Ipsilateral ectopic pregnancy after total or partial salpingectomy is a rare occurrence with very few cases reported in literature. We report a case where the spontaneous ectopic occurred in stump of the previously removed tube. We have explained possible hypothesis for such recurrence and surgical techniques which could possibly avoid such recurrence have been suggested. 

Ectopic pregnancy

Ectopic pregnancy is defined as pregnancy which implants outside the uterine cavity. More than 90% of ectopic pregnancy occur in one of the fallopian tubes. The incidence of ectopic pregnancy is around 1-2%. The incidence of recurrence is 15% after one and 30% after two ectopic pregnancies.^1,2 However, the exact incidence of ectopic pregnancy in remnant stump following salpingectomy is not known.

Case report

A 35-year-old woman, para 0+2, presented to the emergency department with sudden onset of severe lower abdominal pain, vomiting and bilateral shoulder tip pain. The patient had been on her third day of her menstrual cycle, had regular periods and was not on contraception. Her pulse rate was 130 and blood pressure was 84/51mmHg at time of presentation. On examination guarding was noted all over her abdomen with more tenderness in the right iliac fossa. Bloods were taken and fluid resuscitation was commenced. The patient was unable to produce urine therefore an urgent serum beta-hCG was requested. She had had a first trimester miscarriage in her first pregnancy and had a right salpingectomy for ruptured ectopic pregnancy around 18 months previously in her second pregnancy. 

Serum beta-hCG result was 5,574mIU/mL and haemoglobin (Hb) level was 8.3mmol/L. An urgent ultrasound by the gynaecology team showed her abdomen was full of echogenic fluid and no evidence of intrauterine gestational sac. A working diagnosis of ruptured ectopic pregnancy was made and patient was taken to theatre for laparoscopy.

After arrival in theatre routine three-port laparoscopy was done with entry via umbilical incision using Verres needle. Abdomen contained a copious amount of blood, which was suctioned rapidly. The left tube and ovary were noted to be normal. 

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Right tubal stump

Active bleeding was noted from right tubal stump which was cauterised with LigaSure. A few large clots which looked like product of conception were sent for histology.

The patient received four units of blood during laparoscopy. Hb two hours after completion of procedure was 8mmol/L. Beta-hCG on day two was 1,801mIU/mL. 

The patient was discharged on day three but unfortunately failed to return for follow up. Histology of clots showed chorionic villi confirming ectopic pregnancy in tubal stump which had miscarried and had caused active bleeding from the site. 

During laparoscopy for her first ectopic pregnancy, LigaSure electrocautery was used for excision and a total salpingectomy was performed as per operative notes. It was unclear from operative notes if there was any right tubal stump left during that procedure.

Discussion

Various theories have been postulated for recurrence of ectopic pregnancy in tubal stump. Reported hypotheses include transperitoneal migration of spermatozoa or embryo through the patent tube to the stump. Another hypothesis is that the ovum from contralateral side may be fertilised in the patent tube and later implants in the stump via intrauterine migration. A further theory suggests recanalisation of remnant stump allows for fertilisation and implantation in that portion of the tube. The management of ectopic pregnancy can be expectant, medical or surgical, depending on clinical situation. Our patient was not suitable for expectant or medical management due to haemoperitoneum.

Laparoscopic salpingectomy can be performed by various ways using diathermy, newer advanced electrosurgical device or by using endo loops or clips. Although total salpingectomy does not necessarily eradicate all ipsilateral stump ectopics or interstitial ectopics, it certainly decreases an ipsilateral tubal recurrence in proximal or distal stump. 

It is difficult to suggest exact surgical technique because of the rarity of the situation and uncertain nature of mechanism. Few options may be suggested to decrease the recurrence. Partial salpingectomy is not recommended. Generally, it is common practice to leave a remnant stump to minimise the risk of bleeding from the isthmic portion of the fallopian tube; this remnant portion should be minimised. Adequate fulguration of the residual stump should be performed to reduce endosalpingoblastosis and potential fistula formation in the stump, through which sperm can reach the ovum.

It is not known if recurrence of ectopic pregnancy in the remnant stump can be prevented but all possible measures should be taken to avoid this situation. This case also emphasises that salpingectomy does not exclude recurrence of ipsilateral ectopic pregnancy and highlights the need for a high index of suspicion in a patient presenting with pain at the side of previous salpingectomy and positive pregnancy test.

References 

1. Lakhotia S, Yussof SM, Aggarwal I. Recurrent ectopic pregnancy at the ipsilateral tubal stump following total salpingectomy – case report and review of literature. Clin Med Invest 2016;1(2): 35-38. doi: 10.15761/CMI.1000108
2. Anwar S, Uppal T. Recurrent viable ectopic pregnancy in sailpingectomy stump. Australas J Ultrasound Med 2010 Aug; 13(3): 37-40. Published online 2015 Dec 31. doi: 10.1002/j.2205-0140.2010.tb00162.x