AND ITS MANAGEMENT

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ANDITS MANAGEMENT
ECTOPIC PREGNANCY

• DR ASIFA SIRAJ
• CONSULTANT GYNAE/OBG
• MH RAWALPINDI

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Is one in which fertilized ovum is implanted
develops outside normal uterine cavity
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• IMPLANTATIONS SITES

EXTRAUTERINE
UTERINE
-CERVICAL (118,000) -ANGULAR -CORNUAL
TUBAL 97 -Ampulla 80 -Isthmus
12 -Infundibulum 6 -Interstitial 2
OVARIAN (140,000)
ABDOMINAL (110,000)
SECONDARY
PRIMARY
Intraperitoneal
Extraperitoneal Broad Ligament (rare)
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• INCIDENCE
• Increased due to PID, use of IUCD, Tubal
  surgeries, and Assisted reproductive techniques
  (ART).
• Ranges from 125 to 1250
• Average range is 1 in 100 normal pregnencies.
• Late marriages and late child bearing -gt 2
• ART -gt 5
• ETIOLOGY
• Pelvic Inflammatory disease (6-10 times)
• Chlamydia trachomatis is most common

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• Contraceptive Faliure
• CuT -4
• Progestasart -17
• Minipills -4-10
• Norplant -30
• Tubal sterilization faliure -40
• Depends on sterilization technique and age
  of the patient
• Bipolar Cauterisation -65
• Unipolar Cautery -17
• Silicon rubber band -29
• Interval Salpingectomy -43
• Postpartum Salpingectomy -20

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• Reversal of sterilisation
• - Depends on method of sterilization, Site
  of
• tubal occlusion, residual tubal length.
• - Reanastomosis of cauterised tube -15
• - Reversal of Pomeroys - lt 3
• Tubal reconstructive surgery (4-5 times)
• Assisted Reproductive technique
• - Ovulation induction, IVF-ET and GIFT
  (4-7)
• - Risk of heterotopic pregnancy(1)
• Previous Ectopic Pregnancy
• - 7-15 chances of repeat ectopic
  pregnancy
• - If first pregnancy is ectopic then 30
  chance
• of repeat ectopic

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• Developmental defects of tube
• elongation, diverticulum, accessory ostia,
  intamural polyp, entrap the ovum on its way.
• Other Risk factors
• - Age 35-45 yrs
• - Previous induced abortion
• - Previous pelvic surgeries
• - Cigarette smoking
• - DES Exposure in Utero

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• - Infertility
• - Salpingitis Isthmica Nodosa
• - Genital Tuberculosis
• - Fundal Fibroid Adenomyosis of tube
• - Transperitoneal migration of ovum
• - Iffy hypothesis Theory of reflux
• menstural fluid throw the fertilised
  ovum into
• the tube
• Factors facilitating nidation of ovum in tube
• - Premature degeneration of zona pellucida
• - Increased decidual reaction
• - Tubal endometriosis

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• MODE OF TERMINATION
• 1. Tubal mole

Complete absorption
Abortion
Pelvic haematocele
Complete
Pelvic haematocele
2. Tubal Abortion (18-20)
Incomplete
Diffuse Intraperitoneal haemorrhage
Roof
Diffuse Intraperitoneal haemorrhage
3. Tubal Rupture
Floor
Intraligamentary haematoma
(Isthmic 6-8 wks, Ampullary 8-12wks,
Interstitial -4 months)
Roof
Secondary Abdominal pregnancy
4. Tubal Perforation
Floor
Secondary Intraligamentary pregnancy
5.Continuation of Pregnancy
rarest
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• CLINICAL APPROACH
• Dignosis can be done by history, detail
  examination and judicious use of investigation.
• H/o past PID, tubal surgery,current contraceptive
  measures should be asked
• Wide spectrum of clinical presentation from
  asymtomatic pt to others with acute abdomen and
  in shock.

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• ACUTE ECTOPIC PREGNANCY
• Classical triad is present in 50 of pt with
• rupture ectopic.
• - PAIN- most constant feature in 95 pt
• - variable in severity and
  nature
• - AMENORRHOEA- 60-80 of pt
• - there may be delayed period or
  slight
• spotting at the time of expected
  menses.
• - VAGINAL BLEEDING - scanty dark brown
• Feeling of nausea,vomiting,fainting attack,
  syncope attack(10) due to reflex vasomotor
  disturbance.

