A 39-year-old female with a history of partial salpingectomy for tubal pregnancy was diagnosed as having recurrent ectopic pregnancy in the distal portion of the fallopian tube remnant, which was successfully treated by laparoscopic surgery. The patient was multigravida (9 pregnancies) and uniparous. She had undergone right partial salpingectomy by laparotpmy for right isthmic ectopic pregnancy at the age of 31 years. At 6 weeks of the current pregnancy, she was referred to our hospital for suspected ectopic pregnancy. The gestational sac was not observed in the uterus, and a mass was observed in the right adnexal region by transvaginal ultrasonography. Emergency laparoscopic surgery revealed the pregnancy site in the ampulla of the remnant portion of the right fallopian tube; therefore, this portion was resected. Because the proximal portion of the fallopian tube remnant was completely occluded, we concluded that this was a case of ectopic pregnancy resulting from the intraperitoneal migration of a fertilized ovum. With current developments in assisted reproductive technologies, reanastomosis of the fallopian tube is rarely performed. While partial salpingectomy is less likely to contribute to the preservation of fertility, it increases the risk of recurrent ectopic pregnancy. A single-stage total salpingectomy on the affected side should be the first choice of treatment when fallopian tube preservation surgery is not selected.
Recent advances in ultrasound testing equipment have made it possible to identify, to some extent, the implantation site in ectopic pregnancies. This diagnosis involves using the corpus luteum as an indicator and confirming a white ring near the adnexa of the uterus appendages on the same side. In recent years, ectopic pregnancies have become more common because of tubal obstruction due to sexually transmitted diseases, such as chlamydia, as well as advances in assisted reproductive technology. There has also been an increase in reports on ectopic pregnancies in rare locations. In this study, we report the case of a patient who had undergone partial salpingectomy for tubal pregnancy, after which ectopic pregnancy in the ipsilateral fallopian tube remnant was definitively diagnosed by laparoscopy and subsequently treated.
The patient was a 39-year-old female, multigravida (9 pregnancies), and uniparous (1 spontaneous delivery, 1 induced abortion, 1 ectopic pregnancy, and 6 spontaneous abortions).
Medical history: At the age of 31 years, the patient underwent partial salpingectomy by laparotomy for right isthmic ectopic pregnancy at another hospital.
Family history: Not significant.
History of present illness: After natural conception, the patient visited her previous doctor for examination because of a positive over-the-counter pregnancy test 4 weeks and 5 days after her last menstrual period. Serum human chorionic gonadotropin (hCG) level was 1000 IU/L, and transvaginal ultrasonography revealed no intrauterine gestational sac. At 5 weeks and 5 days, she was examined again and referred to our hospital with suspected ectopic pregnancy, and another transvaginal ultrasonography revealed no intrauterine gestational sac. The initial examination at our hospital revealed that her serum hCG level increased to 7167 IU/L, but transvaginal ultrasonography was unable to confirm a gestational sac or mass in the uterus or either of its adnexa. At 6 weeks and 2 days gestation, her serum hCG increased to 8646 IU/L and a mass was observed in the right adnexa. Therefore, the patient underwent emergency hospitalization that day for a suspected right tubal pregnancy.
Clinical course: Typical symptoms of ectopic pregnancy were not observed, but ectopic pregnancy was strongly suspected from the patient’s medical history, along with imaging and testing findings. Because the patient had a history of right salpingectomy, right tubal pregnancy was considered unlikely. However, because imaging findings revealed a hemorrhage-like mass in the right adnexa, it was determined that direct intraperitoneal observation was required for accurate diagnosis of the pregnancy site. On the same day, after receiving the patient’s informed consent, emergency laparoscopic surgery was performed to observe the intraperitoneal area.
