthmic regions. Risk factors include previous pelvic inflammatory disease, prior ectopic pregnancy, tubal surgery, use of assisted reproductive techniques, and intrauterine device usage.

Clinically, patients with rupture present with acute abdominal pain, shoulder-tip pain due to diaphragmatic irritation, vaginal bleeding, and signs of hypovolemic shock such as tachycardia, hypotension, pallor, and syncope. Laboratory findings often show anemia and elevated β-hCG levels, while ultrasonography reveals an empty uterus with adnexal mass and free intraperitoneal fluid.

Role of Laparoscopy in Ruptured Ectopic Pregnancy

Traditionally, laparotomy was considered the standard management for ruptured ectopic pregnancy due to concerns about bleeding control. However, improvements in laparoscopic instrumentation, surgical expertise, and anesthetic safety have allowed laparoscopy to become the preferred approach in hemodynamically stable or stabilized patients.

Laparoscopy provides several advantages:

Direct visualization of the bleeding source.

Accurate diagnosis in uncertain cases.

Ability to evacuate blood and clots from the peritoneal cavity.

Performance of conservative or radical surgical procedures with minimal invasiveness.

Reduced postoperative pain, shorter hospital stay, and quicker recovery.

Indications and Contraindications
Indications

Hemodynamically stable patients with confirmed ruptured ectopic pregnancy.

Patients resuscitated successfully after initial hypotension.

Desire for fertility preservation, where conservative procedures may be attempted.

Contraindications

Persistent hemodynamic instability despite resuscitation.

Massive hemoperitoneum requiring immediate open intervention.

Lack of laparoscopic surgical expertise or facilities.

Laparoscopic Surgical Techniques

The laparoscopic management of ruptured ectopic pregnancy involves the following steps:

Patient Preparation

Aggressive intravenous fluid resuscitation and blood transfusion as needed.

Broad-spectrum antibiotics.

General anesthesia with endotracheal intubation.

Port Placement

A standard three-port technique is employed: a 10 mm umbilical camera port and two 5 mm working ports in the lower quadrants.

In cases of massive hemoperitoneum, an open (Hasson) entry is preferred for safety.

Peritoneal Evacuation

Immediate suction of blood and clots to improve visualization.

Thorough lavage of the abdominal cavity with warm saline to prevent postoperative adhesions.

Definitive Surgery

Two main procedures are performed based on the patient’s fertility desires, tubal condition, and intraoperative findings:

Salpingostomy (Conservative):

Indicated in patients wishing to preserve fertility and when the tube is not severely damaged.

A linear incision is made on the antimesenteric border of the tube.

Products of conception are removed, and the tube is irrigated.

The incision is left to heal by secondary intention.

Salpingectomy (Radical):

Indicated when the tube is ruptured extensively, hemostasis is difficult, or the patient has completed family.

The tube is coagulated and divided using bipolar energy or advanced vessel sealing devices.

Ensures definitive management with reduced risk of recurrent ectopic pregnancy.

Hemostasis and Lavage

Meticulous hemostasis of bleeding points is ensured.

Repeated peritoneal lavage is performed to clear residual blood, preventing postoperative infection and adhesions.

Postoperative Care

Post-surgery, patients require careful monitoring for signs of persistent bleeding, infection, or persistent trophoblastic tissue. Key elements include:

Serial measurement of β-hCG levels, particularly after conservative surgery, to confirm resolution.

Adequate pain relief and early ambulation.

Antibiotic therapy as indicated.

Counseling regarding future pregnancy planning, with advice for early ultrasonography in subsequent pregnancies to detect recurrence early.

Advantages of Laparoscopic Approach

Minimally invasive: Smaller incisions, less postoperative pain, and faster return to daily activities.

Fertility preservation: Salpingostomy allows preservation of the fallopian tube.

Reduced adhesions: Minimizes long-term complications like tubal blockage and chronic pelvic pain.

Better visualization: Magnified view allows precise surgery even in difficult anatomical situations.

Cosmetic benefit: Minimal scarring, especially important for young women.

Outcomes and Prognosis

Laparoscopic management of ruptured ectopic pregnancy has shown excellent outcomes in hemodynamically stable patients. Fertility outcomes are favorable, especially after conservative procedures. Recurrence rates of ectopic pregnancy remain around 10–15%, emphasizing the need for careful follow-up in future pregnancies. Mortality is extremely rare when patients receive timely surgical intervention.

Conclusion

Laparoscopic management of ruptured ectopic pregnancy is now widely accepted as a safe, effective, and fertility-preserving surgical option in stable patients. It provides the dual advantage of accurate diagnosis and definitive treatment with minimal invasiveness. While laparotomy remains the choice in unstable cases with massive hemoperitoneum, laparoscopy offers superior recovery, reduced morbidity, and better quality of life for most women. With skilled surgical expertise and comprehensive postoperative care, laparoscopy ensures excellent outcomes and optimizes future reproductive potential.