Spontaneous ectopic pregnancy occurring in the isthmic portion of the remnant tube after ipsilateral adnexectomy: Report of two cases

Risk factor for interstitial pregnancy following ipsilateral salpingectomy? A retrospective matched case control study

BACKGROUND

Interstitial pregnancy may still happen even after ipsilateral salpingectomy, resulting in massive hemorrhage. Therefore, the purpose of the study is to identify risk factors associated with interstitial pregnancy following ipsilateral salpingectomy and discuss possible prevention.

METHODS

We conducted a retrospective cohort study in a single, large, university-affiliated hospital. Data of 29 patients diagnosed with interstitial pregnancy following ipsilateral salpingectomy from January 2011 to November 2020 were assigned into the case group (IP group). Whereas there were 6151 patients with intrauterine pregnancy after unilateral salpingectomy in the same period. A sample size of 87 control patients was calculated to achieve statistical power (99.9%) and an α of 0.05. The age, BMI and previous salpingectomy side between the two group were adjusted with PSM at a ratio of 1:3. After PSM, 87 intrauterine pregnancy patients were successfully matched to 29 IP patients.

RESULTS

After PSM, parous women were more common and intrauterine operation was more frequent in the IP group compared with control group (P<0.05). There was only one patient undergoing IVF-ET in the IP group as compared with 29 cases in the control group (3.4% vs. 33.3%, P<0.05). Salpingectomy was performed on 5 patients in the IP group and 4 patients in the control group due to hydrosalpinx (P<0.05). Logistic regression indicated that hydrosalpinx was the high risk factor of interstitial pregnancy following ipsilateral salpingectomy (OR = 8.175).

CONCLUSIONS

Hydrosalpinx appears to be an independent factor contributing to interstitial pregnancy following ipsilateral salpingectomy in subsequent pregnancy.

Multiple Spontaneous Ectopic Pregnancies Following Bilateral Salpingectomy

Introduction

Ectopic pregnancy (EP) is a significant cause of gynaecological morbidity and mortality. Salpingectomy is the preferred management modality in recurrent ectopic pregnancies; although they do not eliminate the risk of reoccurrence. The aetiology of recurrent ectopic pregnancies remains unknown but there are identifiable risk factors associated with increased likelihood of occurrence.

Case Presentation

We present the case of a 30-year-old woman who attended the emergency unit with her second spontaneous ectopic pregnancy following a previous bilateral salpingectomy. She had prior multiple spontaneous ectopic pregnancies: laparoscopic salpingectomy for a left cornual EP in 2017 followed by laparotomic salpingectomy for a ruptured right EP after failed medical management in 2018. Lastly, she had laparoscopic removal of an EP sac in the scar of a previous left cornual EP in 2019. She presented with a history of missed periods, pelvic pain, and vaginal spotting. Her examination revealed left lower abdominal pain, soft, non-tender abdomen, and no cervical excitation. Pelvic ultrasound revealed a thin endometrium and no intrauterine pregnancy visualised. A suspicious complex mass near the left ovary with a ring-like structure was noted. Her β-HCG was (251 IU/L) which plateaued after 48 hrs (220 IU/L). She responded well to methotrexate with no need for surgical intervention this time.

Conclusion

This case is unique as it highlights the importance of keeping an open mind when managing recurrent ectopic pregnancies, especially when preventative surgical measures have been performed previously.

Ruptured ectopic pregnancy on a tubal stump: A case report

Tubal stump ectopic pregnancy is a rare event. Early diagnosis and management can spare patients from significant morbidity; however, patients usually present with hemoperitoneum in developing countries. A long tubal stump might increase the risk for tubal stump pregnancy; hence, the length of fallopian tube should be minimized during salpingectomy.

Recurrent ectopic pregnancy on tubal remnant treated by laparoscopic resection: loop and stitch

Ectopic pregnancies occur in about 1-2 % of all pregnancies, with a high rate of maternal mortality due to bleeding caused by the rupture of the ectopic pregnancy. Ipsilateral ectopic pregnancy on a tubal remnant after salpingectomy is rare and it is associated with a higher mortality rate when compared to other ectopic pregnancies. Diagnosis and treatment of these pregnancies can be difficult, requiring a multidisciplinary management to plan the best treatment for the patient. The objective of this video is to show the laparoscopic removal of a tubal pregnancy on the stump of a previous salpingectomy with the application of three laparoscopic rings/endoloops ® to isolate the tubal portion from the uterus.

Tubal stump pregnancy after salpingectomy-Does the time interval from surgical intervention to conception matter?

