Ectopic Pregnancy after Ipsilateral Salpingectomy

Abstract

Ectopic pregnancy is a significant health problem for women prevalence is increase in patient with history of previous ectopic pregnancy or pelvic surgeries or pelvic inflammatory disease, and widespread treatment with assisted reproductive technologies the incidence of ectopic pregnancies has greatly increased during the past two decades and it is now estimated to occur in 2% of all pregnancies recurrent ectopic pregnancy in the remnant portion of the tube after ipsilateral salpingectomy has only rarely been reported. We present unusual cases of ipsilateral ectopic pregnancy occurring in the stump of a previous ectopic site.

1. Introduction

Ectopic pregnancy (EP) is the implantation of a fertilized ovum anywhere outside of the uterine cavity [1].

Ectopic pregnancy still accounts for 4–10% of pregnancy-related deaths and leads to a high incidence of ectopic site gestations in subsequent pregnancies [2]. Early intervention saves lives and reduces morbidity around 90% of ectopic pregnancies occur in one of the fallopian tubes rare sites as in the cervix, ovary, cesarean section scar defect and the abdominal cavity [2, 3].

The fallopian tubes length about 8–10 cm extend from the uterine cornus. The sites of tubal implantation in descending order of frequency are; ampulla (73.3%), isthmus (12.5%), fimbrial (11.6%), and interstitial (2.6%) [4]. If a woman with a previous ectopic gets pregnant, the risk of a recurrent EP is increased four-fold [5].

Recently, literature review reported rare cases of recurrent ectopic pregnancy in the remnant portion of the tube after a previous ipsilateral salpingectomy [6]. Ipsilateral recurrent ectopic pregnancy may occur in the proximal or distal remnant of the operated tube [7, 8].

Ectopic pregnancy in the remnant tube is difficult to diagnose due to the unique anatomic location of the pregnancy sometimes results in delayed diagnosis [6]. Although complete tubal resection cannot prevent cornual pregnancy, it might reduce the risk of recurrent ectopic pregnancy in the remnant tube [6] while the exact incidence of ectopic pregnancy occurred in the remnant tube after ipsilateral adnexectomy is not known [6].

Tubal pregnancy associated with high risk of rupture and severe bleeding [9], due to the poor ability of this portion of the tube to distend as well as the increased vascularity of the area (anastomosis of the uterine and ovarian vessels) [10].

2. Pathophysiology

The mechanism of recurrent ipsilateral ectopic pregnancy is not clear. But there is many hypotheses including contralateral transmigrate of fertilized ovum from the intact fallopian tube across the endometrial cavity to contralateral tubal stump. And another hypotheses transperitoneal migration of the egg or embryo to the contralateral tubal stump or passage of the spermatozoa to fertilize the ovum in the proximal tubal remnant with some degree of patency or recanalization may occur in the tubal stump [6].

Another explanation for the anatomical location of the ectopic pregnancy may be through transperitoneal migration of an ovum from the contralateral ovary to the opposite tube via the pouch of Douglas. This was explained previously, that embryo or ovum migration has been described animals [11]. These findings suggest that normal tubo-ovarian integrity is not essential for pregnancy to occur. The possible paths that the gametes or the fertilized ovum can travel are illustrated in Figure 1.

Figure 1.

Laparoscopic appearance of rupture ectopic pregnancy in the proximal remnant of the right Fallopian tube.

A rare case of transperitoneal ovum migration resulting in an intra-uterine pregnancy is presented. A woman with left congenital ovarian absence and a surgically removed right oviduct, conceived following microsurgical repair of left tubal occlusion [12].

3. Diagnosis

Ultrasonographic examination is effective for the diagnosis of tubal stump pregnancy. However, in some cases, the diagnosis of tubal stump pregnancy is difficult because the tubal stump portion is near the ovary (Figure 2).

Figure 2.

Proposed hypothesis for reurrect ectopic pregnancy post isplitaeral salpingectomy A: recanalization in the tubal stump B: contralatera transmigrate of fertilized ovum from the intact fallopian tube across the endometrial cavity to contralateral tubal stump.

Ectopic pregnancy occurring in tubal stump after tubectomy is extremely rare, and the frequency of tubal stump pregnancy is approximately 0.4% of all pregnancies [13].

Due to unique anatomic location of the tubal stump pregnancy sometimes results in delayed diagnosis and it will carry high risk of rupture of the uterus in some case increase beyond 12 weeks of amenorrhea, and the rupture of the ectopic part occurs in 20% of ectopic pregnancies beyond 12 weeks of gestational age. Earlier diagnosis would decrease morbidity and increase the chance of successful minimal invasive surgery [13].

The ovarian corpus luteum is mistaken for a tubal stump pregnancy. Moreover, it is thought that many doctors pay less attention to the tube in which patients have already undergone salpingectomy because of ectopic pregnancy.

three sonographic criteria for interstitial and tubal stump pregnancies proposed by Lau and Tulandi:

1. clean uterine cavity (no sac)

2. a gestational sac seen separately and > 1 cm from the most lateral edge of the uterine cavity.

