AKRAM ABD ELGHANY

MD.OBS.&GYN.
ALAZHAR UNIVERSITY EGYPT
Consultant obs.& gyn.

A 33-year-multipara presented with

missed period with IUCD.
regular menstrual cycle (28-30
days).
Her last menstruation had been
from March 27 ,2010 for 4 days.
Urinary pregnancy test was
positive on 1 May 2010 repeated
many times over 2weeks.

On MAY 18, 2010 ,She presented with

lower abdominal pain and irregular
vaginal bleeding for 2 weeks.
positive pregnancy test.
vital parameters were normal.
abdominal examination revealed
rigidity suprapubic tenderness and
rebound tenderness .
Pelvic examination tender fornices
and tender cervical motion.

Transvaginal ultrasound (TVS)

showed
AVF bulky empty uterus.
endometrium trilamner 6mm.
LT. complex heterogenous mass
50x40 mm beside left ovary.
RT. adnexa is free.
moderate amount of fluid in the
pouch of Douglas.

The patient was counselled

concerning the possibility of an
ectopic pregnancy and informed
consent for
laparoscopic exploration,with the
possible need for salpingostomy or
salpingectomy was obtained.

At laparoscopy

pelvic collection of blood.

LT .tube ruptured in mesosalpinex
forming a hemorrhagic mass 5x4cm .
Blood escape from LT.fimberia.
The RT. adnexa was free .
The left mesosalpinex was then
found to contain a mass 5cm
consistent with an ectopic pregnancy.

salpingectomy of the LT. tube produced

products resembling hemorrhagic tissue
typically found with ectopic pregnancies.
There were no complications from the
surgery and the patient recovered well.
The products of conception and the LT. tube
were removed through a 10 mm RT. Trocar.
She visited my clinic 4 times thereafter
with no post operative complains except
umbilical wound infection.

On 20 June 2010 she visited

my clinic with 5 weeks
amenorrhea and positive home
pregnancy test.
there were no complain.
general ,abdominal and pelvic
examination were normal.

TVS diagnosed
RT. Adnexal mass 20 mm x 15
mm.
gestational sac 8mm.
yolk sac is present.
no embryonic echo.
minimal fluid in DP.
LT.adnexa is free.

serum B,hCG was 15,000 IU/L.

RT. recent new 5 weeks undisturbed
ectopic pregnancy was diagnosed.
the patient refused conservative
management to save the RT. Tube.
RT. salpingectomy was done through
laparotomy in another clinic on 22
June 2010.
No attemps were made to save the last
tube.
No blood transfusion.

This seems to be a rare, atypical case

of ectopic pregnancies in two
consecutive menstrual cycles.
There is a great rarity of this event.
With the incidence of ectopic
pregnancy increasing, bizarre cases
(for example, heterotopic, bilateral
or consecutive) will be seen more
often.
Irvine,etal.1999

Reported the first case of ectopic

pregnanccies in two consecutive menstrual
cycles.
A 28-year-old multigravid woman reported
six weeks of amenorrhoea and two days of
abdominal pain and vaginal bleeding.
On examination she was
haemodynamically stable.
the abdomen was tender, and the uterus
was bulky with tenderness in the left
fornix.

A urinary pregnancy test was positive.

At laparotomy a small leaking left
distal ectopic pregnancy was seen and
a left partial salpingectomy was
performed.
the right adnexa was noted to be
normal.
She recovered uneventfully and was
discharged home on the fifth
postoperative day.

At her eight-week follow-up visit she

complained of right-sided abdominal pain.
on vaginal examination she was tender in
the right adnexa.
On admission the differential diagnosis was
judged to be pelvic inflammatory disease,
urinary tract infection or appendicitis.
A transabdominal scan showed a normalsized uterus with a 2 cm ill-defined echopoor area by the right ovary, thought to be
a small collection of fluid.
She was afebrile and clinically stable.

Treatment was started with

intravenous erythromycin 200mg
three times daily and blood
samples were taken six days apart
for measurement of beta human
chorionic gonadotropin, which was
120 U/L rising to 170 U/L.

