Ectopic Pregnancy of the Tubal Stump in ART Patients, Two Case Reports and a Review of the Literature

Case Report

iMedPub Journals

2017

Vol.3 No.3:32

Medical Case Reports
ISSN 2471-8041

www.imedpub.com

DOI: 10.21767/2471-8041.100067

Ectopic Pregnancy of the Tubal Stump in ART Paꢀents, Two Case Reports and a Review of the Literature

Piccioni MG¹, Riganelli L^1*, Donfrancesco C^2,3, Savone D¹, Caccetta J¹, Merlino L¹, Mariani M¹, Vena F¹and Aragona C¹

¹Department of Gynecologic-Obstetrical and Urologic Sciences, University of Rome “Sapienza”, Rome, Italy ²Department of Feto-Maternal Medicine, Obstetrics and Gynecology, Portogruaro Hospital, Venice, Italy ³Department of Experimental Medicine, University of Rome “Sapienza”, Rome, Italy ^*Corresponding author: Riganelli Lucia, MD, Department of Gynecologic-Obstetrical and Urologic Sciences, University of Rome “Sapienza”, Umberto I Policlinico of Rome, Viale del Policlinico 155, 00161 Rome, Italy, Tel: +39 3928994062; E-mail: [email protected]

Rec Date: September 24, 2017, Acc Date: September 29, 2017, Pub Date: September 30, 2017

Citaꢀon: Piccioni MG, Riganelli L, Donfrancesco C, Savone D, Cacceꢀa J, et al. (2017) Ectopic Pregnancy of The Tubal Stump in ART Paꢁents, Two Case Reports and A Review of The Literature. Med Case Rep Vol.3 No.3:32.

Introducꢀon

Ectopic pregnancy represents a potenꢁally serious medical

Abstract

and surgical condiꢁon for women during the reproducꢁve age,

Background: An ectopic pregnancy (EP) is the development of an embryo outside of the uterus. A heterotopic pregnancy (HP) is a mulꢁple pregnancy with diﬀerent sites of implantaꢁon, where one is intrauterine. These condiꢁons have arisen also by the use of assisted reproducꢁon techniques (ART), in addiꢁon to other causes.

with the possibility to evolve in an emergency obstetrical situaꢁon caused by the rupture and internal bleeding leading to hypovolemic shock and maternal death during the ﬁrst trimester of gestaꢁon [1,2]. Its reported incidence is around 1.3% to 2% of natural pregnancies [3] and around 1.7% for pregnancies occurring with assisted reproducꢁve technologies (ART), following a recent review performed in the USA [2], and

a

documented 2.5 to 5-fold increased risk toward

Case presentaꢀon: We consider two cases of intersꢁꢁal

gestaꢁon in paꢁents with previous omolateral salpingectomy for ectopic pregnancies, and a review of the literature. The correct diagnosis was achieved for both paꢁents by the use of ultrasound transvaginal

examinaꢁon.

spontaneously conceived pregnancies [4]. Today the increased incidence of pelvic inﬂammatory diseases and the higher request to perform ART represents ampliﬁcaꢁon risk factors.

The vast majority of ectopic pregnancies (90%) implant occur in the tubal ampulla, while 2.5% of cases are idenꢁfied in the tubal intersꢁꢁal porꢁon. In the vast majority of the cases the embryo prematurely implants itself in the fallopian tube before arriving in the uterine cavity. Only in approximately 2% of the cases EP occur in different regions: cornual, cervical, broad ligament, ovarian, and abdominal. An atypical and insidious severe event is that in which the embryo migrates from the uterine cavity to the contralateral tube [5]. The excepꢁonal anatomic posiꢁon into the tubal stump can result in a delayed idenꢁficaꢁon of EP, increasing the risk of uterine rupture that soars aﬅer the 12th week of pregnancy.

The ﬁrst paꢁent received a treatment of methotrexate (MTX) before performing a successful removal of the tubal stump, while the second one was managed directly with

surgery. No postoperaꢁve complicaꢁons occurred and

they were discharged on the second day, postoperaꢁvely. Conclusion: In women with ﬁrst trimester pregnancy and a reported surgical history of a previous salpingectomy, transvaginal ultrasound examinaꢁon should be performed in order to correctly and promptly idenꢁfy the

implantaꢁon site. When

a

salpingectomy becomes

Also, a heterotopic pregnancy (HP) is the result of the increased use of ART. HP is a mulꢁple pregnancy with diﬀerent site of implantaꢁon of embryos: one intrauterine, while the other(s) outside [6]. Infact HP is quite rare among the general populaꢁon (1/7,963-1/30,000) [7], while its incidence in ART pregnancies vary between 1/100 to 1/3,600[8].

necessary, its complete resecꢁon should be performed, in order to prevent or signiﬁcantly lower an EP occurrence in the tubal stump.