3. with thin myometrial layer surrounding the chorionic sac.7 Using the separameters, they found that the diagnosis was relatively specific (88–93%), but on the other hand, the sensitivity was only 40% for the diagnosis of interstitial and tubal stump pregnancies [13].

Another authors Timor-Tritsch et al., advocate an “interstitial line sign” the diagnosis of interstitial and tubal stump pregnancies [11].

In small-sized interstitial pregnancies, the line may represent the interstitial lesion of the tube. In large-sized interstitial pregnancies, it likely represents the endometrial canal. This sign represents the visualization of an echogenic line extending into the abutting interstitial ectopic mass of the tubal mid-portion. The diagnosis of interstitial pregnancy is 80% sensitive and 98% specific with the “interstitial line sign” technique [13]. Spontaneous interstitial pregnancy on a tubal stump after unilateral salpingectomy followed by vaginal Doppler ultrasound [14].

Per-vaginal color and angio Doppler blood flow analysis combined with serial measurement of human chorionic gonadotrophin (HCG) level is reported here for the first time to study the local vascularity of a cornual pregnancy and to monitor the effectiveness of medical therapy. They found, a strong relationship between morphological changes of trophoblastic tissue and the intensity of neovascularization was noted. Methotrexate (MTX) therapy as systemic single-dose allowed successful treatment of an interstitial ectopic pregnancy involving part of the proximal portion of a tubal stump. Conventional transvaginal ultrasonography Compound color Doppler, the outpatient surveillance of ectopic pregnancy evolution following MTX therapy is greatly enhanced. This is of particular value in cornual pregnancies which are highly likely to develop harmful complications during surgical intervention or even during puncture for local MTX injection [15].

4. Treatment

Lau and Tulandi reported, The main treatment for tubal stump pregnancy is surgery and conservative management using methotrexate that the overall success rates in surgical treatment reached 100% and that of methotrexate management was 83% [16].

The difficulty level of laparoscopic operation for interstitial and tubal stump pregnancy is higher than that of common laparoscopic salpingectomy. The operation method for tubal stump pregnancy is almost the same as that of interstitial pregnancy, and hence, the selection of operative method depends on the surgeon’s preference and expertise (Figure 3).

Figure 3.

Sonographic appearance: (A) absence of an intrauterine pregnancy (B) free fluid in the cul de sac (C) a twin ectopic pregnancy in the right adnexa.

There is a lot of successful laparoscopic surgery for interstitial and tubal stump pregnancy using an advanced bipolar device and injecting diluted vasopressin into the uterus [2, 7, 8]. Sherer et al. before incising the cornua, he recommend clamping the adjacent uterine wall to the interstitial pregnancy with long-jaw forceps [17]. Some authors, they are reports of using hysteroscopic surgery for interstitial and tubal stump ectopic pregnancy [12]. However, long-term prognosis for selecting hysteroscopic surgery are unknown.

Any subsequent pregnancy after operation for tubal stump pregnancy should be followed up carefully and cesarean delivery at term may be safer and help decrease the risks of uterine rupture during labor.

In summary, Laparoscopic surgery can be account first-line treatment for a hemodynamically stable patient with interstitial pregnancy of a small size. Sometimes, the accurate diagnosis for this type of ectopic pregnancy is difficult; therefore, we have to pay much attention to the possibility of tubal stump pregnancy when we diagnose the ectopic pregnancy [13, 18].

5. Prevention

There is no certain nature of the mechanism, selecting a method for prevention is difficult. However, there is some options may be suggested to decrease the probability of recurrence of ipsilateral ectopic pregnancy. When performing the tubectomy, care should be taken not to leave a long stump [16] and this remnant portion should be minimized. Additionally, using diathermy or ligation with clips of the proximal portion may be necessary components to decrease the risk of recurrent implantation [9].

Another author, suggest performing hysterosalpingography to evaluate the patency of the fallopian tubes after salpingectomy and ligation [19]. In addition to salpingectomy, he suggests insertion of flexible microinserts (commercial products are available) into the remnant tube. These devices are considered to be effective in occluding the fallopian tubes [11] This can be provided if greater protection left from proximal tube.

In case of the woman has completed her family and has a history of ectopic pregnancy, effective contraception counseling may be given, or permanent contraceptive measures implemented [9].

Clinicians should be aware that one ectopic is a risk factor for future ectopic and that salpingectomy does not exclude ipsilateral ectopic pregnancy.

Ectopic pregnancy on the ipsilateral tube is rare, but we should be aware that history of salpingectomy is a risk factor for future ectopic pregnancy in ipsilateral remnant tube.

6. Discussion

Recurrent ectopic pregnancy in the remnant portion of the tube after ipsilateral salpingectomy has only rarely been reported, The exact incidence of ectopic pregnancy occurred in the remnant tube after ipsilateral adnexectomy is not known, Ko et al. reported that tubal stump pregnancy after salpingectomy is extremely rare, with a prevalence of about 0.4% [20]. Takeda et al. reported an incidence of 1.16% in their department from January 1994 to August 2005 [21], with mortality 10–15 times higher compared to other forms of ectopic [22].