Her abdominal pain settled and she was

clinically well but, in the absence of a
definitive diagnosis.
laparoscopy was done on day seven.
She had a haemoperitoneum of 200 mL and
a right distal leaking ectopic pregnancy.
A right partial salpingectomy was
performed.
Histological examination of both fallopian
tubes revealed chorionic villi, confirming
the ectopic pregnancies.

reported a case of bilateral

chronic and acute tubal
pregnancies following failed
treatment with methotrexate
for a previous ectopic
pregnancy.

Reported evidence in support of

superfetation in a patient who
had an ongoing ectopic
pregnancy. The patient had a
documented rise in mid-cycle
basal body temperature,
suggesting ovulation occurred
while she carried a tubal
pregnancy.

encountered a unique case

of combined pregnancy in
which an intrauterine
pregnancy was established
following a spontaneous
ovulation occurring whilst
the woman had another
ectopic pregnancy.

S,b,HCG 1024 IU/L .

Pelvic examination and
ultrasonography indicated an
extrauterine pregnancy, which was
confirmed by laparotomy and
histological identification of
trophoblast cells.
HCG concentration markedly
decreased after the operation.

The HCG level increased again on the

fifth postoperative day,and
a gestational sac (11 mm) was
identified in the uterine cavity on the
11th post-operative day, indicating
that this intrauterine pregnancy was
established following spontaneous
ovulation which occurred before the
removal of the extrauterine
pregnancy.

This case indicates that a

combined pregnancy can
occur not only after
simultaneous multiple
ovulations but also after the
separate spontaneous
ovulations.

Reported Bilateral tubal pregnancies

in the absence of preceding
induction of ovulation are an
extremely unusual occurrence and
are thought to represent the rarest
form of extrauterine pregnancy.
More common are twin
pregnancies in the same tube and
heterotopic pregnancies.

A 25-year-old gravida 3, para 0 woman was

an approximate gestational age of 9 weeks
and 2 days.
Presented with vaginal bleeding and
intermittent lower abdominal cramping.
The patient was hemodynamically stable.
The initial level of serum hCG was 24,242
IU/L.
A transvaginal pelvic ultrasound
examination revealed an empty uterus
with a right adnexal mass measuring 4.3 x
2.3 cm.

bilateral tubal pregnancies diagnosed

intraoperatively.
The pathology report confirmed the
diagnosis of spontaneous bilateral tubal
pregnancies,
the tissue removed from the right tube
showing blood clot admixed with
chorionic villi.
The tissue obtained from the left tube
showed multiple fragments of fetal
tissue, including the vertebral column,
neurological structures, liver, intestine,
umbilical cord, and chorionic villi.

Reported a 31-year-old woman with a

positive pregnancy test.
a transvaginal ultrasound scan result that was
suggestive of a right tubal ectopic pregnancy.
a laparoscopy, showed bilateral
hematosalpinx.
In the presence of active bleeding and
deteriorating hemodynamic status of the
patient, a minilaparotomy was performed
that revealed a right-sided hematosalpinx
and a left-sided ectopic gestation.

described a unique case of

concurrent chronic and acute
ectopic pregnancies in an
ipsilateral tube.
A 33-year-old woman presented
with symptoms suggestive of
miscarriage that resolved on
conservative management,
resulting to normal hCG level.

she was readmitted 5 weeks later with

vaginal spotting, right iliac fossa pain .
TVS revealed an empty uterus, no signs
of retained products of conception and
a small 1.9x1.6x1.3cm mass medial to
right ovary. hCG was 34 U/L.
A diagnosis of pregnancy of unknown
location was made and she was managed
conservatively.

Four weeks later the patient presented once again

with vaginal bleeding and a positive pregnancy test.
TVS showed a right adnexal mass (1.3x1.5x1.6 cm)
and some free fluid in pelvis.
hCG was highly elevated at 9661 U/L.
A diagnosis of ectopic pregnancy was made and the
patient underwent laparoscopic salpingectomy.
Histopathological examination showed two ectopic
pregnancies within the same tube; an older
(chronic) ectopic positioned within proximal end of
the tube and a more recent acute one at the distal
end.

