Ectopic pregnancy (EP) is an obstetric emergency that can be life-threatening, in which the fertilized ovum implants outside the uterine cavity, most often in the fallopian tube.[1] It is responsible for about 1-2% of pregnancies and is the most common cause of maternal death in the first trimester.[2] It is responsible for a significant amount of early pregnancy-related morbidity because of tubal rupture and massive intra-abdominal bleeding.[3] Despite the improvement in diagnosis with ultrasonography and the introduction of serum β-human chorionic gonadotropin (β-hCG) testing, delayed presentation remains common in LMICs.[4]

The treatment for an ectopic pregnancy depends on the patient's hemodynamic status, β-hCG level, sonogram, and her fertility desires.[5] Laparoscopic surgery is now the preferred surgical technique in hemodynamically stable patients, due to the advances in this field during the last 20 years and the advantages it has over laparotomy, such as decreased blood loss, less postoperative pain, shorter hospital stay, faster postoperative recovery, and better cosmetic results.[6] More recent systematic reviews have also found that laparoscopic management gives an excellent perioperative benefit and is equivalent in treatment success.[7]

Although diagnosis and treatment of ectopic pregnancy have improved over the years, the condition still has a significant impact on health globally.[5] The Global Burden of Disease study showed that while age-standardized incidence and mortality rates have decreased in the past few decades, the burden is still disproportionately high in LMICs where late diagnosis and limited access to minimally invasive surgery are the norm.[8, 9]

In Pakistan, published experience with laparoscopic treatment of ectopic pregnancy is scanty, and most reports have been from a single centre with a small number of patients.[10]  Assessing the experience and outcomes of laparoscopic management is crucial to understanding the surgical outcomes, challenges, and to creating local evidence for improving clinical practice in resource-limited settings. This information can also inform future recommendations for patient selection, surgical techniques, and peri-operative care. The present study aimed to assess the clinical features, intra-operative findings, and surgical results of the patients undergoing laparoscopic treatment of ectopic pregnancy in a tertiary care centre in Pakistan.

A total of 120 women with ectopic pregnancy who underwent laparoscopic management were included in the study. The mean age was 29.8 ± 5.7 years, mean body mass index was 25.3 ± 3.9 kg/m², and the mean gestational age at presentation was 7.4 ± 1.8 weeks. The median serum β-hCG level was 4,120 mIU/mL (IQR: 2,350–6,980). The majority of the patients were between 25 and 34 years of age (55.8%), and 67.5% of patients were multiparous. In 22.5% of patients, there was a history of previous abdominal or pelvic surgery, 11.7% had a history of previous ectopic pregnancy, 15.8% had a history of pelvic inflammatory disease, and 13.3% had a history of infertility. (Table 1).

The most common symptom was lower abdominal pain (96.7%), followed by amenorrhea (92.5%) and vaginal bleeding (65.0%). On admission, 90.0% of women were hemodynamically stable. At presentation, 28.3% were found to be mildly anaemic and 21.7% moderately to severely anaemic. (Table 2).

At the time of the operation, it was found that the most frequent ectopic site was the ampullary region (73.3%), and the isthmic region was the second most frequent site (12.5%). The majority of patients had a left-sided ectopic pregnancy (59.2% vs. 40.8%). Of those, 35.8% had tubal rupture and 57.5% had hemoperitoneum with a median amount of 420 mL (IQR: 200–850). In 9.2% of cases, fetal heart movement was identified. (Table 3).

The mean operative time was 61.8 ± 18.4 minutes, mean estimated blood loss was 188.5 ± 105.6 mL, and the average hospital stay was 1.8 ± 0.7 days. The most common surgical procedure was salpingectomy (80.0%), and salpingostomy was performed in 16.7% of patients. In 15.0% of patients, blood transfusion was necessary, 4.2% needed laparotomy and postoperative complications were noted in 6.7%. The laparoscopy was performed successfully in 95.8% of the patients. (Table 4).

