Three consecutive ipsilateral tubal pregnancies

Two Consecutive Ruptured Tubal Ectopic Pregnancies after Interval Bilateral Tubal Ligation

Background

Bilateral tubal ligation (BTL) is an effective permanent method of birth control that is surgically performed to block the woman's fallopian tube and prevent the egg from meeting the sperm. It is preferred by women or couples who have achieved their reproductive potential and do not desire pregnancy. BTL carries a low risk of method failure with a subsequent pregnancy which is likely to be ectopic. We present a case of two consecutive ruptured tubal ectopic pregnancies following an interval BTL.

Case Presentation

A 40-year-old female, with 7 living children, who previously underwent an interval BTL, presented with acute abdominal pain for 2 days and amenorrhea for 6 weeks. She was stable but had generalized abdominal tenderness, guarding and rebound tenderness, and cervical motion tenderness. Her urine HCG was positive, and a trans-abdominal ultrasound scan revealed a tender echo-complex right adnexal mass, free fluid in the Cul-de-sac, and an empty uterine cavity, consistent with a ruptured right ectopic pregnancy. An emergency exploratory laparotomy was done with findings of a ruptured right distal tube containing products of conception, hemoperitoneum, and previous tubal ligation and left salpingectomy. A right total salpingectomy was done, and the excised right tube containing the mass was sent for histological examination, which revealed chorionic villi and hemorrhagic vascular decidual tissue in the fallopian tube, features suggestive of tubal ectopic pregnancy.

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.

Laparoscopic treatment of recurrent ectopic pregnancy in the ipsilateral salpinx after ovulation induction and intrauterine insemination

OBJECTIVE

To report a case of recurrent ectopic pregnancy in the ipsilateral salpinx after and intrauterine insemination treated by laparoscopy.

CASE REPORT

A 33-year-old woman with unexplained infertility sought evaluation at our hospital due to pelvic pain after ovulation induction and intrauterine insemination. She had a history of a right salpingectomy. Transvaginal ultrasonography did not reveal an intrauterine pregnancy, but showed a suspected extrauterine gestational sac on the operated adnexal area with free fluid in the pouch of Douglas. The patient was diagnosed with a recurrent ruptured ectopic pregnancy and an emergency laparoscopy was performed.

CONCLUSION

Recurrent ectopic pregnancy in the ipsilateral fallopian tube is rare, but it is important to be suspicious of the diagnosis to prevent serious morbidity. This case also demonstrates transtubal or transperitoneal migration of the gametes because ovulation and ectopic pregnancy occurred on opposite sides.

Recurrent viable ectopic pregnancy in the salpingectomy stump

Ipsilateral ectopic pregnancy after total salpingectomy is a rare occurrence and in theory should not happen. We report a case where a spontaneous ectopic pregnancy was found in the stump of the previously removed tube. This case highlights the need for further consideration of the diagnosis of an ectopic pregnancy in the setting of a previous ipsilateral salpingectomy.

When salpingectomy is not salpingectomy-ipsilateral recurrence of tubal pregnancy

Theoretically, total salpingectomy eliminates the risk of an ipsilateral tubal pregnancy. However, total salpingectomy is difficult to achieve using endoloops alone. We describe a situation where this resulted in an ipsilateral recurrence of tubal pregnancy which required emergency intervention and removal of the tubal remnants.