Histopathological examination of the removed tube

showed two separate lesions manifesting two
ectopic pregnancies; an older (chronic) one
positioned proximally and more recent one at the
distal end.
Sections of the 6 mm lesion towards the uterine
proximal end of the fallopian tube showed
characteristic features of chronic ectopic
pregnancy: a fibrinous nodule with evidence of
fresh and old haemorrhage. Within this; the "ghost"
outlines of a few necrotic chorionic villi were
identified .
The other lesion noted at the distal end of the
fallopian tube close to the fimbria was a viable
decidua, and unvascularised small chorionic villi .

Milingos ,etal. reported the case of a

patient who had three consecutive ectopic
pregnancies on the ipsilateral side after
natural conception and was treated
surgically in each case with partial
salpingectomy, removal of tubal stump, and
resection of the uterine cornua,
respectively. The contralateral normal tube
was resected at the time of last operation.
Obstet Gynecol. 2008

Clinically, ovulation has been

reported to occur 2 weeks after
artificial abortion of intrauterine
pregnancy .
Boyd and Holmstrom,1972
operation for ectopic pregnancy .
Spirtos et al,1987

50% demonstrated ovulation before day 14

after mangement of chronic ectopic
pregnancy. (serum progesterone at least 3
ng/mL on day21)
the onset of ovulation is missed in
approximately three-quarters of cases and
hence the possibility of further pregnancy.
contraception should be introduced
immediately after surgery, if further
pregnancy is unwanted or contraindicated.
Spirtos,et al.Obstet Gynecol 1987

reported that the administration of

exogenous HCG for ovulation induction
or luteal support lowered the FSH in
the late luteal phase, and increased
the size of persistent follicles in the
late luteal phase and the follicular
phase of the next cycle.
They speculated that the trigger of the
second ovulation was endogenous HCG.

There is a wide range in the normal

hCG level at each week of pregnancy
5,000 to 150,000 IU/L.
Silva et al, 2006 .
Quantitative tests are not useful for
estimating gestational age because of
the wide range in hCG levels at any
given point in pregnancy .
Seeber, Obstet Gynecol 2006.

The hCG concentration rises at a much

slower rate in most, but not all, ectopic
and nonviable intrauterine pregnancies.
only 21 percent of ectopic pregnancies
were associated with hCG levels that
followed the minimum doubling time of a
viable intrauterine pregnancy (defined in
this series as 53 percent increase over
two days).
Silva et al, 2006.
The serum B,HCG of ectopic pregnancy
may be very high as in viable undisturbed
ectopic , twin ectopic , vesicular mole
with ectopic and bilateral tubal ectopic.

A falling hCG concentration is

most consistent with a failed
pregnancy eg,
arrested pregnancy.
anembryonic pregnancy.
tubal abortion, spontaneously
resolving ectopic pregnancy.
complete or incomplete
abortion.

The earliest sonographic sign of

an intrauterine pregnancy is the
presence of
A true gestational sac, which
has double echogenic rings
surrounding the sac.
Bradley, Radiology 1982.

the gestational sac is usually visible

at 4.5 to 5 weeks of gestation.
an embryo with cardiac activity is
first detected at 5.5 to 6 weeks.
Pseudosacs are often found in
association with ectopic pregnancy.
They tend to be located in the middle
of the uterine cavity rather than
embedded in the decidua, and
conform to contour of the cavity.

Visualization of an extrauterine
gestational sac containing a yolk sac or
embryo is diagnostic of ectopic
pregnancy, but this combination of
findings is detected in only a small
proportion of cases 20% .
in expert ultrasound units,
abnormalities suggestive of the
diagnosis will be identified in 90
percent of ectopic pregnancies .
Condous,etal. Hum Reprod 2005.

