about ectopics

1. STUMP ECTOPIC

2. INTRODUCTION
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Stump ectopic is in which pregnancy takes place in
the residual part of tube.
Incidence of recurrent ectopic after previous one
ectopic is approx 15% and this rises to 30% following
two ectopics.
We
present a rare case of recurrent ectopic
occurring
in the proximal remnant part of left fallopian tube after
ipsilateral partial distal salpingectomy.
Ref: Obstet Gynae colscand 2002 81:11139-43 Publisher fill text open URI.

3. CASE PRESENTATION
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A 29 yrs old infertile Female, with previous H/O Left Salpingectomy for ectopic
pregnancy one year back presented with severe pain in abdomen with
minimal vaginal bleeding . She was overdue by three days.
On investigation her Urine pregnancy test was positive . And Beta HCG done on
04/08/11 was 408 & after 48 hrs 787 so supportive treatment started.
Then she came in emergency with severe abdominal pain after one week.
O/E- Her vitals were stable and tenderness was there in lower abdomen on left
side.
On P/V – Cervical excitation test was positive and fullness in left fornix. On trans
vaginal sonography there was no intra uterine sac with minimum fluid in uterine
cavity with echogenic space occupying lesion about 8.0x5.1 cm visible behind
the uterus consistent with left ectopic. Emergency laparoscopy was performed.

4. ON LAPAROSCOPY
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Haemoperitoneum about 1 lit lying in pelvis.
Uterus was normal. Both ovaries normal.
Right tube looked convoluted & unhealthy.
Oh it is stump ectopic !!!
Bleeding from tubal stump on left side was present
The stump was excised and sent for histopathology.
Thorough peritoneal wash done.

5. MANAGEMENT
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She was an infertility patient who was trying to conceive.
Can we say this girl was lucky? In a way Yes. She had
ectopic pregnancy on same fallopian tube which was
previously affected.
She has still more than 65% chances of intrauterine
pregnancy if contra lateral tube is healthy.
Unfortunately this tube was also unhealthy and
convoluted morphologically so it was also removed avoid
another ectopic pregnancy, and sent for HPE
She was planned for subsequent IVF.
The clinical diagnosis of tubal ectopic pregnancy was
confirmed histologicaly. She was discharged on 3rd post
operative day.

6. DISCUSSION
Diagnosis of ectopic needs high degree of
suspicion.
 Triad of Amenorrhea, Pain and vaginal
bleeding present only in 50% patients.
 Particular risk factors in our case was
previous ectopic pregnancy, prior fallopian
tube surgery and history of infertility led to
prompt Hospitalization.
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7. LAPAROSCOPY VERSUS LAPAROTOMY
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After laparoscopy recurrence is 7%.
After Laparotomy recurrence for ectopic is 14%.
However there is no statically significant difference in laparoscopy
and Laparotomy but laparoscopy is the reference surgical
approach because it reduces hospital stay, analgesic
requirement, Hospital cost, risk of post surgical adherence & also
result in low morbidity & better aesthetic appearance
Laparotomy only performed when laparoscopy is Contraindicated.
J Gynae colo obstet Bio reporod (Paris) 2003 Nov.

8. SALPINGOSTOMY VERSUS SALPINGECTOMY
Recurrence after first ectopic is 10% after
salpingectomy and 15% after salpingotomy.
 Salpingectomy remains the standard surgical
treatment for ectopic.
 However the final decisive ability rest with
patient and her husband.
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(Yao and tuland in 1997)

9. 
Concomitant bilateral tubal ectopic
pregnancies after bilateral partial
salpingectomy for sterilization have also
been reported.
Br Med J 1977

10. Sangal and Kotwal reported an unusual
presentation of a 3rd tubal pregnancy associated
with fimbrial end of a previous right partial
salpingectomy and left tubal salpingectomy.
 The incidence of tubal pregnancy distal to the
site of sterilization is five times that in the
segment proximal to the site of sterilization.
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J. Reprod Med 1987

11. 
High rate of ectopic pregnancy following
laparoscopic tubal coagulation failure by a
tuboperitoneal fistula formation have been
reported.
Jeffcoate’s Principles of Gynaecology. 5th ed. London:

12. 
Ectopic pregnancy in the distal part of the
fallopian tube following vaginal hysterectomy
(graffagnino,1963; moayer, 1966) or
abdominal hysterectomy (ledger &
daly, 1963) was shown to be the result of
simple trapping of the fertilized ovum in the
ligated tube at the time of hysterectomy.

13. CONCLUSION
Recurrent ectopic pregnancy following
ipsilateral partial salpingectomy is a rare
occurrence. At primary care level and
emergency department urine pregnancy testing
should be performed in any woman of
reproductive age with unexplained per vaginal
bleeding. At tertiary level, management protocol
should be in place to enable expedient
diagnosis and therapeutic intervention of ectopic
pregnancies, Nevertheless, BHCG trending may
not be entirely conclusive in every case and
hence the maintenance of a high index of
clinical suspicion is a paramount importance.

14. THANK YOU