Ectopic pregnancy following tubal sterilization SURINDER KUMAR, MD; HARRY OXORN, MD
We undertook a retrospective clinical study to evaluate evidence suggesting that tubal sterilization is a causative factor in ectopic pregnancy. We also noted the procedures used for tubal sterilization. Although more definitive correlation between the occurrence of ectopic pregnancy and tubal sterilization may require wider sampling, our findings are notable. Equally relevant is the nexus of ectopic pregnancy to the procedure used in tubal sterilization. During a 3-year period, 1974 through 1976, 92 cases of tubal pregnancy were dealt with at the Ottawa Civic Hospital; 11 of the ectopic pregnancies occurred in 10 women who had undergone tubal sterilization. In our review of the cases we tried to evaluate the possible sequelae of tubal sterilization procedures and their relation to ectopic pregnancy. We concluded that the diagnosis of ectopic pregnancy must be considered carefully in a woman with signs or symptoms of pregnancy, lower abdominal pain or abnormal uterine bleeding regardless of previous tubal sterilization. 1-3
Findings Study group and sterilization procedures Ninety-two cases of ectopic pregnancy dealt with at the Ottawa Civic Hospital from 1974 through 1976 were studied. Eleven of the pregnancies occurred in 10 women who had undergone tubal sterilization. Information on the sterilization procedure was obtained from hospital records and from the surgeons involved. The procedure had been performed at the Ottawa Civic Hospital in five instances and elsewhere in the other five. Three women underwent transvaginal procedures, performed by the same surgeon, in which 2 to 3 cm From the department of obstetrics and gynecology, University of Ottawa and Ottawa Civic Hospital Reprint requests to: Dr. Harry Oxorn, Department of obstetrics and gynecology, Ottawa Civic Hospital, 1053 Caning Ave., Ottawa, Ont. KLY 4E9
of the midsegment of the fallopian tubes was resected with a cutting knife or an electrocautery.4 In five women the Pomeroy procedure5 was used; the surgeons were different in each case. Two of these five operations were performed at the Ottawa Civic Hospital; segments of the fallopian tubes were removed and confirmed as such by histologic study. One patient underwent tubal sterilization by the Ushida technique6 at another hospital, and one underwent dilatation and curettage with laparoscopic tubal cauterization at the Ottawa Civic Hospital. Details of pregnancy and management The interval between tubal sterilization and ectopic pregnancy was more than 24 months in 8 of 10 cases; one woman had two tubal pregnancies after sterilization at intervals of 24 and 48 months. In one woman who underwent transvaginal tubal sterilization the interval was 4 months, and in one woman who underwent laparoscopic tubal cauterization the interval was only 3 weeks; probably the fertilized ovum was in the distal portion of the fallopian tube, free or implanted, when the laparoscopic procedure was performed. All the women presented with abdominal pain, variable periods of amenorrhea and vaginal spotting. A tender adnexal mass was palpable in five. Of the 10 women 9 had hemoperitoneum, the volume of blood ranging from 500 to 1500 mL. In all cases the pregnancy was noted in either the ampulla or the distal segment of the fallopian tube. One patient presented because of chronic pelvic pain that had been worse for 3 weeks. A left adnexal mass was palpable. Surgical exploration showed a tubo-ovarian mass thought to be endometriosis; total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. In addition to removal of the affected fallopian tube, salpingectomy or fimbriectomy of the opposite tube was carried out in seven women. A
156 CMA JOURNAL/JULY 22, 1978/VOL. 119
second tubal pregnancy occurred 18 months after the first in one woman whose opposite fallopian tube had been left intact. Discussion In this series of 92 tubal pregnancies, 11 occurred after tubal sterilization, a frequency of 12%. Brenner, Benedetti and MishelP reported seven such occurrences in a series of 100 cases. Conception after tubal sterilization can be explained by fistula formation and recanalization.7'8 There is evidence that recanalization occurs more readily if the tubal stumps are apposed or if the distance between the stumps is minimal. When partial recanalization results in a constricted tubal lumen the rate of subsequent ectopic pregnancy is higher than that of subsequent intrauterine pregnancy because migration of the large fertilized ovum is blocked by the reduced lumen though the much smaller spermatozoa can pass readily. So that tubal sterilization would