A complex adnexal mass in the

presence of a positive pregnancy
test and empty uterus is highly
suggestive of an extrauterine
gestation and is the most
common sonographic
abnormality.

the sensitivity of 73.9 percent

(95% CI 65.1 81.6),
a specificity of 99.9 percent (95%
CI 99.8 100),
a positive predictive value of 96.7
percent (95% CI 90.7 99.3),
a negative predictive value of
99.4 percent (95% CI: 99.2 99.6).
Kirk,etal. Hum Reprod 2007.

TVS does not reveal an

intrauterine pregnancy and
shows a complex adnexal mass,
an extrauterine pregnancy is
almost certain.
The diagnosis of ectopic
pregnancy is less certain if no
complex adnexal mass can be
visualized.

repeat the TVS examination

and hCG concentration two
days later.
If an intrauterine pregnancy
is still not observed on TVS,
then the pregnancy is
abnormal.

A serum hCG concentration less

than 1500 IU/L should be followed
by repetition of hCG in three days
to follow the rate of rise.
HCG concentrations usually double
every 1.4 to two days until six to
seven weeks of gestation in viable
intrauterine pregnancies (and in
some ectopic gestations).

A normally rising hCG

concentration should be
evaluated with TVS when the
hCG reaches the discriminatory
zone. At that time, an
intrauterine pregnancy or an
ectopic pregnancy can be
diagnosed.

If the hCG concentration does not

double over 72 hours then the
pregnancy is abnormal (an ectopic
gestation or failed intrauterine
pregnancy).
The clinician can be reasonably
certain that a normal intrauterine
pregnancy is not present.
If an adnexal mass is visualized on
TVS, then medical or surgical
treatment is administered for a
presumed ectopic pregnancy.

If an adnexal mass is not

visualized, some clinicians
administer methotrexate and
others perform curettage to
determine the type of nonviable
pregnancy and thereby avoid
medical therapy of nonviable
intrauterine pregnancies .
Seeber,etal.Obstet Gynecol 2006.

Previous ectopic
pregnancy.recurrence is 15%
Tubal pathology and surgery.
chronic salpingitis, is observed
in up to 90 percent of ectopic
pregnancies.
Intrauterine contraception

is a problematic diagnosis.
The clinical presentation can be mild, with
absent or subtle symptoms.
The high incidence of negative pregnancy
tests or very low hCG, the poor
specificity of sonographic patterns can be
misleading.
The correct diagnosis can only be
established at surgery or following
histopathological examination of the
resected specimen.

The presentation of chronic ectopic

pregnancy as an inflammatory mass
can cause problems in differential
diagnosis.
The involution of the trophoblast
may allow the menstrual cycles to
re-establish and the convoluted,
blood- filled tube often involving the
ipsilateral ovary may simulate
tumour or an endometriotic mass

The classic symptoms of ectopic

pregnancy are :
Abdominal pain 99%.
Amenorrhea 74%.
Vaginal bleeding 54%.
these symptoms are not diagnostic of
ectopic pregnancy; they are the same
as those associated with threatened
abortion, which is far more common.

dramatically moved away from a

primarily surgical approach .
Yao,etal.Fertil Steril 1997.
Currently, most women with unruptured
ectopic pregnancies are treated with
methotrexate.
some women undergo surgical therapy
by choice or by necessity, if they are
not good candidates for medical
therapy.

The extent of surgical management

would depend on the size of the
mass, involvement of adjacent
organs and the reproductive
history of the patient. This might
vary from conservative surgical
excision of the mass to salpingooophorectomy or even more
extensive surgery.