Keywords: Ectopic pregnancy (EP); Assisted reproducꢁve technologies (ART); Tubal stump; Methotrexate (MTX); In

vitro ferꢁlizaꢁon (IVF)

In this case report we illustrate two rare clinical cases of intersꢁꢁal EP occurring into the proximal tubal stump in women subjected to monolateral salpingectomy for a history of ectopic pregnancy. All procedures performed are in accordance with the ethical standards of the insꢁtuꢁonal and

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naꢁonal research commiꢀee and with the 1964 Helsinki

We present also a systemaꢁc revision of intersꢁꢁal

declaraꢁon and its later amendments. Approval and informed pregnancies that occurred in tubal stump Table 1 and a review consent have been obtained from each paꢁent. The about EP in unusual sites in women having had previous Insꢁtuꢁonal Review Board approved this study protocol.

salpingectomies Table 2.

Table 1 Review of literature: intersꢁꢁal pregnancies in tubal stump.

Author

Year

Age

Gravity

and parity
Previous history

operation

Mode

conception

of

Gestation,

weeks

Management

Internal

Bleeding

Corti [9]

1964

-

G3, P2

Appendicectomy,

left

Spontaneous

5+3 d

Subtotal

50 ml

salpingo-oophorectomy

hysterectomy

for

a

serous ovarian

cyst

Benzi [10]

1967

1968 1998
27 30 36
G2, P0 G2, P2 G4, P0
Righ oophorectomy ectopic pregnancy

salpingo-

Spontaneous

Spontaneous Spontaneous

5

Laparotomic

excision of right tubal stump
Poor None NA for
Krzaniak [11]

Bernardini [12]

Appendicectomy,

9

Laparotomic

excision of left tubal stump
Ovarian cystectomy

Appendicectomy,

4+5 d

A

single i.m.

dose of MTX (100 mg) on day 61 of gestation

Left

salpingo-

for

oophorectomy

interstitial pregnancy tubal

Sills [13]

2002

-
39 36
G0, P0 G1, P1
Laparoscopic salpingectomy hydrosalpinx right for
IVF-ET (heterotopic pregnancy)
6+4 d 8
Laparotomic excision of right tubal stump
150 mL

20 mL

-

Laparotomic

right

Spontaneous

Laparoscopic excision of right tubal stump salpingo-oophorectomy for an ovarian dermoid cyst

27

38
G3, P2 G6, P3

Laparoscopic

right

6

Laparoscopic

100 mL NA salpingo-oophorectomy for ruptured ovarian pregnancy

Milingos [14]

2008

Laparoscopic

salpingectomy laparoscopic excision of the right tubal stump right and

5+6 d

Laparotomic

excision of right tubal stump and left salpingectomy

Faleyimu [15]

Muppala [16]
2008 2009
22 38
G2, P0 G3, P1
Left corneal resection for tubal pregnancy
56
Laparotomic left salpingooophorectomy
600 mL

500 mL

Right salpingectomy for

tubal pregnancy
Laparoscopic cauterisation of

right

bleeding

tubal stump

Pluchino [17]

Sturlese [18] -
2009 2009 -
34 30 30 40 32
G1, P0 G1, P0 G2, P0 G7, P4 G4, P0
Left salpingectomy for tubal pregnancy
Spontaneous Spontaneous Ovulation induction Ovulation induction IVF-ET
76868
Laparoscopic excision of left tubal stump
1500 mL

NA

Left

salpingo-

Laparoscopic

excision of left tubal stump oophorectomy for an ovarian dermoid cyst

Laparoscopic

right

Laparoscopic

500 mL 550 mL 700 mL salpingectomy for tubal pregnancy

Laparoscopic

right

Laparoscopic

excision of right tubal stump salpingectomy for tubal pregnancy

Laparoscopic

left

Laparoscopic

excision of left tubal stump salpingectomy for tubal pregnancy

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G3, P0

Laparoscopic bilateral

salpingectomy for right ovarian pregnancy and left tubal pregnancy after ICSI

ICSI-ET

7

Laparotomic

excision of tubal stump
2000 mL
42 32 33
G3, P1 G4, P0 G4, P0
Laparoscopic salpingectomy for tubal pregnancy after IUI

left

IVF-ET

ICSI-ET IVF-ET

7

Laparoscopic

excision of left tubal stump
20 mL
Laparoscopic bilateral salpingectomy bilateral hydrosalpinx

6

Laparoscopic

excision of tubal stump
200 mL 100 mL for

-

Appendicectomy,

7+1 d

Laparoscopic

laparoscopic partial left salpingectomy, excision of left

tubal

stump

laparoscopic total right salpingectomy
(salpingectomy with cornuostomy).