Median β-hCG levels, operative duration, blood loss, blood transfusion requirement, and hospital stay were all significantly higher in women with tubal rupture when compared to those with unruptured ectopic pregnancy (all p<0.001). No statistically significant difference was found between the two groups concerning age (p = 0.183). (Table 5).

Univariate analysis revealed that age ≥ 35 years, obesity (BMI ≥ 30 kg/m²), previous pelvic surgery, tubal rupture, hemoperitoneum more than 500 mL, operative time more than 60 minutes, and blood transfusion were significantly associated with postoperative complications. (Table 6).

Multivariable logistic regression demonstrated that tubal rupture (p=0.022), hemoperitoneum >500 mL (p=0.010), operative time >60 minutes (p=0.035), and blood transfusion (p = 0.007) remained independent predictors of postoperative complications. In contrast, age ≥35 years and BMI ≥30 kg/m² were not independently associated with adverse postoperative outcomes after adjustment for potential confounders. (Table 7).

Table 1. Baseline demographic and clinical characteristics of the study participants (n=120)

Table 2. Clinical presentation of patients (n=120)

Table 3. Ultrasonographic and operative findings (n=120)

Table 4. Operative characteristics and surgical outcomes (n=120)

Table 5. Comparison of patients with ruptured and unruptured ectopic pregnancy (n=120)

Table 6. Factors associated with postoperative complications  (n=120)

Table 7. Multivariable binary logistic regression for predictors of postoperative complications

In the present study, there was a high success rate of laparoscopy for treating ectopic pregnancy, and the conversion rate to laparotomy was low (4.2%). This is corroboration of the prevailing evidence that laparoscopy is a safe and effective surgical technique in hemodynamically stable women with ectopic pregnancy. A recent systematic review and meta-analysis conducted by Zhai et al. (2024) has also found that laparoscopic surgery had a lower risk of blood loss, shorter hospital stay, lower postoperative pain, and quicker postoperative recovery than laparotomy surgery while providing similar treatment success.[12] In the same vein, excellent perioperative results and enhanced reproductive potential after laparoscopic surgery were reported by Yu et al. (2024), further supporting the use of minimally invasive surgery as the preferred treatment method.[13]

The median age of our patients was 29.8 years (range 24-35 years), and most of these patients were in the age group 25-34. About two-thirds of the study population was multiparous, and previous ectopic pregnancy, low fertility, and pelvic inflammatory disease were found in smaller percentages. These results are similar to those of Mutiso et al., (2026), who reported that the majority of women who had been treated with laparoscopy were in the reproductive age group with comparable risk factor characteristics. A similar age distribution was reported by Mutiso (2024) who found that the women who had ectopic pregnancies on laparoscopy were most likely to be aged 28-32 years. These similarities probably mirror the age at which women are most likely to become pregnant, which is the age at which ectopic pregnancy occurs most frequently.

In terms of clinical presentation, the dominant symptoms in our cohort were lower abdomen pain, amenorrhea, and vaginal bleeding, with almost 90% of patients being hemodynamically stable. These are similar to the findings of Mutiso (2024), who found that abdominal pain and amenorrhea were the most common complaints reported by women with ectopic pregnancy.[14] Similarly, Vertongen et al. (2025) noted that most patients who underwent minimally invasive surgery were antecedents to circulatory collapse and thus were suitable for laparoscopy. The growing number of stable patients undergoing laparoscopy has probably been a result of early diagnosis, which is assisted by transvaginal ultrasonography and serum β-hCG estimation.

