Obstetrics and Gynecology International

Obstetrics and Gynecology International / 2009 / Article

Case Report | Open Access

Volume 2009 |Article ID 524864 | 3 pages | https://doi.org/10.1155/2009/524864

When Salpingectomy Is Not Salpingectomy—Ipsilateral Recurrence of Tubal Pregnancy

Academic Editor: Mary E. D'Alton
Received03 Jul 2009
Accepted16 Sep 2009
Published28 Oct 2009

Abstract

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.

1. Introduction

Despite major advances in its early diagnosis and treatment, ectopic pregnancy continues to account for a significant number of maternal deaths. A World Health Organization analysis of maternal deaths showed ectopic pregnancy to be responsible for 4.9% of all and 6.1% of direct maternal deaths in developed countries [1]. With a frequency of 1% to 2% of pregnancies [2, 3], it is the main cause of maternal death in early pregnancy in countries where unsafe abortion has been eliminated. However, ipsilateral ectopic pregnancy after partial or total salpingectomy is a rare occurrence with less than a dozen cases reported in the English literature in the last 10 years [412].

2. Case Report

A woman, aged 28, gravida 4, para 0, presented at 5 weeks gestation with lower abdominal pain and mild vaginal bleeding. She had 2 terminations of pregnancy and her last pregnancy had been ectopic, managed laparoscopically by a left salpingectomy using endoloops. Transvaginal ultrasound showed an empty uterus, no evidence of ectopic pregnancy, and a moderate amount of peritoneal fluid. -hCG was 500 IU/L. After 48 hours, -hCG had increased to 695 IU/L. A further 3 days later, the -hCG level was 1,300 IU/L which prompted referral to hospital for further investigation. Ultrasound showed a left adnexal ectopic pregnancy measuring  mm with a yolk sac, but no evidence of a fetal heart. As the woman was clinically stable, methotrexate was administered intramuscularly at 50 mg/ , with follow-up of -hCG levels.

Four days after the methotrexate administration, -hCG had risen to 2,200 IU/L and another dose of 50 mg/ was administered. Four days after the second dose of methotrexate and 15 days after the initial presentation, she attended the emergency department with severe lower abdominal pain, vaginal bleeding, and an acute abdomen. The -hCG level at that time was 1,300 IU/L. Laparoscopy showed a significant haemoperitoneum and an ectopic pregnancy on the proximal segment of the left fallopian tube, which had its mid-portion missing. The right tube and ovaries were normal. Both remnants of the left tube were removed laparoscopically and haemostasis established. She recovered well and -hCG levels were below the level of detection 3 weeks later. Histology confirmed the clinical findings.

3. Discussion

Ectopic pregnancies occurred in 1.1% of pregnancies and caused 10 maternal deaths between 2003 and 2005 in the UK, with no evidence of these having become less important as a cause of direct maternal death over the last 20 years [3].

In this case, it took 15 days between the initial presentation and the definitive emergency treatment. At her first referral to hospital, the patient fulfilled all criteria commonly considered as conditional for methotrexate treatment and she was followed up appropriately. However, the further evolution with an acute abdomen and the need for emergency intervention is reminiscent of the times before the advent of vaginal ultrasound and -hCG quantitation. It is speculative whether she would have undergone an earlier planned intervention to remove the ectopic and remaining tubal segments, if it had been suspected that the ectopic was located in a remaining tubal segment. It is also speculative whether methotrexate treatment would have been used initially, if there had been awareness that the ectopic was located in a tubal remnant. Indeed, most gynaecologists would perceive this as a firm indication to remove the tubal remnants either now or later on. Certain is, though, that the presence of a tubal remnant was not suspected because of her history of a previous left salpingectomy.

There is a great deal of variation in surgical treatments of tubal pregnancies [13]. Although there is general agreement that, where feasible, the laparoscopic approach is to be preferred over laparotomy, there is less agreement on the specific procedures. The main area of debate still centers on the relative merits of salpingectomy versus salpingostomy, in terms of subsequent fertility and ectopic recurrences. A multicentre randomized controlled trial is currently underway to address these issues [14].