AIM

Ectopic pregnancy implantation on the tubal stump after salpingectomy is a rare location for extrauterine pregnancy, whose pathogenesis is still unknown. The purpose of this study was to examine whether the time interval elapsed from salpingectomy may predispose the embryo to implantation on the tubal stump in the next pregnancy subsequent to tube removal.

METHODS

Nine women operated for stump pregnancy (study group) between 2008 and 2019 were retrospectively identified. For each case in the study group, 12 consecutive cases that underwent laparoscopic salpingectomy constituted the control group. A sample size of 100 control patients was calculated to achieve statistical power (97.8%) and an α of 0.05. The control groups were triple-matched with the study group for patients' age, indications for salpingectomy (tubal pregnancy or hydrosalpinx prior to in vitro fertilization treatment) and mode of conception of the subsequent pregnancy following salpingectomy.

RESULTS

Nine women underwent surgery for stump pregnancy during the study period. All women had a surgical history of laparoscopic salpingectomy. The time interval from prior salpingectomy to subsequent pregnancy was significantly shorter in study group than in the control group (4.3 ± 2.1 months vs. 15.6 ± 13.7 months, respectively, p = 0.016).

CONCLUSION

A possible association between the short time interval from prior salpingectomy to ectopic implantation on the tubal stump in the subsequent pregnancy was found. The clinical implications of these findings and in particular whether patients should be advised to wait at least 4 months from the salpingectomy to the subsequent pregnancy remain unclear.

Two cases of intrauterine pregnancy with tubal stump pregnancy after in vitro fertilization and embryo transfer following ipsilateral salpingectomy: A case report

RATIONALE

The recently increased rate of heterotopic pregnancies (HPs) has been largely attributed to the increased use of assisted reproduction technologies (ARTs). HP is a rare and potentially life-threatening condition. It is unusual in natural conception cycles, occurring in 1:10,000 to 1:50,000 pregnancies. However, with the increased use of ART such as in vitro fertilization and embryo transfer (IVF-ET), the incidence has risen to 0.5-1%.

PATIENT CONCERNS

Case 1 was a 28-year-old woman who presented to our center complaining of a sudden onset of right-side lower abdominal pain with a small amount of vaginal bleeding. She had undergone IVF-ET and received a thawed embryo transfer with two embryos 23 days previously. She had a history of right salpingectomy for an ectopic pregnancy during the downregulation of her ovulatory cycle 1 year ago. Case 2 was a 25-year-old woman who presented to our center complaining of a sudden onset of right-side lower abdominal pain. She had also undergone thawed embryo transfer following IVF-ET with two embryos 35 days previously. She had a history of right salpingectomy for an ectopic pregnancy 1.5 years previously.

DIAGNOSES

Both patients were diagnosed as having a heterotopic pregnancy.

INTERVENTIONS

Patient 1 underwent emergency laparoscopy; patient 2 underwent emergency laparotomy and both were treated medically to prevent abortion of the intrauterine pregnancies.

OUTCOMES

Patient 1 had an incomplete abortion and underwent uterine curettage on the day 10 after the operation. Patient 2 experienced no further complications during pregnancy and a healthy baby girl was born at the 38th gestational week.

LESSONS

Reproductive physicians need to pay more attention to patients who have received more than one embryo at transfer, especially those with a history of salpingectomy.

Laparoscopic Management of 42 Cases of Tubal Stump Pregnancy and Postoperative Reproductive Outcomes

STUDY OBJECTIVE

Tubal stump pregnancy is a rare variant of ectopic pregnancy. The aim of this study was to evaluate laparoscopic surgery for tubal stump pregnancy and to investigate postoperative pregnancy outcomes.

DESIGN

Retrospective study.

SETTING

University-affiliated hospital.

PATIENTS

Patients (n = 42) diagnosed with tubal stump pregnancy.

INTERVENTIONS

Data were extracted from the electronic medical records system of the hospital.

MEASUREMENTS AND MAIN RESULTS

Patients diagnosed with tubal stump pregnancy between June 2010 and July 2018 were included. Data included demographic characteristics, gravidity and parity, history of pelvic surgery, clinical features, and treatment. All procedures were laparoscopic. Postoperative pregnancy outcomes were identified from electronic medical records or by telephone. Patients' mean age was 30 (range, 21-39) years. Twelve of 42 tubal stump pregnancies (28.6%) had ruptured ectopic pregnancy at the time of operation. The remaining 30 cases had intact stump pregnancy during surgery. Patients were followed for a mean of 31 (range, 10-60) months. Follow-up data were available for 33 of 39 patients (3 with heterotopic tubal stump pregnancy were not included in follow-up data because all resulted in a live births and had no desire for future pregnancy). Eighteen of 28 patients (64.3%) who attempted conception had intrauterine pregnancies (IUPs) during the follow-up period; of these 18 IUPs, 14 (77.8%) resulted in live births. There was 1 case of uterine rupture in a singleton pregnancy at 20⁺⁵ weeks that resulted in fetal death. Three of 18 IUPs (16.7%) ended in the first trimester with spontaneous abortions.