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• O/E- patient is restless in agony, looks
  blanched,
• pale, sweating with cold clammy
  skin.
• Features of shock, tachycardia,
  hypotension.
• P/A- abdomen tense, tender mostly in lower
• abdomen shifting dullness, rigidity
  may be
• present.
• P/S- minimal bleeding may be present
• P/V- uterus may be bulky, deviated to opposite
• side, fornix is tender, excitation
  pain on
• movement of cervix.
• POD may be full, uterus floats as if
  in water.

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• CHRONIC ECTOPIC PREGNANCY
• It can be diagnosed by high clinical suspicion.
• Patient had previous attack of acute pain from
  which she has recovered.
• She may have amenorrhoea, vaginal bleeding with
  dull pain in abdomen,and with bladder and bowel
  complaints like dysuria,frequency or retention of
  urine, rectal tenesmus.

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• O/E- patient look ill, varying degree of pallor,
  
• slightly raised temperature.
  Features of shock
• are absent.
• P/A- Tenderness and muscle guard on the lower
• abdomen.
• A mass may be felt, irregular and
  tender.
• P/V- Vaginal mucosa pale, uterus may be normal
• in size or bulky, ill defined boggy
  tender
• mass may be felt in one of the
  fornix.
• P/R- Corrobarate the pelvic findings.

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• UNRUPTURED ECTOPIC
• High degree of suspicion ectopic conscious
  clinician can diagnose.
• Diagnosed accidentally in Laparoscopy or
  Laparotomy
• C/F delayed period, spotting with discomfort
  in
• lower abdomen.
• P/A tenderness in lower abdomen
• P/V should be done gently
• uterus is normal size, firm
• small tender mass may be felt in the
  fornix

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• DIAGNOSIS
• Patient with acute ectopic can be diagnosed
  clinically.
• Blood should be drawn for Hb gm, blood grouping
  and cross matching, DC and TWBC, BT, CT.
• Should be catheterized to know urine output.
• Bed side test-
• 1. Urine pregnancy test- positive in 95
  cases.
• ELISA is sensitive to 10-50 mlU/ml of ß
  hCG and
• can be detected on 24th day after LMP.

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• 2. Culdocentesis- (70-90)
• - Can be done with 16-18 G lumbar
• puncture needle through posterior
  fornix
• into POD.
• - Positive tap is 0.5ml of non
  clotting blood.
• Other Investigations-
• 1. Ultra Sonography-
• a) Transvaginal Sonography (TVS) is
  more
• sensitive
• -It detect intrauterine
  gestational sac at 4-5
• wks and at S-ß hCG level as low
  as 1500
• IU/L .

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• b) Color Doppler Sonography(TV-CDS)
• - Improve the accuracy.
• - Identify the placental shape
  (ring-of-fire
• pattern) and blood flow outside the
  uterine cavity.
• c) Transabdominal Sonography
• - can identify gestational sac at 5-6 wks
• - S-ß hCG level at which intrauterine
  gestational
• sac is seen by TAS is 6500 IU/L.

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• USG PICTURE
• 1.Bagel sign Hyperechoic ring around
  gestational sac in adnexal region
• 2. Blob sign Seen as small inconglomerate
  mass next to ovary with no evidence of sac or
  embryo.
• 3. Adnexal sac with fetal pole and cardiac
  activity is most specific.
• 4. Corpus luteum is useful guide when looking for
  EP as present in 85 cases in Ipsilateral ovary.

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Hyperechoic ring around gestational sac in
adnexal region
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• CO RELATION BETWEEN USG HCG

S-hCG lt 6500 IU/L sac not visible
S hCG gt 6500 IU/L

• - Normal pregnancy at
• early wks
• Abnormal IU pregnancy
• Recent abortion
• Ectopic pregnancy
• Non pregnant pt

Sac not visible
Sac visible by TAS
Ectopic or Non viable
Viable Intrauterine pregnancy
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• 2. ß-HCG Assay-
• a) Single ß-HCG little value
• b) Serial ß-HCG is required when result
  of
• initial USG is confusing.
• - When hCG level lt 2000 IU/L doubling
  time
• help to predict viable Vs nonviable
  pregnancy.
• -Rise of ß-HCG lt66 in 48 hrs indicate
• ectopic pregnancy or nonviable
  intrauterine
• pregnancy .
• Biochemical pregnancy is applied to those
  
• women who have two ß-HCG values gt10 IU/L

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• 3. Serum Progesterone
• - level gt25 ngm/ml is suggestive of
  normal
• intrauterine pregnancy.
• - level lt15 ngm/ml is suggestive of
  ectopic
• pregnancy.
• - level lt5 ngm/ml indicates nonviable
• pregnancy, irrespective of its location.
• 4. Diagnostic Laparoscopy (Gold standard)
• - Can be done only when patient is
• haemodynamically stable.
• -It confirms the diagnosis and removal of
  
• ectopic mass can be done at the same
  time.