There is an extensive literature on the use of endoloops in laparoscopic surgery most of it related to gastrointestinal procedures. In gynaecology, endoloops became popular mainly for laparoscopic tubal ligation, mimicking the classical open surgery Pomeroy approach, as an alternative to fallopian rings and clips [15]. With regard to ectopic pregnancies, which are mostly located in the fallopian tube and may not permit a substantial delay between diagnosis and treatment, the main attraction of the endoloop technique is that it can be used by persons with basic rather than advanced laparoscopic skills [16]. A randomised controlled trial, comparing the endoloop approach with conventional electrocautery in 102 patients, was recently reported from Malaysia [17]. There were benefits to the endoloop approach in terms of a shorter operating time and less postoperative pain, but other outcomes were basically similar. The paper provides no information on the completeness of the tubal resection, though, and no information on long-term outcomes.

We are aware of only one report on the long-term outcome of the endoloop approach for treatment of ectopic pregnancy and this related specifically to cornual (i.e., interstitial) ectopic pregnancies [18]. Of 18 women treated with endoloop tied around the cornual area, 14 had a wish for a further pregnancy and 12 of them achieved a pregnancy. Nine resulted in a term birth, two ended in miscarriage, and one was an ectopic again, but this occurred in the contralateral tube [18]. Our search further revealed only one case, such as ours, in which it was clear that the ipsilateral tubal pregnancy occurred after endoloop treatment [6]. We do not know how many have occurred that were not reported. It is not known either how many endoloop procedures are performed. Therefore, one cannot estimate the frequency of this complication.

Salpingectomy, while not necessarily eliminating all ipsilateral ectopics, certainly prevents a tubal recurrence on that side. However, our case illustrates that it is fallacious to assume that total salpingectomy is always as total as the word implies. In fact, it is inherently difficult to achieve a total salpingectomy when using nothing but endoloops. Such cases and others that leave a tubal remnant may well need to be considered as akin to salpingostomy in terms of the risk of recurrence. Whilst few generalisations can ever be made from a case report, it is important for clinicians to be aware of this inherent problem, especially as it is not the only consequence. Hydrosalpinges can develop in tubal stumps, resulting in decreased fertility and an occasional need for further surgical intervention.

In conclusion, it is unwise to discount ipsilateral tubal pregnancies too quickly. Surgical variations in what is purported to be salpingectomy are sufficiently large and their consequences important enough for clinicians to remain vigilant.