CONCLUSION

Laparoscopic surgery is a feasible option for tubal stump pregnancy and is associated with favorable pregnancy outcomes.

Disturbed Interstitial Pregnancy: A First Case of Successful Treatment Using a Mini-Laparoscopic Approach

Interstitial ectopic pregnancy (EP) is a life-threatening condition due to the risk of massive hemorrhage in the event of its disturbance. We present the case of a 27-year-old patient who was admitted with massive hemoperitoneum, caused by the rupture of an interstitial pregnancy in the area of the fallopian tube stump, which had been removed after a previous ectopic pregnancy. The condition was overcome using a mini-laparoscopic approach (2.6 mm, 30° optics), with one 3 mm port for micro-laparoscopic instruments and one 10 mm port. Such an approach has not yet been reported in the available literature, among the casuistically reported cases of pregnancy in the tubal stump. We consider that the technique is safe, completely in the interest of the patient, applicable by an experienced team, and in agreement with modern trends regarding the minimization of operative access.

Spontaneous live recurrent ectopic pregnancy after ipsilateral partial salpingectomy leading to tubal rupture

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This is the first reported case in the literature describing a recurrent ectopic pregnancy with a fetal heartbeat after ipsilateral salpingectomy that led to tubal rupture.

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Although exceptionally rare, recurrent ectopic pregnancy may occur after ipsilateral salpingectomy.

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Physicians should be aware that ectopic pregnancies may not only occur repeatedly but may also present atypically.

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We recommend when performing a salpingectomy that efforts be undertaken to minimize the length of the tubal remnant and to assure adequate coagulation of tissue so as to reduce the risk of recurrence.

Introduction

Ectopic pregnancy accounts for 1–2% of all pregnancies in the United States. The most common site of implantation for an ectopic pregnancy is the fallopian tube. We present the first case describing a recurrent ectopic pregnancy with a fetal heartbeat after ipsilateral salpingectomy that led to tubal rupture.

Presentation of case

The patient presented with abdominal pain approximately six weeks after her last menstrual period. Seven years prior to presentation, a laparoscopic partial right salpingectomy had been performed for a tubal ectopic pregnancy. Physical exam was significant for diffuse abdominal tenderness and guarding. Ultrasonography revealed a right tubal pregnancy with a fetal pole and a fetal heart rate that was calculated to be 108 beats per minute. Free fluid was also noted. 1.5 l of hemoperitoneum was subsequently evacuated and the right fallopian tube remnant with the ectopic pregnancy was removed. Pathology of the tubal remnant showed immature chorionic villi and fetal parts.

Discussion

The mechanism by which a recurrent ectopic pregnancy after ipsilateral salpingectomy occurs is unclear, but is theorized to be secondary to contralateral fertilization and/or tubal recanalization that may occur due to inadequate diathermy.

Conclusion

Physicians should be aware that ectopic pregnancies may not only occur repeatedly but may also present a typically. We recommend when performing a salpingectomy that efforts be undertaken to minimize the length of the tubal remnant and to assure adequate coagulation of tissue so as to reduce the risk of recurrence.

Recurrent ectopic pregnancy in the tubal remnant after salpingectomy

We present two cases of ectopic pregnancy located within the remnant tube following ipsilateral salpingectomy. This particular pathology is rare and yet has significant consequences for the patient, with mortality rates 10–15 times higher than other ectopic pregnancies. It demonstrates that salpingectomy does not exclude ectopic pregnancy on the ipsilateral side. We suggest careful clinical consideration and bring attention to the current surgical technique.

Spontaneous ectopic pregnancy occurring in the remnant tube after ipsilateral salpingectomy: a report of 2 cases

Ectopic pregnancy occurring in the remnant tube after ipsilateral salpingectomy is assumed to be rare. We report 2 cases of spontaneous ectopic pregnancy occurring in the remnant tube that were treated surgically. Even in spontaneous pregnancy, attention should be paid to the remnant tube so as not to miss an ectopic pregnancy after previous salpingectomy.