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• 5. Dilatation Curettage
• - Is recommended in suspected case of
• incomplete abortion vs ectopic pregnancy.
• - Identification of decidua without chorionic
  
• villi is suggestive of extra uterine
  pregnancy.
• - Arias-Stella endometrial reaction is
• suggestive but not diagnostic of ectopic
  
• pregnancy.
• 6. Other hormonal Tests
• - Placenta protein (PP14) decrease in EP
• - PAPPA (Pregnancy Associated Plasma Protein
  A),
• PAPPC (schwangerchaft protein 1) has low
  value in EP
• - CA-125, Maternal serum creatine kinase,
  Maternal serum AFP elevated in ectopic pregnancy.

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• SUSPECTED ECTOPIC PREGNANCY
• Urine Pregnancy test
  positive

Transvaginal USG
IU sac
No IU sac
Quantitative S-hCG
S progesterone
lt 66 rise in 48 hr or S progesterone lt 5-10 ng/ml
gt66 rise in 48 hr or
S progesterone gt 5-10 ng/ml
D C
Repeat S-hCG in 48 hrs till USG discrimination
zone
Villi present
Villi absent
Laparoscopy
IU sac
No sac
Incomplete abortion
Continue to monitor
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• DIFFERENTIAL DIAGNOSIS
• D/D of Acute Ectopic
• 1. Rupture corpus luteum of pregnancy
• 2. Rupture of chocolate cyst
• 3. Twisted ovarian cyst
• 4. Torsion / degeneration of pedunculated
  fibroid
• 5. Incomplete abortion
• 6. Acute Appendicitis
• 7. Perforated peptic ulcer
• 8. Renal colic
• 9. Splenic rupture

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• D/D OF CHRONIC (SUB ACUTE) ECTOPIC
• 1. Pelvic abscess
• 2. Pyosalpinx
• 3. Subserous uterine fibroid
• 4. Salpingintis
• 5. Retroverted gravid uterus
• 6. Appendicular lump

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• MANAGEMENT

Expectant management
Medical management
Surgical management
Radical
Conservative
Local
Systemic
(USG or Laparoscopic)
Salpingectomy
salpingocentesis
Methotrexate

• Salpingostomy
• Salpingotomy
• - Segmental
• resection
• Milking or fimbrial
• expression

• Methotrexate
• - Potassium chloride
• - Prostagladin(PGF2a)
• - Hypersmolar glucose
• Actinomycin D
• Mifepristone

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• EXPECTANT MANAGEMENT
• CRITERIA
• 1. Haemodynamically stable
• 2. Haemoperitoneum lt 50ml
• 3. Adnexal mass of lt 3.5 cm without heart
  beat.
• 4. Initial ß HCG lt1000 IU/L and falling in
  titre
• SUCCESS RATE - Upto 60
• PROTOCOL
• - Hospitalization with strict monitoring of
  clinical symptom
• - Daily Hb estimation
• - Serum ß HCG monitoring 3-4 days until it
  is lt10 IU/L

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• MEDICAL MANAGEMENT
• Surgery is the mainstay of T/t worldwide
• Medical M/m may be tried in selected cases
• CANDIDATES FOR METHOTREXATE (MTX)
• Unruptured sac lt 4cm without cardiac activity
• or lt 3.5 cm with cardiac activity
• S-hCG lt 10,000 IU/L
• Persistant Ectopic after conservative surgery
• PHYSICIAN CHECK LIST
• CBC, LFT, RFT, S-hCG
• Transvaginal USG within 48 hrs
• Obtain informed consent
• Anti-D Ig if pt is Rh negative
• Follow up on day1, 4 and 7.

