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

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Ectopic Pregnancy of the Tubal Stump in ART Patients, Two Case Reports and a Review of the Literature Case Report iMedPub Journals Medical Case Reports 2017 www.imedpub.com Vol.3 No.3:32 ISSN 2471-8041 DOI: 10.21767/2471-8041.100067 Ectopic Pregnancy of the Tubal Stump in ART Patients, Two Case Reports and a Review of the Literature Piccioni MG1, Riganelli L1*, Donfrancesco C2,3, Savone D1, Caccetta J1, Merlino L1, Mariani M1, Vena F1 and 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 Citation: Piccioni MG, Riganelli L, Donfrancesco C, Savone D, Caccetta J, et al. (2017) Ectopic Pregnancy of The Tubal Stump in ART Patients, Two Case Reports and A Review of The Literature. Med Case Rep Vol.3 No.3:32. Introduction Abstract Ectopic pregnancy represents a potentially serious medical and surgical condition for women during the reproductive age, Background: An ectopic pregnancy (EP) is the with the possibility to evolve in an emergency obstetrical development of an embryo outside of the uterus. A situation caused by the rupture and internal bleeding leading heterotopic pregnancy (HP) is a multiple pregnancy with to hypovolemic shock and maternal death during the first different sites of implantation, where one is intrauterine. trimester of gestation [1,2]. Its reported incidence is around These conditions have arisen also by the use of assisted 1.3% to 2% of natural pregnancies [3] and around 1.7% for reproduction techniques (ART), in addition to other pregnancies occurring with assisted reproductive technologies causes. (ART), following a recent review performed in the USA [2], and a documented 2.5 to 5-fold increased risk toward Case presentation: We consider two cases of interstitial gestation in patients with previous omolateral spontaneously conceived pregnancies [4]. Today the increased salpingectomy for ectopic pregnancies, and a review of incidence of pelvic inflammatory diseases and the higher the literature. The correct diagnosis was achieved for both request to perform ART represents amplification risk factors. patients by the use of ultrasound transvaginal The vast majority of ectopic pregnancies (90%) implant examination. occur in the tubal ampulla, while 2.5% of cases are identified in the tubal interstitial portion. In the vast majority of the The first patient received a treatment of methotrexate cases the embryo prematurely implants itself in the fallopian (MTX) before performing a successful removal of the tubal tube before arriving in the uterine cavity. Only in stump, while the second one was managed directly with approximately 2% of the cases EP occur in different regions: surgery. No postoperative complications occurred and cornual, cervical, broad ligament, ovarian, and abdominal. An they were discharged on the second day, postoperatively. atypical and insidious severe event is that in which the embryo Conclusion: In women with first trimester pregnancy and migrates from the uterine cavity to the contralateral tube [5]. a reported surgical history of a previous salpingectomy, The exceptional anatomic position into the tubal stump can transvaginal ultrasound examination should be performed result in a delayed identification of EP, increasing the risk of in order to correctly and promptly identify the uterine rupture that soars after the 12th week of pregnancy. implantation site. When a salpingectomy becomes Also, a heterotopic pregnancy (HP) is the result of the necessary, its complete resection should be performed, in increased use of ART. HP is a multiple pregnancy with different order to prevent or significantly lower an EP occurrence in site of implantation of embryos: one intrauterine, while the the tubal stump. other(s) outside [6]. Infact HP is quite rare among the general population (1/7,963-1/30,000) [7], while its incidence in ART Keywords: Ectopic pregnancy (EP); Assisted reproductive pregnancies vary between 1/100 to 1/3,600[8]. technologies (ART); Tubal stump; Methotrexate (MTX); In vitro fertilization (IVF) In this case report we illustrate two rare clinical cases of interstitial 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 institutional and © Copyright iMedPub | This article is available from: http://medical-case-reports.imedpub.com/ 1 Medical Case Reports 2017 ISSN 2471-8041 Vol.3 No.3:32 national research committee and with the 1964 Helsinki We present also a systematic