2025 Volume 47 Issue 1 Pages 15-20
To report a rare case of recurrent ectopic pregnancy in an ipsilateral fallopian tube remnant after left salpingectomy for tubal pregnancy. A 33-year-old patient presented with suspected ectopic pregnancy. The patient had previously undergone a left salpingectomy for a tubal pregnancy. Laparoscopy revealed ruptured swelling and bleeding from the left fallopian tube remnant. We diagnosed intra-abdominal hemorrhage due to ectopic pregnancy occurring in the fallopian tube remnant following a previous ipsilateral salpingectomy. Most ectopic pregnancies occur in the ampulla of the fallopian tube, but the occurrence of spontaneous ectopic pregnancy in a remnant tube is rare. There are several mechanisms underlying this phenomenon. In this study, we consider both the prevention and treatment of this rare form of ectopic pregnancy.
Most ectopic pregnancies occur in the ampulla of the fallopian tube. The incidence of ectopic pregnancy in the fallopian tubes is about 95%. Ectopic pregnancies occur in 1.3–2% of all pregnancies. Women with a history of ectopic pregnancy have an approximately eight-fold increased risk of future occurrences. Treatment of ectopic pregnancy includes administration of methotrexate and surgical management. Surgery for tubal pregnancy, in particular, includes radical (total or partial salpingectomy) or conservative (usually salpingostomy) methods [1]. The incidence of ipsilateral interstitial pregnancy after salpingectomy has been reported to be 0.3–4.2% [2]. Even with complete resection of the visible fallopian tube, a subsequent interstitial pregnancy can occur. The frequency of recurrent ectopic pregnancy may be higher if enough remnant fallopian tube is present [3, 4]. Therefore, total salpingectomy should be the treatment of choice, rather than partial salpingectomy of the damaged fallopian tubes, if conservative methods are not suitable [1]. Ipsilateral ectopic pregnancy in a tubal remnant after salpingectomy is associated with higher mortality rates than those of other ectopic pregnancies [3, 4], likely due to the poor distensibility of the remnant tube, as well as the increased vascularity of the area [3, 5].
We encountered a case of spontaneous ectopic pregnancy occurring in a remnant tube after a previous ipsilateral salpingectomy. In reviewing the previous surgical images, a small fallopian tube remnant was visible to the naked eye. In this report, we present this case of recurrent ectopic pregnancy in a fallopian tube remnant following previous ipsilateral salpingectomy, along with a review of the available literature regarding the mechanism underlying its occurrence. This novel report emphasizes the need for an optimal initial salpingectomy and an appropriate treatment of the later ectopic pregnancy in the ipsilateral fallopian tube remnant.
A 33-year-old woman (gravida 3 para 1) with a history of left salpingectomy for a tubal pregnancy visited a practitioner because of a positive pregnancy test and 5-week amenorrhea. Transvaginal ultrasonography revealed no gestational sac within the uterus. Two days later, the patient experienced abdominal pain and re-visited the hospital. Subsequently, transvaginal ultrasonography revealed a hematoma-like mass and an echo-free space within the pouch of Douglas. Moreover, there was no gestational sac within the uterus. On the same day, the patient was immediately referred to our hospital. Palpation revealed lower abdominal tenderness, and transvaginal ultrasonography showed a normal-sized uterus and a right ovarian cyst. A hematoma was visualized near the cyst (Figure 1). The serum human chorionic gonadotropin (HCG) concentration was 6,986 mIU/ml, and the hemoglobin level was 10.9 g/dl. We suspected a gestational sac on the right adnexal side, and diagnosed a right tubal pregnancy. Ultimately, an emergency laparoscopic surgery was performed.
A hematoma was visualized at Douglas’ pouch (yellow arrow).
Laparoscopic findings established the diagnosis of ruptured left tubal pregnancy with a hemoperitoneum of 300 ml. The right fallopian tube was normal in appearance and clear of obstruction, and the presence of a right ovarian cyst was confirmed. The remnant left fallopian tube was incised and cauterized (Figure 2). After the removal of the products of conception, we confirmed that the myometrium was not exposed. Pathological examination confirmed the presence of trophoblastic cells in the proximity of the tubal stump (Figure 3).