Failure to diagnose ectopic pregnancy

before tubal rupture limits the treatment
options and increases maternal morbidity
and mortality.
four factors that increased the risk of
rupture when an ectopic pregnancy was
suspected:
(1) never having used contraception,
(2) history of tubal damage and infertility,
(3) induction of ovulation, and
(4) high level of HCG (at least 10,000 IU/L) .

is not recommended.
It is possible that some ectopics will
resolve spontaneously.
The initial titer of hCG and the trend on
serial monitoring are both predictors of
success for expectant management.
The higher the initial concentration, the
more likely it is that expectant treatment
will fail.
If the initial concentration is <1000
mIU/mL, expectant management can be
successful in 88% of cases

Hemodynamic instability.
Impending rupture of ectopic .
mass Contraindications to use of methotrexate.
Coexisting intrauterine pregnancy .
Not able or willing to comply with medical
therapy posttreatment follow-up.
Lack of timely access to a medical institution
for management of tubal rupture .
Desire for permanent contraception .
Known tubal disease with planned in vitro
fertilization for future pregnancy.
Failed medical therapy

In hemodynamically stable
women, surgical intervention
should only be considered if a
transvaginal ultrasound
examination (TVS) clearly shows
a tubal ectopic pregnancy or an
adnexal mass suggestive of
ectopic pregnancy.

If no abnormality is imaged sonographically,

there is a high probability that an ectopic
pregnancy will not be visualized or
palpated at surgery.
these women should be managed
conservatively with either medical therapy
or expectant management.
A repeat ultrasound examination after a
few days may visualize an abnormality,
thus enabling a surgical procedure, if this
option is desired.

less time for resolution of

the ectopic pregnancy.
avoidance of the need for
prolonged monitoring.

Operative morbidity is similar for both

procedures.
Salpingectomy does not appear to compromise
the rate of subsequent intrauterine pregnancy
in women whose contralateral fallopian tube
appears to be normal and avoids the
complication of persistent or recurrent ectopic
pregnancy in the same tube.
reproductive outcome reflect tubal status at
surgery, rather than the choice of surgical
procedure. Dubuisson, et al.Hum Reprod 1996.

In these situations, there is a low probability of

future normal tubal function and the risk of
persistent or recurrent tubal problems is high.
We perform salpingectomy, instead of
salpingostomy in the following situations:
Uncontrolled bleeding from the implantation
site.
Recurrent ectopic pregnancy in the same tube.
Severely damaged tube.
Large tubal pregnancy (ie, greater than 5 cm).
Women who have completed childbearing.

hemodynamically stable.
reasonable probability of
future normal tubal
function in the affected
tube.

Laparoscopic surgery is the standard

surgical approach for ectopic pregnancy.
Most ectopic pregnancies, even in the
presence of hemoperitoneum, heterotopic
pregnancy, and interstitial pregnancy, can
be treated by a laparoscopic procedure.
However, the surgical approach depends
upon the experience and judgment of the
surgeon and the anesthetist, and the
clinical status of the patient.

The incidence 4 to 15 percent.

higher after laparoscopic salpingostomy than after
open procedures.
The serum beta-hCG concentration on the first
postoperative day generally declined by more than 50
percent of the preoperative value .
In series of 147 women treated conservatively for
ectopic pregnancy, there were no cases of persistent
ectopic pregnancy when the postoperative beta-hCG
on day 1 fell by more than 76 percent .

Spandorfer, etal. Fertil Steril 1997.

Transvaginal ultrasound examination

of the pelvis and measurement of
serum beta-hCG concentration are
then performed weekly until the level
is undetectable.
Alternatively, prophylactic treatment
with one dose of methotrexate can be
given after all salpingostomies.
Gracia, etal. Fertil Steril 2001.

Ectopic implantation usually occurs

because clinical or subclinical
salpingitis has caused anatomic and
functional changes in the fallopian
tubes.
These changes are typically bilateral
and permanent.
it is not surprising that ectopic
pregnancy often leads to recurrent
ectopic pregnancy and infertility.

In women with a history of ectopic

pregnancy, 38 to 89 percent will
achieve a subsequent intrauterine
gestation .
Recurrent ectopic pregnancy is 15
percent (range 4 to 28 percent).
Farquhar, Lancet 2005.
The recurrence risk rises to 30
percent following two ectopic
pregnancies.
Tulandi,etal.Fertil Steril 1988.

Recurrence of an ectopic
pregnancy seems to be
similar for all modes of
treatment and is variously
quoted as up to 26%, with
averages around 6-12%.

 akram103g@yahoo.com
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