Surgery findings: No abnormal findings were observed in either ovary or left fallopian tube. The corpus luteum was observed in the left ovary. The right isthmus of the fallopian tube had been removed in a previous surgery, but a mass was observed in the remaining right ampulla of the uterine tube (
the permeability of the left fallopian tube, but the fallopian tube remnant was completely occluded. Total salpingectomy of the right fallopian tube remnant was performed. The surgery time was 43 min, and the hemorrhage volume was 30 mL. No complications occurred, and the patient was discharged five days after surgery.
Ectopic pregnancy is often difficult to diagnose. With some cases exhibiting no symptoms and other cases suffering hemorrhagic shock, a diverse range of clinical findings is observed. Approximately 50% cases of ectopic pregnancy are believed to exhibit the classic three symptoms: anemia, abdominal pain, and genital bleeding [
For cases in which ectopic pregnancy is strongly clinically suspected, but the pregnancy site cannot be identified with ultrasound, laparoscopic surgery is an effective method of combining both diagnosis and treatment. In the present case, laparoscopic surgery findings allowed us to diagnose pregnancy in the right fallopian tube remnant. However, this case was an extremely atypical case and the mechanism of onset seemed to be complex:
1) The right fallopian tube was divided at the isthmus, and indigo carmine testing indicated complete occlusion;
2) In contrast, the left fallopian tube appeared normal, with chromotubation indicating permeability; and
3) The corpus luteum was observed in the left ovary.
As shown in
As in the present case, it is extremely rare for an ectopic pregnancy to occur in the fallopian tube remnant after partial salpingectomy. Based on a literature search (search of PubMed with key words “ectopic pregnancy,” “salpingectomy,” and “remnant tube,” we observed 5 English articles from 2000 to 2012) and found only 2 similar case reports [
Treatment for ectopic pregnancy must be comprehensively determined taking into account the patient’s general condition, desire to bear children, ultrasound findings, serum hCG levels, and changes in hCG levels. Surgery and pharmacotherapy with methotrexate (MTX) are commonly selected treatments worldwide. However, surgery is the first choice of treatment in Japan because surgical procedures are widely used, safe, and fast, and MTX treatment is not reimbursed by national health insurance. Laparoscopic surgery is rapidly becoming a popular choice because it can make definitive diagnosis possible with intraperitoneal observation, allows a smooth transition from observation to treatment in the same procedure in most cases, and is less invasive than laparotomy. Randomized controlled trials comparing laparotomy with laparoscopic surgery for ectopic pregnancies were systematically reviewed in the 2007 Cochrane review [
Typical surgical procedures for tubal pregnancies, such as the present case, are salpingostomy, a conservative surgery, and salpingectomy. Regarding pregnancy prognosis, it has been reported that salpingostomy was less likely to increase the intrauterine pregnancy rate than salpingectomy, while it significantly increased the recurrent ectopic pregnancy [
There are two types of salpingectomy: total salpingectomy, which involves completely removing the affected fallopian tube, and partial salpingectomy, which involves only removing the site of the ectopic pregnancy. Not enough evidence exists to establish which of the two procedures is superior. In the past, partial salpingectomy was selected in some cases because fallopian trauma was limited to the pregnancy site, and reanastomosis could be performed in the future, if required. However, because recurrent ectopic pregnancy can occur in the fallopian tube remnant, fallopian function is not restored in several cases, despite fallopian reanastomosis. In addition, assisted reproductive technologies such as in vitro fertilization and embryo transfer have advanced in Japan; therefore, fallopian reanastomosis is currently rarely conducted, and partial salpingectomy is unlikely to contribute to fertility preservation.
When organ-preserving surgery of the fallopian tubes is not selected, we believe that one-stage total salpingectomy of the affected tube should be the first choice, along with a swift response regarding a desire to bear subsequent children.
EijiroHayata,TakehikoTsuchiya,ToshimitsuMaemura,YukikoKatagiri,TomonoriHasegawa,MinetoMorita, (2015) Recurrent Ectopic Pregnancy in the Remnant Fallopian Tube Following Ipsilateral Partial Salpingectomy. Open Journal of Obstetrics and Gynecology,05,373-377. doi: 10.4236/ojog.2015.57054