37

35 33
G0, P0 G0, P0 G11, P3

IVF-ET

6+2 d

Laparoscopic

Large amount

of free fluid

salpingectomy

for

bilateral hydrosalpinx

and

blood

clots

Shavit [19]

2013

2014

IVF-ET

6

Laparoscopic

Large amount

of blood in the

salpingectomy

for

bilateral hydrosalpinx

pouch

of

Douglas

Drakopoulos [20]

Laparoscopic

sterilisation by partial bilateral segmental

tubal

Spontaneous

4+4 d

Laparoscopic

NA

excision of right tubal stump + a single i.m. dose of MTX 1 mg/kg isthmic salpingectomy

-

21

38

G1, P0

Tonsillectomy,

laparoscopic salpingectomy for right paratubal cyst torsion

Spontaneous

7+3 d

Laparoscopic

100 mL

right

excision of right

tubal stump after tube expression

+

a

single i.m.

dose of MTX mg/kg
1

G4, P1

Laparoscopic

right

Spontaneous

5

Laparoscopic

excision of right tubal stump+ single i.m. dose of MTX 1 mg/kg
600 mL 600 mL salpingotomy for ectopic pregnancy, laparoscopic right salpingectomy for a

another

extrauterine

pregnancy

35

27
G6, P1 G0, P0
Laparoscopic bilateral salpingectomy for ectopic pregnancies

IVF-ET

6

Laparoscopic

bilateral excision of tubal stumps
3

Oral [21]

2014

bilateral salpingectomy

IVF-ET (heterotopic

pregnancy)

NA

Laparoscopic

Extensive hemoperitoneum and septum hysteroscopic resection
(bilateral hydrosalpinx + uterine septum), laparoscopic left cornual resection for cornual pregnancy

Abraham [22]

Nishida [23] Xu [24]
2015 2015 2016
27 26 28
G5, P1 G4, P1 G0, P0
Laparoscopic salpingectomy for tubal pregnancy

right

Spontaneous

Spontaneous IVF-ET
5+6 d 6
Laparoscopic excision of right tubal stump
1500 mL

NA

Laparoscopic

salpingectomy for tubal pregnancy

right

Laparoscopic

Bilateral tubal ligation

8+6 d

Emergency

500 mL

laparotomic left salpingectomy/ adhesion

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decomposition and left ovary repair

Iwahashi [25]

2017

26

G3, P0

right

salpingectomy remnant salpingectomy partial right

Spontaneous

6+5 d

Emergency

laparotomic left salpingectomy
Massive hemoperitoneum
+

Table 2 Review of literature: EP in unusual sites in women with previous salpingectomies.

Author

Year

Age

Gravity and

parity
Previous history

operation

Type

fecundatio n

of

Site

pregnancy

of

ectopic

Management

Ferland [26] Fisch [27]
1991 1996
32 38
G4, P0 G2, P0 right salpingectomy for tubal pregnancy
IVF-ET IVF-ET

upper retroperitoneum

LPTM

LPS

(bilateral

abdomen (posterior aspect

salpingectomy for two tubal pregnancies)

of

the

right

broad

ligament)

-

28

33

G0

LPS

salpingectomy hydrosalpinx)
(bilateral for
IVF-ET IVF-ET right uterine cornu left uterine cornu
LPTM

LPTM

G1, P0

right salpingectomy for

hydrosalpinx, right tuboplasty, successively left salpingectomy for tubal pregnancy)

32

34
G0 G0 bilateral tuboplasty for tubal disease
IVF-ET IVF-ET right uterine cornu head of pancreas
LPTM

LPTM

Dmowsky

[28]
2002 2003 2005 2011 2016
LPS salpingectomy hydrosalpinx)
(bilateral for

Cormio [29]

Hsu [30]
30 29 26 28
G2, P0 G0

LPS

(bilateral

IVF-ET

IVF-ET IVF-ET abdomen (lower end of the omentum, adherent to the uterine fundus and cecum)
LPTM salpingectomy for two tubal pregnancies)

LPS salpingectomy hydrosalpinx)
(bilateral for ovary ovary Ovary
MTX and LPS

LPS

Cruciani [31]

Xu [24]

G0

LPS

salpingectomy hydrosalpinx)
(bilateral for

G3, P0

LPS (right salpingectomy

for 2 ectopic pregnancies +left salpingectomy for hydrosalpinx)
IVF-ET (heterotopic pregnancy)
LPTM

accordance with the paꢁent’s desire, using the single dose i.m. MTX regimen (50 mg/m2). Four days aﬅer treatment the paꢁent complained sudden lower abdominal pain and weakness, that were associated with low blood pressure and severe anemia (Hb 8 g/dL). An operaꢁve laparoscopy was performed with excision of the right tubal stump. Histological

examinaꢁon conﬁrmed the diagnosis of ectopic intersꢁꢁal

pregnancy of the right tubal stump. Intraperitoneal blood collected was around 700 mL. The paꢁent was discharged on day 2 postoperaꢁvely and no short or long-term complicaꢁons were reported.

Case Presentaꢀon

Case 1

A 36-year-old paꢁent, gravida-1 para-0, referred to our