References

  1. K. S. Khan, D. Wojdyla, L. Say, A. M. Gülmezoglu, and P. F. A. van Look, “WHO analysis of causes of maternal death: a systematic review,” The Lancet, vol. 367, no. 9516, pp. 1066–1074, 2006. View at: Publisher Site | Google Scholar
  2. S. Boufous, M. Quartararo, M. Mohsin, and J. Parker, “Trends in the incidence of ectopic pregnancy in New South Wales between 1990–1998,” Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 41, no. 4, pp. 436–438, 2001. View at: Google Scholar
  3. “Saving mothers' lives: reviewing maternal deaths to make motherhood safer—2003–2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom,” in The Confidential Enquiry into Maternal and Child Health, G. Lewis, Ed., CEMACH, London, UK, 2007. View at: Google Scholar
  4. C. A. Adebamowo and O. A. Fakolujo, “Second ipsilateral ectopic gestation after total salpingectomy: a case report,” African Journal of Medicine and Medical Sciences, vol. 29, no. 1, pp. 63–64, 2000. View at: Google Scholar
  5. M. Mathew, R. Kumari, and V. Gowri, “Three consecutive ipsilateral tubal pregnancies,” International Journal of Gynaecology and Obstetrics, vol. 78, no. 2, pp. 163–164, 2002. View at: Publisher Site | Google Scholar
  6. A. Rizos, E. Eyong, and A. Yassin, “Recurrent ectopic pregnancy at the ipsilateral fallopian tube following laparoscopic partial salpingectomy with endo-loop ligation,” Journal of Obstetrics and Gynaecology, vol. 23, no. 6, pp. 678–679, 2003. View at: Publisher Site | Google Scholar
  7. R. Zuzarte and C. C. Khong, “Recurrent ectopic pregnancy following ipsilateral partial salpingectomy,” Singapore Medical Journal, vol. 46, no. 9, pp. 476–478, 2005. View at: Google Scholar
  8. M. A. Okunlola, O. A. Adesina, and A. O. Adekunle, “Repeat ipsilateral ectopic gestation: a series of 3 cases,” African Journal of Medicine and Medical Sciences, vol. 35, no. 2, pp. 173–175, 2006. View at: Google Scholar
  9. T. L. Tan, A. Elashry, I. Tischner, and A. Jolaoso, “Lightning does strike twice: recurrent ipsilateral tubal pregnancy following partial salpingectomy for ectopic pregnancy,” Journal of Obstetrics and Gynaecology, vol. 27, no. 5, pp. 534–535, 2007. View at: Publisher Site | Google Scholar
  10. D. S. Milingos, M. Black, and C. Bain, “Three surgically managed ipsilateral spontaneous ectopic pregnancies,” Obstetrics & Gynecology, vol. 112, no. 2, pp. 458–459, 2008. View at: Google Scholar
  11. B. L. Faleyimu, G. O. Igberase, and M. O. Momoh, “Ipsilateral ectopic pregnancy occurring in the stump of a previous ectopic site: a case report,” Cases Journal, vol. 21, no. 1, p. 343, 2008. View at: Google Scholar
  12. L.-L. Chou and M.-C. Huang, “Recurrent ectopic pregnancy after ipsilateral segmental salpingectomy,” Taiwanese Journal of Obstetrics and Gynecology, vol. 47, no. 2, pp. 203–205, 2008. View at: Publisher Site | Google Scholar
  13. P. J. Hajenius, F. Mol, B. W. J. Mol, P. M. M. Bossuyt, W. M. Ankum, and F. van der Veen, “Interventions for tubal ectopic pregnancy,” Cochrane Database of Systematic Reviews, no. 1, Article ID CD000324, 2007. View at: Google Scholar
  14. F. Mol, A. Strandell, D. Jurkovic et al., “The ESEP study: salpingostomy versus salpingectomy for tubal ectopic pregnancy; the impact on future fertility: a randomised controlled trial,” BMC Women's Health, vol. 8, p. 11, 2008. View at: Publisher Site | Google Scholar
  15. J. E. Murray, M. L. Hibbert, S. R. Heth, and G. S. Letterie, “A technique for laparoscopic pomeroy tubal ligation with endoloop sutures,” Obstetrics & Gynecology, vol. 80, no. 6, pp. 1053–1055, 1992. View at: Google Scholar
  16. M. D. Fox, C. A. Long, G. R. Meeks, M. L. Jutras, and B. D. Cowan, “Laparoscopic pomeroy tubal ligation as a teaching model for residents,” Journal of Reproductive Medicine, vol. 39, no. 11, pp. 862–864, 1994. View at: Google Scholar
  17. Y.-H. Lim, S. P. Ng, P. H. O. Ng, A. E. Tan, and M. A. Jamil, “Laparoscopic salpingectomy in tubal pregnancy: prospective randomized trial using endoloop versus electrocautery,” Journal of Obstetrics and Gynaecology Research, vol. 33, no. 6, pp. 855–862, 2007. View at: Publisher Site | Google Scholar
  18. H. S. Moon, Y. J. Choi, Y. H. Park, and S. G. Kim, “New simple endoscopic operations for interstitial pregnancies,” American Journal of Obstetrics and Gynecology, vol. 182, no. 1, pp. 114–121, 2000. View at: Google Scholar

Copyright © 2009 Simona Fischer and Marc J. N. C. Keirse. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


More related articles

2787 Views | 567 Downloads | 3 Citations
 PDF  Download Citation  Citation
 Download other formatsMore
 Order printed copiesOrder

Related articles

We are committed to sharing findings related to COVID-19 as quickly and safely as possible. Any author submitting a COVID-19 paper should notify us at help@hindawi.com to ensure their research is fast-tracked and made available on a preprint server as soon as possible. We will be providing unlimited waivers of publication charges for accepted articles related to COVID-19. Sign up here as a reviewer to help fast-track new submissions.