In our study, the most frequent site of implantation was the ampullary portion (73.3%), followed by the isthmic part of the fallopian tube. One-third of patients had tubal rupture. The results are very similar to those of Mutiso (2024), who found that the ampulla was the most common site, accounting for more than three-quarters of the cases.[15] The same distribution is reported by other researchers, such as Yu et al. (2024), who also found that ampullary ectopic pregnancy is the most common location due to the relatively long time the fertilized ovum takes to pass through this part of the fallopian tube.[13]

Salpingectomy was applied to 80% of patients, while 20% of women who wanted to maintain fertility received salpingostomy. This choice aligns with the current international practice, especially in the event of tubal rupture or a considerable amount of tubal injury. Lin et al. (2022) conducted a systematic review and found that salpingostomy should be considered in some patients to allow for future fertility, although salpingectomy is the recommended surgery if the tube is highly damaged or bleeding.[16] Moreover, the meta-analysis by Marchand et al. (2025) showed that various types of laparoscopy lead to surgical success with comparable results and good peri-surgical outcomes, and that the choice of the procedure can be made based on individual clinical situations.[17]

The operative time was around 62 minutes, a low amount of blood loss, and a hospital stay of 1.8 days were recorded in our study. These observations are similar to those of Yu et al. (2024), who found that hospitalization duration was shorter and blood loss decreased after laparoscopic surgery.[13] Similarly, Vertongen et al. (2025) showed that minimally invasive surgical techniques resulted in a rapid postoperative recovery and early discharge, which are continued benefits of laparoscopic surgery over more invasive techniques.[18]

The serum β-hCG level, blood loss, operative time, transfusion requirements, and length of hospital stay were significantly greater in patients with ruptured ectopic pregnancy than in those with unruptured ectopic pregnancy in our study. Similar findings were noted by Mutiso (2024), who reported a correlation between ruptured ectopic pregnancy and complicated intra-operative findings and the extent of surgical difficulty.[15] Similarly, in their retrospective study comparing minimally invasive surgery for ectopic pregnancy with conventional surgical treatment, Zhang et al. (2025) reported similar adverse relationships between the degree of advanced disease and perioperative results.[19]

Tubal rupture, blood transfusion, and an operative time longer than 10 minutes were independent factors associated with postoperative complications as revealed by a multivariable analysis. Tubal rupture, hemoperitoneum >500 mL, and the need for blood transfusion were independent risk factors for postoperative complications as revealed by a multivariable analysis. The results are clinically plausible as extensive intra-abdominal bleeding and technically challenging procedures result in increased operative difficulty and postoperative morbidity. Few recent studies have specifically examined predictors of complications, but Mutiso et al. (2026) also found that disease severity and extensive findings during the surgery were correlated with poorer surgical outcomes. The systematic review by Zhai et al. (2024) also highlighted that early diagnosis and prompt laparoscopic management significantly decrease perioperative complications, as they do not allow tubal rupture and massive hemoperitoneum to occur.[11, 12]

All literature published internationally showed that laparoscopy is a tool that offers high surgical success, little morbidity, fast postoperative recovery, and low complication rates in suitable patients for managing ectopic pregnancy. The present study adds useful information from Pakistan, where the published evidence of laparoscopy in the management of ectopic pregnancy is limited, and will help in the wider use of minimally invasive surgery in tertiary-level hospitals.

Limitations

There were some limitations to this study. The first is that it is a retrospective study that was conducted in a single center, which limits the generalizability of the results to other healthcare settings. Secondly, using medical records could have led to incomplete medical information and information bias. Third, subsequent pregnancies, ectopic pregnancy recurrence, and patients' reported quality of life could not be assessed due to a lack of follow-up data. Lastly, because no control group received medical management or laparotomy, there was no opportunity to compare the effectiveness of the two treatment options directly.

The laparoscopic treatment of ectopic pregnancy was determined to be a safe and effective surgical procedure, with a high rate of laparoscopic completion, low conversion rates to laparotomy, no significant postoperative complications, and a short hospital stay. Ampullary ectopic pregnancy was the most common presentation, and tubal rupture, large-volume hemoperitoneum, operative time, and transfusion were independent risk factors for postoperative complications. Early diagnosis and prompt referral for laparoscopic intervention may be beneficial in improving surgical outcomes and minimizing morbidity. The results of this study reinforce the use of minimally invasive surgery in the management of suitable cases of ectopic pregnancy in the tertiary care hospitals of Pakistan.

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