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• MEDICAL MANAGEMENT
• Methotrexate

(Systemically IM, IV, Oral)
Single dose (recent)
Multiple dose (in the past)
MTX 1mg/kg IM on D 1,3,5,7
Citrovorum 0.1mg/kg on D 2,4,6,8
50mg/m2 IM

• D1 ß-HCG, CBC, LFT, RFT
• D4 - ß-HCG
• D7 - ß-HCG, CBC, LFT, RFT

• Weekly ß-HCG till negative titre

• If ß-HCG decrease is lt 15 D4 D7
• then repeat the MTX dose
• If decline is gt 15 then weekly measure
• ß-HCG until level is lt 15 IU/L.

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SURGICALLY ADMINISTERED MEDICAL Tt (SAM)
By Salpingocentesis, MTX (1mg/kg), KCL, PGF2a,
Hyperosmolar glucose, mifepristone, Anti hCG Ab
is injected into sac by transvaginally under USG
guidance, Laparoscopy, transcervical tubal
cannulization
Advantage of local MTX -
Increase tissue concentration at local site
- Decrease systemic side effects
- Decrease hospitalization
- Greater preservation of fertility
Follow up - Serum ß HCG twice weekly till lt 10
IU/L - TVS weekly for 4-6
weeks - HCG after 6 months for
tubal patency
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• INSTRUCTION TO THE PATIENTS
• If T/t on outpatient basis rapid transportation
  should be available
• Refrain from alcohol, sunlight, multivitamins
  with folic acid, and sexual intercourse until
  S-hCG is negative.
• Report immediately when vaginal bleeding,
  abdominal pain, dizziness, syncope (mild pain is
  common called separation pain or resolution pain)
• Failure of medical therapy require retreatment
• Chance of tubal rupture in 5-10 require
  emergency Laparotomy.

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• MANAGEMENT OF RUPTURED ECTOPIC
• PRINCIPLE Resuscitation and Laparotomy
• ANTI SHOCK TREATEMENT
• - IV line made patent, crystalloid is started
• - Blood sample for Hb, blood grouping cross
  matching, BT, CT
• - Folleys catheterization done
• - Colloids for volume replacement
• LAPAROTOMY
• Principle is Quick in and Quick out
• - Rapid exploration of abdominal cavity is
  done
• - Salpingectomy is the definitive surgery
  (sent for HP study)
• - Blood transfusion to be given
• - Autotransfusion only when donated blood not
  available.

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• MANAGEMENT OF UNRUPTURED ECTOPIC
• Conservative Surgery
• Can be done Laparoscopically or by microsurgical
  laparotomy
• INDICATION
• - Patient desires future fertility
• - Contralateral tube is damaged or surgically
  removed
• previously
• CHOICE OF TECHNIQUE depends on
• - Location and size of gestational sac
• - Condition of tubes
• - Accessibility

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• VARIOUS CONSERVATIVE SURGERIES
• 1.Linear Salpingostomy
• - Indicated in unruptured ectopic lt2cm in
  ampullary region.
• - Linear incision given on antimesentric border
  over the site
• and product removed by fingers, scalpel
  handle or gentle
• suction and irrigation.
• - Incision line kept open (heals by secondary
  intention)
• 2. Linear Salpingotomy
• - Incision line is closed in two layers with
  7-0 interrupted
• vicryl sutures.
• 3. Segmental Resection Anastomosis
• - Indicated in unruptured isthmic pregnancy
• - End to end anastomosis is done immediately
  or at later
• date

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• 4. Milking or fimbrial Expression
• - This is ideal in distal ampullary or
  infundibular pregnancy.
• - It has got increased risk of persistent
  ectopic pregnancy.
• ADVANTAGES OF LAPAROSCOPY
• - It helps in diagnosis, evaluation, and
  treatment .
• - Diagnose other causes of infertility.
• - Decreased hospitalization, operative time,
  recovery period,
• analgesic requirement.
• Follow up after conservative surgery
• - With weekly Serum ß HCG titre till it is
  negative.
• - If titre increases methotrexate can be
  given.

