Solanke SS*, Parulekar SV**.
(* Second Year Resident, ** Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & K E M Hospital, Mumbai, India.)
A patient with a history of 6 weeks, 1 day of amenorrhea, with a history of right partial salphingectomy for tubal ectopic gestation 5 months ago presented with another right tubal ectopic pregnancy. The epidemiology, etiology and management of ipsilateral ectopic pregnancies is discussed.
Ectopic pregnancy is 1-2% of all pregnancies. The commonest site of implantation of an ectopic pregnancy, primary as well as recurrent, is the fallopian tube. There is 11-15% chance of recurrent ectopic pregnancy. We present the a case describing a recurrent ectopic pregnancy with a cardiac activity after ipsilateral salpingectomy that led to tubal rupture.
A 26-years-old woman, underwent exploratory laparotomy with right partial salpingectomy for ruptured right tubal ectopic pregnancy. She returned to our hospital 5 months later as gravida 3, previous one ectopic pregnancy and one spontaneous abortion with 6 weeks and 1 day of amenorrhea. She had lower abdominal pain for 2 days. She had done her own pregnancy test at home, which was positive. Her general condition was fair. Her vital parameters were in normal limits. General and systemic examination revealed no abnormality. Abdominal examination showed a 5 cm long midline vertical infraumbilical scar. Bimanual pelvic examination showed a normal sized uterus and mild tenderness in the right vaginal fornix. Transvaginal ultrasonography revealed no intrauterine gestational sac but a right adnexal mass containing gestational sac of diameter 10.1 mm and fetus of crown-rump length of 3.3 mm. Fetal cardiac activity was present. Her serum beta-hCG level was 13240 mIU/ml. A diagnosis of right tubal ectopic pregnancy was made. Her investigations for fitness for anesthesia showed normal results. A diagnostic laparoscopy was performed, which showed an ectopic pregnancy in the medial remnant of the right fallopian tube. Omental adhesions were seen to the lateral part of the pelvic peritoneum. Mild hemoperitoneum was seen, which was suggestive of recent rupture of ectopic pregnancy. An exploratory laparotomy was done and excision of right fallopian tubal stump attached to the uterus along with ectopic gestational sac was done. The lateral part of the tube was absent. Modified Coffey’s stitch was taken to cover right cornual stump. The patient's postoperative recovery was uneventful. The histopathology report showed chorionic villi, confirming the diagnosis of an ectopic pregnancy.
Figure 1. Ectopic pregnancy (arrows) in the right tubal medial stump (FT). The right ovary (O) and uterus (U) are also seen.
The occurrence of a tubal pregnancy in the remnant of a fallopian tube after ipsilateral salpingectomy for an ectopic pregnancy is very rare, there being only sixteen cases in the literature. This is the seventeenth such case in the world literature. The residual stump of the fallopian tube left attached to the uterus after partial salpingectomy is likely to be small, usually the isthmic portion of the tube. Maternal mortality is much higher with isthmic ectopic pregnancy than with ectopic pregnancy in the other parts of the fallopian tube. In the case presented, the ectopic pregnancy was indeed in the isthmic part of the fallopian tube.
When a tubal ectopic pregnancy is managed by removing the affected segment of the fallopian tube (partial salpingectomy), the medial and lateral segments left behind remain separate in most of the cases. However, a pregnancy may still occur through that fallopian tube, due to recanalization or tuboperitoneal fistula formation (of the medial segment). If the opening in the recanalization or fistula is too small to permit the passage of a fertilized ovum, it gets arrested lateral to that opening and a tubal pregnancy results. Another explanation is transmigration of the fertilized ovum from the other side. Occurrence of an ectopic pregnancy after surgical removal of a tubal ectopic pregnancy in the past is more common on the contralateral side.[7,8]
Our patient was found to have undergone a partial salpingectomy, and had an isthmic stump. There was no lateral part of the tube. This ruled out a tubo-tubal recanalization as a cause of the ectopic pregnancy. The ectopic was just lateral to the lateral end of the medial segment, suggesting that the cause was tuboperitoneal fistula formation. This risk would have been avoided by covering the cut and ligated ends of the fallopian tube with peritoneum after partial salpingectomy in the past. A modified Coffey’s stitch would have avoided it too.
We recommend partial salpingectomy for the management of a tubal ectopic pregnancy, keeping the cut ends separate, followed by modified Coffey’s stitch or peritonization of the cut and ligated ends of the fallopian tube. This preserves the potential for a future tubotubal anastomosis should the need arise due to loss of the other fallopian tube and the patient desires a pregnancy. Assisted reproduction would be a better option than a tubal reconstructive surgery, but the cost prevents a lot of poor patients from opting for that form of treatment. Adequate peritonization prevents occurrence of an ectopic pregnancy on that side.
We thank Dr Durga Valvi for taking operative photograph.
- Farquhar C.M. Ectopic pregnancy. Lancet. 2005;366(August 13–19(9485)):583–591.
- Bouyer J., Coste J., Fernandez H., Pouly J.L., Job-Spira N. Sites of ectopic pregnancy: a 10-year population-based study of 1800 cases. Hum. Reprod. 2002;17:3224–3230.
- Abraham C, Seethappan V. Spontaneous live recurrent ectopic pregnancy after ipsilateral partial salpingectomy leading to tubal rupture. Int J Surg Case Rep. 2014;7C:75–78. doi:10.1016/j.ijscr.2014.12.028
- Lau S., Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil. Steril. 1999;72(2):207–215.
- Kaplanoğlu M, Kaplanoğlu D, Yüce T, Kiran H. Ruptured ipsilateral ectopic pregnancies: a rare emergency case series. Clin Exp Obstet Gynecol. 2015;42(1):67-8.
- Ross JA, Davison AZ, Sana Y, Appiah A, Johns J, Lee CT. Ovum transmigration after salpingectomy for ectopic pregnancy. Hum Reprod. 2013 Apr;28(4):937-41.
- Liang C, Li X, Zhao B, Du Y, Xu S. Ruptured ipsilateral ectopic pregnancies: a rare emergency case series. J Obstet Gynaecol Res. 2014 Mar;40(3):849-52.
- Longoria TC, Stephenson ML, Speir VJ. Live unilateral twin ectopic pregnancy in a fallopian tube remnant after previous ipsilateral salpingectomy. J Clin Ultrasound. 2014 Mar-Apr;42(3):169-71.