Recurring Ectopic Pregnancy Following Previous Bilateral Salpingectomy: A Rising Concern

Dr.Jacqueline John1 , Dr.Yusor Al-Nuaimy 2 , Dr.Shabana Kapadia 1 , Dr.Mohammad Aoun Hakmi 1 ,Dr.Omaema Omar Al-Baghdadi 1 Department of Obstetrics and Gynaecology, Tawam Hospital, Abu Dhabi, United Arab Emirates 1 College of Medicine, Ajman University, Ajman, United Arab Emirates 2

Ipsilateral Ectopic pregnancy {EP} after bilateral total salpingectomy is rare and the likelihood of recurrent EP increases significantly upto 30% following two EPs 1 . We report a case where a spontaneous EP was diagnosed in a setting of previous bilateral salpingectomy. This case highlights the post salpingectomy potential for ipsilateral recurrence of EP and hence delves into the need for further consideration of the diagnosis of an EP especially when preventative surgical measures have been previously performed.

A 30 year-old lady, Gravida 8 Para 3+5Abortions was referred to our clinic as a case of suspected EP. She has a history of previous 3 EPs viz. left tubal EP (2017), right tubal EP (2018), and left cornual EP (2019) for which she underwent management via laparoscopic left salpingectomy, laparotomy right salpingectomy post failed methotrexate management, and laparoscopic resection of left uterine cornu respectively. She currently presented with left lower abdominal pain associated with vaginal bleeding. There were no significant findings on clinical examination. Pelvic Ultrasound revealed a suspicious complex left adnexal mass (2.1 x 1.5 x 1.5 cm) with a ring-like structure; no intrauterine pregnancy was visualized. Laboratory investigations revealed plateauing of β-HCG over 48 hours(251 IU/L→220 IU/L). Treatment modalities offered included medical vs surgical management, however she opted the former. A single dose of Methotrexate (50mg/m2 ) IM was administered to the patient with weekly follow-up of β-HCG levels which progressively declined to insignificant levels over the following weeks. A hysterosalpingography done confirmed bilateral patent salpinges suggesting possible partial tubal recanalization.

March 2023 - XR Hysterosalpingography 2019 - Left cornual pregnancy 2022- US:left adnexal mass 2019 – Laparoscopic resection of left cornua

The mechanism by which a recurrent EP after ipsilateral salpingectomy occurs is unclear, but is theorized to be secondary to contralateral fertilization and/or tubal recanalization due to inadequate diathermy. Nonetheless, existence of such cases advocates for a more aggressive surgical approach in the management of EP. Although a salpingectomy doesn’t necessarily eradicate all ipsilateral ectopic cases, it certainly minimizes a tubal recurrence on the same side. Furthermore, our case illustrates it is erroneous to believe total salpingectomy is always as complete as the word implies. 1

Although exceedingly rare, recurrent EP may occur after bilateral salpingectomy. Physicians should be aware that EPs may not only occur repeatedly but also present atypically. We recommend when performing a salpingectomy, efforts be undertaken to minimize length of tubal remnant and ensure adequate tissue coagulation so as to reduce any further risk of recurrence. 2

1.Recurrent-viable-ectopic-pregnancy-in-the-salpingectomy-stump; Australas-J-UltrasoundMed.-2010-Aug;-13(3):37–40S.Anwar et.al

2.Spontaneous-live-recurrent-ectopic-pregnancy-after-ipsilateral-partial-salpingectomyleading-to-tubal-rupture,-Int-J-Surg-Case-Rep.-2015;7:75–78C.Abraham et.a