Table 1 shows the results of a literature review of previously reported cases with a history of previous salpingectomy which were diagnosed as a ectopic pregnancy in ipsilateral remnant tube with spontaneous conception.

Author	Years	History	GA	Diagnosis	Management
Felemban [23]	2017	A29years old G4P1	5 weeks	The right ectopic pregnancy in tubal stump	Systemic single-dose Methotrexate .
Cynthia [24]	2015	A 27 year-old G5P1	NA	Ectopic pregnancy in right tubal remnant .	Resected by laparoscopy
Longoria [25]	2014	A 44-year-old G5P1	8 weeks	A live twin ectopic pregnancy	Laparoscopic the remnant of the tube with ectopic pregnancy was resected .
Masakazu [2]	2014	A 26 year-old G4P1	NA	Tubal Stump Pregnancy	Laparoscopic surgery for tubal Stump Pregnancy resection was performed
Bahareh [26]	2013	A 35-year-old G8P2	49 days	Ruptured left ectopic pregnancy	Laparoscopic intervention demonstrated a ruptured left ectopic pregnancy
Bahareh [26]	2013	A42 year-old G11P7	NA	Ectopic pregnancy in the remnant of the right tube.	Laparoscopic resection of the remnant of the right tube.
Sonia [8]	2010	a 35 year-old multiparous	6 weeks	Ectopic pregnancy within the right tube.	Laparoscopy Right salpingectomy and removal of ectopic was performed
Yung-Liang [27]	2009	A 28 year-old G1P0	NA	Ectopic pregnancy in left tube.	Removal of the gestational products and resection of the proximal left fallopian tube were performed laparoscopically.
Tomone Yano [11]	2009	A 35 year-old G7P3	NA	Ectopic pregnancy in the isthmic portion of the left remnant tube.	Laparoscopy tubal stump resected
Tomone Yano [11]	2009	A 34 year-old G1P0	NA	Ectopic pregnancy in right remnant tube.	Laparoscopy excision of tubal stump.
Li-Ling Chou [28]	2008	A 23 year-old G1P0	NA	An ectopic pregnancy in the distal remnant of the right tube	Laparoscopy excision of The distal remnant and the products of conception .
Takeda et al. [6]	2006	A 27 year-old G3P2	6 weeks	Ruptured ectopic pregnancy occurring in the remnant tube	Laparoscopic surgery, ruptured remnant tube was excised.
Takeda et al. [6]	2006	A 36 year-old G2P1	8 weeks	Ectopic pregnancy in the remnant tube	Laparoscopic surgery, the unruptured remnant tube was excised.
Bernardini [10]	1998	A 36 year-old G4P0	52 days	Ectopic pregnancy in the left tubal stump	Systemic single-dose Methotrexate

Table 1.

The results of a literature review of previously reported cases with a history of the previous salpingectomy which diagnosed as a case of ectopic pregnancy in ipsilateral remnant tube with spontaneous conception.

Table 2 shows findings associated with reported cases of ectopic pregnancy in the remnant tube after ipsilateral salpingectomy induced by ovulation induction and intrauterine insemination. Agarwal et al. [30], these authors reported seven cornual and tubal stump pregnancies in patients with prior salpingectomy undergoing IVF. Also, two literature reported cases of ectopic pregnancy in the remnant tube after ipsilateral salpingectomy conceived after IVF, [20] he report Six cases of tubal stump pregnancy, four of six conceived with IVF and all managed surgically, Only one of the cases managed successfully by methotrexate and the remaining six were treated surgically.

Author	Years	History	Specific history	Diagnosis	Management
Tsuyoshi ota [12]	2016	A 40 years G2P1	History of right salpingectomy	Ectopic pregnancy in right tube stump.	Laparoscopy, tubal stump removed .
Turab [29]	2013	A 33-years G1P0	history of a right salpingectomy	Recurrent ruptured ectopic pregnancy	Laparoscopy was performed, tube stump was resecte with the products of conception

Table 2.

The reported cases of ectopic pregnancy in the remnant tube after ipsilateral salpingectomy induced by ovulation induction intrauterine insemination.

The mechanism of recurrent ipsilateral ectopic pregnancy is not clear. But there is many hypotheses including Transperitoneal migration of the egg or embryo to the contralateral tubal stump or Passage of the spermatozoa to fertilize the ovum in the proximal tubal remnant with some degree of patency or recanalization may occur in the tubal stump or contralateral fertilization occurred and the fertilized ovum transmigrate from the intact fallopian tube across the endometrial cavity to contralateral tubal stump.

In The literature review, there are some of the suggestions to decrease the risk of recurrence of ectopic pregnancy in a remnant tube after tubectomy, the length of the remnant tube should be minimized and adequate closer to the tip of the remnant tube achieved by diathermy or using clip.