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• DEBATABLE ISSUES
• ? Salpingectomy Vs Salpingostomy
• ? Laparotomy Vs Laparoscopy
• ? Reproductive outcome
• ? Risk of Recurrent Ectopic

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• Salpingectomy Vs Salpingostomy
• - If future fertility is a consideration
  the factors to be taken into account are status
  of Ipsilateral tube, Contralateral tube, other
  pelvic pathology.
• - Report shows there is no significant
  difference in subsequent reproductive outcome
  with regard to IU pregnancy or recurrent Ectopic.
• - Linear Salpingostomy is currently procedure
  of choice, when pt has unruptured Ectopic and
  wishes to retain her potential for future
  fertility.
• - In pt with only one tube, conservative
  surgery may be appropriate but only when pt is
  aware and accept the risk involved.

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• Laparotomy Vs Laparoscopy
• - Laparoscopy is reserved for pt who are
• hemodynamically stable.
• - Ruptured Ectopic does not necessarily require
  
• Laparotomy, but if large clots are present
• Laparotomy should be considered.
• Reproductive outcome
• Is similar in pt treated with either
  Laparoscopy or Laparotomy.
• Identical rates of 40 of IUP, around 12 risk
  of recurrent pregnancy with either radical or
  conservative pregnancy.

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• PERSISTENT ECTOPIC PREGNANACY
• Defined as continued growth of trophoblastic
  tissue after
• conservative treatment (3 20 incidence)
• Risk Factor
• 1. Early ectopic pregnancy (lt 6 wks
  amenorrhoea)
• 2. Smaller size lt 2 cm (Incomplete removal)
• 3. Preoperative high serum ß HCG (gt 3,000
  IU/L)
• 4. Decrease in postoperative Day1 titre is lt
  50 of
• preoperative level, is predictor of
  persistent EP.
• Treatment

surgery
Medical
(selected Asymptomatic pt)
Total or partial salpingectomy
MTX Leukovorin
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• OVARIAN ECTOPIC PREGNANCY
• Incidence 140,000
• Risk factor - IUCD
• - Endometriosis on surface of
  ovary
• Course C/F are same as tubal pregnancy
• ruptures within 2-3 wks
• Diagnosis On Laparotomy
• Spiegelbergs Criteria
• 1. Ipsilateral tube is intact and separate
  from sac
• 2. Sac occupies the position of the ovary
• 3. Connected to uterus by ovarian ligament
• 4. Ovarian tissue found on its wall on HP
  study
• M/M

Unruptured
Ruptured
Ovarian wedge resection
Laparotomy
Ovarian Cystectomy
Oophorectomy
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• ABDOMINAL PREGNANCY
• Incidence Rarest
• MMR 7-8 times gt tubal ectopic
• 90 times gt Intrauterine pregnancy
• H/O - Irregular bleeding, spotting
• - Nausea, vomiting, flatulence,
  constipation,
• diarrhoea, abdominal pain.
• - Fetal movement may be painful and high
  in
• the abdomen
• O/E - Abnormal fetal position, easy in
  palpating
• fetal parts.
• - uterus palpated separate from sac
• - no uterine contraction after oxytocin
  
• infusion

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• Diagnosis Confirmed by USG, CT scan, MRI,
  Radiography
• TYPE

Primary
Secondary
Studifords criteria
Conceptus escapes out through a rent from
primary site

• Both tubes and ovaries normal
• Absence of Uteroperitonal fistula
• Pregnancy related to Peritoneal
• surface young enough to rule
• out possibility of secondary
• implantation

Intraperitoneal
Extraperitoneal Broad ligament
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• FATE OF SECONDARY ABDOMINAL PREGNANCY
• 1. Death of ovum complete absorption
• 2. Placental separation massive
  intraperitoneal
• 
  haemorrhage
• 3. Infection fistulous communication
  with intestine,
• bladder, vagina, or
  umbilicus
• 4. Fetus dies (majority)
  mummification, adipocere
• formation, or
  calcified to lithopaedion
• 5. Rarely continue to term
  (malformation)
• M/M
• - Urgent Laparatomy irrespective of
  period of gestation
• - Ideal to remove entire sac fetus,
  placenta, membrane
• - Placenta may be left if attached to
  vital organs, get
• absorbed by aseptic autolysis

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• CERVICAL PREGNANCY
• Implantation occurs in cervical canal at or below
  internal Os.
• Incidence 1 in 18,000
• RISK FACTORS
• - Previous induced abortion
• - Previous caesarean delivery
• - Ashermans syndrome
• - IVF
• - DES exposure
• - Leiomyoma