Laparoscopic findings revealed not only hemorrhage but also the products of conception in the remnant left fallopian tube.
Pathological examination revealed trophoblastic cells (B) in proximity to the tubal stump (A).
After examining the photographs of the previous laparoscopic surgery for left tubal pregnancy (Figure 4), we discovered that portions of the fallopian tube had remained after the initial resection.
The image revealed the left fallopian tube remnant (C) after salpingectomy.
The postoperative course was uneventful, and the patient was discharged on day 3 postoperatively. Three weeks after surgery, a blood examination revealed a significant decrease in serum HCG level.
Ectopic pregnancy, especially tubal pregnancy, is a commonly seen condition, although ipsilateral ectopic pregnancy in the tubal remnant following initial salpingectomy, which is the most frequent treatment, is rare. This report provides an explanation for the mechanisms of such ectopic pregnancies along with a review of salpingectomy methods.
Women with a previous ectopic pregnancy are reported to be eight times more likely to have a recurrence in the future [1]. It has also been reported that the incidence of recurrent ectopic pregnancy is reported to be 6–28% [6].
Ipsilateral ectopic pregnancies in tubal remnants after salpingectomy have seldom been reported. The exact incidence of such pregnancies is currently unknown, although Takeda et al, have reported an incidence of 1.16% [5]. According to other reports, the incidence of ectopic pregnancy in ipsilateral fallopian tube remnant after salpingectomy is expected to be 0.3–0.4% among all ectopic pregnancies and 3–4% among cases with a history of salpingectomy [7, 8].
The mechanism underlying recurrent ectopic pregnancy following ipsilateral salpingectomy remains unclear. Two possible mechanisms have been hypothesized. The first presupposes that at ovulation, an oocyte from the ipsilateral ovary is normally fertilized in the tube on the healthy side and that the fertilized egg passes subsequently via intrauterine transmigration into the stump of the resected contralateral tube. The second theory, in contrast, presumes the recanalization of the resected fallopian tube, in which case the fertilized egg migrates transperitoneally from the serosa into the interstitial portion of the tube before local embryonic nidation takes place [9, 10]. In any case, a complete resection of the fallopian tube with suture or sealing of the surgical wound is necessary at the initial salpingectomy to prevent the possibility of a remnant fallopian tube or the patency of the tubal stump.
The recurrence of ectopic pregnancy in a remnant tube after ipsilateral tubal surgery with partial salpingectomy, tubal milking, and bilateral tubal surgery has been reported previously [1, 7]. Although total salpingectomy has a lower risk of recurrent ectopic pregnancy than partial salpingectomy, there have been reports of spontaneous interstitial/cornual pregnancy after total salpingectomy. Therefore, although the fallopian tubes may have been completely excised, avoiding ectopic pregnancy in the remnant portion of the tube after ipsilateral salpingectomy/adnexectomy remains a challenge [5].
Reports state that additional cornual resection performed at the initial salpingectomy for ectopic pregnancy may prevent subsequent interstitial ectopic pregnancies [7, 11], but some reports indicate that cornual resection increases the risks of uterine rupture and placenta accreta because the myometrium is damaged [7, 12]. Additional cornual resection may not be a good preventive measure with regards to such complications, although the fallopian tube must be removed to ensure that there is no residual during salpingectomy.
The reported cases of ipsilateral ectopic pregnancy after salpingectomy are listed in Table 1. Four of the eight cases underwent urgent operations, and the other four underwent laparoscopic resections relatively early, although details are not provided. Two patients had severe hemoperitoneum (1,000 ml); therefore, emergency surgery was performed in both cases. Some cases were clinically diagnosed as interstitial pregnancy or cornual ectopic pregnancy, but not tubal pregnancy, although pathological examinations showed residual fallopian tube tissue. Owing to the variety of surgeries and procedures, the outcomes following the use of each surgical approach remain unclear, based only on the available data that is shown in Table 1. In particular, the probability of pregnancy and the risks during pregnancy after each surgery are unclear.
