Ectopic pregnancy is a gynecological condition in which a fertilized ovum implants outside the uterine cavity, most commonly in the fallopian tube. While acute presentations with rupture are common and often dramatic, a less typical form known as chronic ectopic pregnancy occurs in a smaller subset of patients. Chronic ectopic pregnancy is characterized by a slow, incomplete tubal abortion or repeated minor hemorrhages from trophoblastic tissue, leading to the formation of a chronic inflammatory mass. Because symptoms mimic other gynecological and gastrointestinal disorders, diagnosis is often delayed.

With the growing expertise in minimally invasive gynecology, laparoscopy has become the standard approach for both diagnosis and management of chronic ectopic pregnancy. It allows accurate identification of pathology and effective treatment while preserving fertility whenever possible.

Pathophysiology and Clinical Features

Unlike acute ectopic pregnancy, chronic ectopic pregnancy does not usually present with rupture and massive hemorrhage. Instead, persistent or intermittent bleeding from the ectopic implantation site leads to:

Chronic inflammation in the pelvis.

Hemoperitoneum with organization of clots.

Adhesion formation between pelvic organs.

Development of a tubo-ovarian mass mimicking adnexal tumors.

Typical clinical features include:

Chronic lower abdominal or pelvic pain.

Irregular vaginal bleeding.

Palpable adnexal mass.

History of amenorrhea may be absent or minimal.

Low-grade fever, anemia, and general malaise.

Laboratory investigations often reveal only mildly elevated or even negative serum β-hCG levels due to degeneration of trophoblastic tissue. Ultrasonography typically shows a complex adnexal mass with heterogeneous echoes, making it difficult to distinguish from ovarian neoplasms or pelvic inflammatory disease.

Diagnostic Role of Laparoscopy

Chronic ectopic pregnancy often eludes diagnosis on imaging and laboratory findings. Laparoscopy plays a pivotal role by providing:

Direct visualization: The surgeon can identify a mass with dense adhesions, clots, and organized tissue in the adnexa.

Differential diagnosis: Laparoscopy distinguishes chronic ectopic pregnancy from ovarian cysts, endometriosis, and tubo-ovarian abscess.

Therapeutic intervention: Diagnosis and treatment can be achieved in the same sitting, reducing the need for multiple procedures.

Laparoscopic Surgical Technique
Patient Preparation

Preoperative counseling regarding fertility preservation.

Correction of anemia, if present.

Administration of broad-spectrum antibiotics.

Port Placement

A standard three-port laparoscopic technique is employed:

A 10 mm umbilical port for the laparoscope.

Two 5 mm working ports in the lower quadrants.

Exploration

On entering the peritoneal cavity, organized blood clots, adhesions, and an adnexal mass are often found. Adhesiolysis is performed carefully to mobilize the adnexa.

Definitive Surgery

The choice of procedure depends on the extent of tubal damage and the patient’s reproductive wishes:

Salpingostomy (Conservative):

Performed if the tube is relatively intact and fertility preservation is desired.

A linear incision is made on the fallopian tube.

Organized tissue and old blood clots are removed.

The incision is left unsutured for secondary healing.

Salpingectomy (Radical):

Indicated when the tube is extensively damaged, densely adherent, or distorted.

The tube is excised after coagulation and division of the mesosalpinx.

Preferred in women with completed families or recurrent ectopic pregnancies.

Hemostasis and Lavage

Bipolar cautery or advanced energy devices are used for hemostasis.

Copious peritoneal lavage is performed to remove residual clots and inflammatory debris.

This step is crucial in reducing adhesion formation and preventing chronic pelvic pain.

Specimen Retrieval

Excised tissue is placed in an endobag and removed through the umbilical port to avoid contamination. Histopathological examination confirms the diagnosis of chronic ectopic pregnancy.

Postoperative Care

Monitoring: Vital signs, hemoglobin levels, and urine output are checked closely.

Analgesia: Nonsteroidal anti-inflammatory drugs and other pain relief measures are provided.

Antibiotics: Continued to prevent infection.

β-hCG Follow-up: Although levels are often low, monitoring ensures complete resolution of trophoblastic activity.

Counseling: Patients are advised regarding future fertility and the risk of recurrence, which remains around 10–15%. Early ultrasound in subsequent pregnancies is strongly recommended.

Advantages of Laparoscopy

Accurate diagnosis: Visual confirmation distinguishes chronic ectopic pregnancy from other adnexal pathologies.

Minimally invasive: Smaller incisions, reduced postoperative pain, and faster recovery.

Fertility preservation: Conservative procedures can be performed with precision.

Reduced adhesions: Thorough lavage and minimally invasive handling lower adhesion formation compared to laparotomy.

Cosmetic benefits: Minimal scarring, particularly important for young women.

Prognosis and Fertility Outcomes

Laparoscopic management of chronic ectopic pregnancy offers favorable outcomes. Pain relief and resolution of symptoms are achieved in most patients. Fertility outcomes depend on the condition of the contralateral tube and the extent of surgery. Conservative approaches maximize the chance of natural conception, while assisted reproductive techniques remain an option if both tubes are compromised.

Conclusion

Chronic ectopic pregnancy is an uncommon and diagnostically challenging condition that often mimics other pelvic pathologies. Laparoscopy has revolutionized its management by enabling accurate diagnosis, effective removal of pathological tissue, and fertility-preserving surgical options. By minimizing postoperative morbidity and adhesions, laparoscopy ensures excellent outcomes and improved quality of life. With timely intervention and skilled surgical expertise, women affected by chronic ectopic pregnancy can look forward to relief from symptoms and the possibility of future fertility.