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• Diagnosis
• CLINICAL CRITERIA Paulman McEllin
• 1. Uterine bleeding, no cramping,
  following
• amenorrhoea
• 2. Cervix gt Corpus, soft consistency
• 3. POC confined to endocervix
• 4. Internal Os is closed
• 5. External Os is partially opened
• USG CRITERIA American Journal of OG
• 1. Echo-free uterine cavity/
  pseudo-gestational
• sac
• 2. Decidual reaction
• 3. Hourglass uterus with ballooned
  cervical canal
• 4. Gestational sac in endocervix
• 5. Closed internal Os
• 6. Placental tissue in Cx canal

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• HISTOPATHOLOGIC CRITERIA Rubins
• 1. Cervical glands present opposite to
  placenta
• 2. Placental attachment to the cervix must
  be
• below the entrance of uterine vessels .
• 3. Fetal element absent from corpus uteri.
• D/d
• - Carcinoma Cx
• - Cervical submucous fibroid
• - Trophoblastic tumour
• - Placenta previa

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• M/M
  

Medical
Surgical
Recently proposed
Mainstay therapy in past
Single or Combination OR Adjunct to
surgery
Conservative
Radical surgery
D C

• Methotrexate
• Actinomycin
• KCl
• Etoposide

(risk of torrential bleeding)
Hysterectomy

• Cerclage Bernstein Mc Donalds
• Wharton Shirodkars

• Transvaginal ligation of Cx branch of
• uterine artery
• - Angiographic uterine A embolisation

• Intracervical vasopressin inj
• Foleys catheter as tamponade

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• CORNUAL PREGNANCY
• SITE Implantation occurs in rudimentary horn of
  Bicornuate
• uterus
• COURSE Rupture of horn occurs by 12 20 wks
• D/D
• 1. Interstitial tubal pregnancy
• 2. Painful leiomyoma along with pregnancy
• 3. Ovarian tumor with pregnancy
• 4. Asymmetrical enlargement of uterus.
• Implantation into cornu of normal uterus
  is sometime
• called Angular pregnancy .
• TREATEMENT
• - Affected cornu with pregnancy is
  removed
• - Hysterectomy
• - Hysteroscopically guided suction
  curettage if

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• HETEROTYPIC PREGNANCY
• Co-existing intrauterine and extra uterine
  pregnancies
• Incidence 1 30,000
• With ART 17000
• With ovulation induction
  1900
• More likely
• a) Ass. reproductive technique
• b) Rising HCG titre after D C
• c) More than 1 corpus luteum at
  laparotomy
• M/M
• Depends on the site. Ectopic site may be
  removed
• with continuation of IU pregnancy
• (Rh Immunoglobulin dose of 50 µ gm is
  sufficient to
• prevent
  sensitization.)

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• INTERSTITAL PREGNANCY (2)
• It ruptures late at 3-4 months gestation.
• Fatal rupture severe bleeding as both uterine
  
• ovarian artery supply.
• Early Unruptured Local or IM MTX with
  followup
• Cornual resection by Laparotomy may be
  done.
• There is high risk of uterine rupture in
  
• subsequent pregnancy.
• Rupture Hysterectomy is indicated

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• CAESAREAN SCAR ECTOPIC PREGNANCY
• Recently reported
• USG slows on empty uterine cavity and gestational
  sac attached low to the lower segment caesarean
  scar.
• C/F similar to threatened or inevitable
  abortion
• Diagnosis Doppler imaging confirms
• T/t Methotrexate injection
• Hysterectomy in a multiparous women.
• In young pt resection suturing of scar
  may be
• done (high risk of rupture).

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• OTHER RARE TYPES
• 1. Multiple Ectopic pregnancy
• 2. Pregnancy after hysterectomy
• 3. Primary splenic pregnancy
• 4. Primary hepatic pregnancy
• 5. Rectroperitoneal pregnancy
• 6. Diaphragmatic pregnancy
• MORTALITY In general population is 10-15
  mainly
• due to haemorrhage.

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• CONCLUSION
• Ectopic pregnancy can be diagnosed early (before
  it ruptures) with recent advances in Immunoassay
  to detect S-hCG , high resolution USG, and
  dignostic Laparoscopy.
• There has been shift in the M/m from ablative
  surgery to conservative fertility preserving
  therapy
• Laparotomy should be done when in doubt
• Surgeon should not be ashamed of having negative
  abdominal exploration, rather to be disgraced for
  the mistake in diagnosis with the eventual
  fatality.

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Thank you