| Author (year) |
Age (years) |
GP (including this pregnancy) |
Gestational week at surgery |
IVF (yes/no) |
Time from previous surgery | Bleeding | Treatment | Residual fallopian tube (pathological examination) | Pregnancy outcome |
|---|---|---|---|---|---|---|---|---|---|
| Janbakhishov et al (2013) [6] | 33 | G2P0 | 4 weeks 2 days | Unknown | 2 years | Unknown | Salpingeal stump was removed | Present | Unknown |
| Xi et al (2019) [14] | |||||||||
| Case 1 | 28 | Unknown | IVF 23 days prior (two embryos) | IVF | 1 year | 1,000 ml | Removed and effective hemostasis achieved | Present | The other ET: incomplete abortion (on day 10 after the operation) |
| Case 2 | 25 | Unknown | 7 weeks | IVF | 1.5 years | 300 ml | Removed and effective hemostasis achieved | Present | Delivery, no complications |
| Manea et al (2014) [13] | |||||||||
| Case 1 | 21 | G2P0 | 7 weeks | Unknown | 6 months | 100 ml | Removed and effective hemostasis achieved. Uterine cornu was closed using absorbable sutures. | Unknown | Pregnancy, C-section |
| Case 2 | 38 | G4P1 | 5 weeks | Unknown | 3 months | 600 ml | Corneal wedge resection | Unknown | Unknown (contraception at least 6 months) |
| Case 3 | 35 | G6P1 | Unknown | IVF | Unknown | 600 ml | Sutured and reinforced | Present | Unknown (contraception at least 6 months) |
| Kodate et al (2018) [7] | 27 | G2P1 | 4 weeks | Unknown | 3 years (adnexectomy) | 1,000 ml | Salpingectomy | Present | Pregnancy, 3 months after the operation |
G: gravida, IVF: in vitro fertilization, P: para, ET: Embryo transfer
At least three of the eight patients were pregnant after in vitro fertilization and embryo transfer (IVF-ET). Although our patient had spontaneous ovulation and fertilization, the possibility of a link between ectopic pregnancy and IVF-ET has been noted in some studies [6, 13].
The occurrence of ectopic pregnancy should be anticipated in cases of multiple embryo transfer in an IVF-ET cycle [14]. Though reports indicate that abnormally vigorous uterine contractions during the implantation period are associated with recurrent ectopic pregnancies, the cause of such contractions is unknown. However, ovarian hyperstimulation due to the administration of parenteral gonadotropins in these cases may have contributed to this problem [15]. Abnormally vigorous uterine contractions may also occur even without IVF-ET or the use of parenteral gonadotropins. Although such uterine contractions are a known risk factor for recurrent ectopic pregnancy, their contribution to the risk of recurrent ectopic pregnancy in a remnant ipsilateral fallopian tube is still unreported in the literature.
To prevent recurrence, a report suggested that patients with previous tubal ectopic pregnancy who were at risk of developing ipsilateral interstitial ectopic pregnancy are better managed with total salpingectomy followed by interventional blockage of the uterotubal ostium and intramural portion of the tube [15]. Hence, we should consider the possibility of a recurrent ectopic pregnancy in the ipsilateral fallopian tube remnant after salpingectomy for tubal pregnancy and operate promptly.
Herein, we reported a case of spontaneous ectopic pregnancy occurring in the remnant tube with intra-abdominal hemorrhage after previous ipsilateral salpingectomy. There had been no reports of reliable and effective prevention at the time of the initial surgery. Because spontaneous occurrence of interstitial/cornual pregnancy after ipsilateral salpingectomy is possible, avoiding repeated ectopic pregnancies may be difficult. However, when fallopian tube remnant is obvious, as in this case, recurrent ectopic pregnancy could theoretically can be avoided if the fallopian tube is completely removed at the time of the initial surgery. It should still be recommended that the surgeon remove as little of the remaining fallopian tube as possible at the time of surgery. Early examination and early treatment should be performed, keeping in mind that recurrent ectopic pregnancy in the ipsilateral fallopian tube remnant after salpingectomy for tubal pregnancy can also occur.
We would like to thank Editage (www.editage.com) for English language editing.
The authors have no conflicts of interest directly relevant to the contents of this article.
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