revision of interstitial declaration and its later amendments. Approval and informed pregnancies that occurred in tubal stump Table 1 and a review consent have been obtained from each patient. The about EP in unusual sites in women having had previous Institutional Review Board approved this study protocol. salpingectomies Table 2. Table 1 Review of literature: interstitial pregnancies in tubal stump. Author Year Age Gravity Previous operation Mode of Gestation, Management Internal and history conception weeks Bleeding parity 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 27 G2, P0 Righ salpingo- Spontaneous 5 Laparotomic Poor oophorectomy for excision of right ectopic pregnancy tubal stump Krzaniak [11] 1968 30 G2, P2 Appendicectomy, Spontaneous 9 Laparotomic None excision of left Ovarian cystectomy tubal stump Bernardini [12] 1998 36 G4, P0 Appendicectomy, Spontaneous 4+5 d A single i.m. NA dose of MTX Left salpingo- (100 mg) on day oophorectomy for 61 of gestation interstitial tubal pregnancy Sills [13] 2002 39 G0, P0 Laparoscopic right IVF-ET (heterotopic 6+4 d Laparotomic 150 mL salpingectomy for pregnancy) excision of right hydrosalpinx tubal stump - - 36 G1, P1 Laparotomic right Spontaneous 8 Laparoscopic 20 mL salpingo-oophorectomy excision of right for an ovarian dermoid tubal stump cyst 27 G3, P2 Laparoscopic right Spontaneous 6 Laparoscopic 100 mL salpingo-oophorectomy excision of right for ruptured ovarian tubal stump pregnancy Milingos [14] 2008 38 G6, P3 Laparoscopic right Spontaneous 5+6 d Laparotomic NA salpingectomy and excision of right laparoscopic excision of tubal stump and the right tubal stump left salpingectomy Faleyimu [15] 2008 22 G2, P0 Left corneal resection Spontaneous 5 Laparotomic left 600 mL for tubal pregnancy salpingo- oophorectomy Muppala [16] 2009 38 G3, P1 Right salpingectomy for Spontaneous 6 Laparoscopic 500 mL tubal pregnancy cauterisation of right bleeding tubal stump Pluchino [17] 2009 34 G1, P0 Left salpingectomy for Spontaneous 7 Laparoscopic 1500 mL tubal pregnancy excision of left tubal stump Sturlese [18] 2009 30 G1, P0 Left salpingo- Spontaneous 6 Laparoscopic NA oophorectomy for an excision of left ovarian dermoid cyst tubal stump - - 30 G2, P0 Laparoscopic right Ovulation induction 8 Laparoscopic 500 mL salpingectomy for tubal excision of right pregnancy tubal stump 40 G7, P4 Laparoscopic right Ovulation induction 6 Laparoscopic 550 mL salpingectomy for tubal excision of right pregnancy tubal stump 32 G4, P0 Laparoscopic left IVF-ET 8 Laparoscopic 700 mL salpingectomy for tubal excision of left pregnancy tubal stump 2 This article is available from: http://medical-case-reports.imedpub.com/ Medical Case Reports 2017 ISSN 2471-8041 Vol.3 No.3:32 30 G3, P0 Laparoscopic bilateral ICSI-ET 7 Laparotomic 2000 mL salpingectomy for right excision of tubal ovarian pregnancy and stump left tubal pregnancy after ICSI 42 G3, P1 Laparoscopic left IVF-ET 7 Laparoscopic 20 mL salpingectomy for tubal excision of left pregnancy after IUI tubal stump 32 G4, P0 Laparoscopic bilateral ICSI-ET 6 Laparoscopic 200 mL salpingectomy for excision of tubal bilateral hydrosalpinx stump - - 33 G4, P0 Appendicectomy, IVF-ET 7+1 d Laparoscopic 100 mL laparoscopic partial left excision of left salpingectomy, tubal stump laparoscopic total right (salpingectomy salpingectomy with cornuostomy). 37 G0, P0 Laparoscopic bilateral IVF-ET 6+2 d Laparoscopic Large amount salpingectomy for excision of right of free fluid bilateral hydrosalpinx tubal stump and blood clots Shavit [19] 2013 35 G0, P0 Laparoscopic bilateral IVF-ET 6 Laparoscopic Large amount salpingectomy for excision of right of blood in the bilateral hydrosalpinx tubal stump pouch of Douglas Drakopoulos [20] 2014 33 G11, P3 Laparoscopic tubal Spontaneous 4+4 d Laparoscopic NA sterilisation by partial excision of right bilateral segmental tubal stump + a isthmic salpingectomy single i.m. dose of MTX 1 mg/kg - - 21 G1, P0 Tonsillectomy, Spontaneous 7+3 d Laparoscopic 100 mL laparoscopic right excision of right salpingectomy for right tubal stump after paratubal cyst torsion tube expression + a single i.m. dose of MTX 1 mg/kg 38 G4, P1 Laparoscopic right Spontaneous 5 Laparoscopic 600 mL salpingotomy for ectopic excision of right pregnancy, laparoscopic tubal stump+ a right salpingectomy for single i.m. dose another extrauterine of MTX 1 mg/kg pregnancy 35 G6, P1 Laparoscopic bilateral IVF-ET 6
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