Biology and Medicine
Editor-in-Chief: Eytan R. Barnea MD, FACOG
|
EARLY
PREGNANCY: Biology and Medicine Editor-in-Chief: Eytan R. Barnea MD, FACOG |
**ULB, Pharmacy Institute, Boulevard du triomphe, 1050 Brussels
Correspondence : Dr
Isabelle Govaerts. Avenue Général Dubois, 24. 1380 Lasne.
Tel :3226522694 /3223404202.
E-mail : sungurtekin-govaerts@unicall.be
Key Words: persistent ectopic pregnancy, laparoscopic salpingostomy.
Abstract
Conservative management of ectopic pregnancy is important because it allows preservation of the fallopian tube. It has been reported to result in extratubal secondary trophoblastic implants (ESTI) in 3% to 22% of cases.
The aim of this case report is to highlight the factors predicting the risk of ESTI.
Introduction
The incidence of ectopic pregnancy (EP) after spontaneous conception and after medical assisted procreation respectively is about 1-2% and 4-11%. To preserve the fertility the treatment of choice of unruptured tubal EP is laparoscopic salpingostomy. However the major complication of this surgical procedure is the persistence of trophoblastic implants to the peritoneum with severe abdominal bleeding. This case report is uncommon because the latent period(51 days) between the surgery for EP and the complication of ectopic secondary trophoblast implants (ESTI) diagnosed by severe abdominal bleeding. It illustrates the importance of the follow-up of Beta Human Chorionic Gonadotrophin (Beta hCG) level after laparoscopic treatment of tubal ectopic pregnancy.
Case Report A 34-year-old woman, gravida 2, para 1 presented vaginal bleeding at six weeks of gestation after induction of pregnancy by clomiphene citrate (100 mg per day during five days) for anovulation (polycystic ovaries). One month after ovulation the beta hCG plasmatic level was 1466 mUI/ml and progesterone level was 39 ng /ml.At six weeks of amenorrhea the serum hormonal levels were 3528 mUI/ml for beta hCG and 56 ng/ml for progesterone. The vaginal ultrasound demonstrated an ectopic gestational sac with yolk and without embryo. She had laparoscopic salpingostomy for right ampullar ectopic pregnancy. After evacuation of the trophoblastic tissue there was always bleeding in the tube and coagulation with argon was necessary. Histology confirmed ectopic pregnancy. The patient left the hospital on postoperative day 1 with a normal hematological exam. As beta hCG value was less then 10% (311 ng/ml) of initial value (3528 ng /ml) by postoperative day 7, other follow-up examination was not performed.
Fifty one days after the laparoscopic removal of tubal pregnancy she presented with abdominal pain. Over the last few days she had felt increasing lower abdominal pain with nausea and headache. Her systolic blood pression was 110 mm Hg. Clinical examination showed a tender abdomen with pain without rebound and without defense. Haemoglobin and Hematocrite rates were respectively 7.3 gr/dl and 23% with normal platelets (180000/mm3). Plasmatic beta hCG level was 979 mUI/ml. Vaginal ultrasound showed a large amount of hyperechogenic blood in the abdomen but no adnexal or uterine abnormalities. Laparoscopy revealed 2000 ml coagulated blood in the peritoneal cavity . Small dark blue implants of what look like trophoblastic tissue were presented on the fimbria, on the uterus and on the bladder peritoneum. A 2-cm actively bleeding node was found in the mesosalpinx between the uterine right horn and the utero-ovarian ligament. This trophoblastic implant was excised with argon coagulation because high vascularisation of the uterine right horn. All implants were excised or coagulated . Because presence of trophoblast in the fimbria, right salpingectomy was performed. Histology confirmed trophoblastic tissue in implants but no trophoblast was found in the tube at the first place of EP. The other tube and ovaries were normal. Two units of packed red blood cells were administered postoperatively. Serial beta hCG levels were respectively 122 mUI /ml , 27 mUI/ml, 7 mUI/ml on postoperative days 1, 5 and 12. One month after operation beta hCG was always negative.
Discussion The frequency of persistent trophoblastic proliferation after conservative procedures for treatment of ectopic pregnancy varies from 3 % (Graczykowski, 1997) to 22% (Milad MP, 1998).The likelihood of success of laparoscopic salpingostomy is unrelated to gestational age, size of the EP, surgical technique, or experience of the surgeon (Milad MP, 1998). In this retrospective study ( serum beta hCG levels were significantly higher in patients who underwent failed salpingostomy (3549-19962 MUI/ml) compared to with those who underwent successful salpingostomy (565-3971 MUI/ml). For this author a preoperative serum beta hCG level above 8000 mUI/ml was highly predictive of failure of laparoscopic salpingostomy. For Kemmann (1994) patients whose Beta hCG levels increased more than 40% per day had a significantly greater risk to develop ESTI. In addition, at surgery, tubal bleeding was significantly more common in patients with persistent EP than in patients with successful salpingostomy (55% versus 9 %). For Hagstorm (1994) cases with progesterone level above 35 nmol/l (11 ng/ml) and a daily hCG change exceeding 100 mUI/ml had a 61% risk for a second therapeutic intervention, whereas with a progesterone value below 11 ng/ml and/or a daily change of less than 100mUI/ml, the risk was only 2%. In the case report , the progesterone level was 56 ng/ml but the patient had been treated by clomiphene citrate which induces multiple ovulations with higher progesterone level than in spontaneous ovulation.
For Graczykowski (1997) the incidence of persistent ectopic pregnancy was significantly reduced after a single prophylactic dose of systemic methotrexate (1 mg/kg intramuscularly within 24 hours postoperatively). The regimen was safe and could be used to decrease the extent of postoperative monitoring after conservative treatment of unruptured EP.
Moreover monitoring of postoperative serum hCG until it becomes undetectable is mandatory in order to reveal late-onset types of persistent trophoblast. If hCG level is rising, additionnal therapy is necessary.
Therefore, it would be advisable to give patients with bhCG level higher than 1000 mUI/ml a shot of methotrexate after laparoscopic evacuation of ectopic pregnancy.
For personal use. Only reproduce with permission from SIEP.
References
Graczykowski JW and Mishell DR. (1997). Methotrexate Prophylaxis for Persistent
Ectopic Pregnancy After Conservative Treatment by Salpingostomy. Obstet.Gynecol 89,
118-122.
Milad MP, Klein E and Kazer R. (1998). Preoperative Serum hCG Level and Intraoperative
Failure of Laparoscopic Linear Salpingostomy for Ectopic Pregnancy. Obstet.Gynecol
92, 373-376.
Kemmann E, Trout S and Garcia A (1994). Can We predict patients at risk for persistent
ectopic pregnancy after laparoscopic salpingotomy. J Am Assoc Gynecol Laparosc; 1,
122-126.
Hagstrom H-G, Hahlin M, Bennegard-Edèn B, Sjoblom P, Thorburn J and Lindblom B. (1994). Prediction of Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy. Obstet.Gynecol.84, 798-802.