be more effective the technique of transvaginal tubal resection was modified in 1974; after removal of the midsegment of the fallopian tube the transected ends are now coagulated. Likewise, in the Pomeroy procedure the stumps are cauterized after a loop of the fallopian tube has been resected. Conclusions Every method of tubal sterilization has its share of failures, but the direct relations shown in this study, as well as in earlier ones, provide evidence that the frequency of failure varies with the method. Ectopic pregnancy must be considered, irrespective of a previous sterilizing procedure, in any woman with signs or symptoms of pregnancy, lower abdominal pain or abnormal uterine bleeding. References 1. BRENNER PF, BENEDETTI T, MISHELL DR .JR: Ectopic pregnancy following tubal sterilization surgery. Obstet
Gynecol 49: 323, 1977 2. HARRALSON JD, VAN NAGELL JR JR, RoDDIcK JW JR: Operative manage-
ment of ruptured tubal pregnancy. Am I Obstet Gynecol 115: 995, 1973 3. THELIN TJ, VAN NAGELL JR JR: Rup-
tured ectopic pregnancy after bilateral tubal ligation. Obstet Gynecol 39: 589, 1972 4. SHUTE WB: Transvaginal sterilization:
use of a new uterine retroverter and method. Am J Obstet Gynecol 115: 998, 1973 5. MATTINGLY RF: Te Linde's Operative Gynecology, 5th ed, Lippincott, Philadelphia, 1977, p 339 6. Ibid, p 343
7. SThPTOE PC: Recent advances in surgical methods of control of fertility and infertility. Br Med Bull 26: 60, 1970 8. SHEIKR HH: Hysterosalpingographic follow-up of laparoscopic sterilization. Am J Obstet Gynecol 126: 181, 1976
A rare cause of massive intraperitoneal hemorrhage JOHN T. BATE, MD, FRCSIIC]
In the human female, failure of development or lack of fusion of the paired miillerian ducts gives rise to a variety of genitourinary anomalies. When implantation occurs in a rudimentary horn of a uterus didelphys that does not communicate with the vagina, nonoperative delivery is impossible and serious complications may ensue. As early as 1699 Mauriceau and Vassal reported such a case.1 Unfortunately most of the early cases were diagnosed at autopsy when maternal death had resulted from intraperitoneal hemorrhage. In 1900 Kehrer reported a maternal mortality of 47.6% associated with this condition.1 Currently, with prompt surgical intervention and availability of blood transfusion, death should be prevented in such cases. In 1965 Rolen, Choquette and Semmens1 noted that in the past 50 years 65 cases had been reported in the English and American literature. Ninety percent of the patients present with spontaneous rupture early in the second trimester, around the 16th week of gestation.2 In 1976 Zervoudakis, Lauersen and Saary' reported a case of twin pregnancy occurring in the two horns of a uterus didelphys; the rudimentary horn did not communicate with the vagina or with the other horn. Below is described a case of massive intraperitoneal hemorrhage secondary to spontaneous rupture of a From the department of obstetrics and gynecology, York Central Hospital, Richmond Hill Reprint requests to: Dr. John T. Bate, Department of obstetrics and gynecology, York Central Hospital, 10 Trench St., Richmond Hill, Ont. L4C 4Z3
rudimentary uterine horn containing a developing embryo.
Case report On July 1, 1976 a 24-year-old woman, gravida 1, para 0, was seen in the emergency department with severe abdominal pain of 2 hours' duration. Her last menstrual period had begun Mar. 8, 1976. Early in June her family physician had palpated a mass adjacent to the enlarged uterus, which was assumed to be a corpus luteal cyst. She had been well until the evening of admission, when she experienced severe midabdominal pain; signs of clinical shock - restlessness, air hunger, marked pallor and a rapid thready pulse developed rapidly. The blood pressure was 80/60 mm Hg. The abdomen was rigid and distended, and pelvic examination revealed a tender mass arising from the right side of the pelvis. Movement of the cervix produced extreme pain. A diagnosis of intraperitoneal hemorrhage of unknown cause was proposed and emergency laparotomy arranged. The abdomen was entered through a paramedian incision in the right lower quadrant, and 2000 mL of blood was removed by suction and sponging. A uterus didelphys was enlarged to a size compatible with 15 weeks' gestation. Profusely bleeding placental tissue was protruding through a rupture 6 cm long in the superior surface of the enlarged rudimentary right horn. This horn did not communicate with the left horn or the vagina. The left uterine horn was connected to the cervix, and the left fallopian tube and ovary were normal. The ruptured uterine horn and the right tube and ovary were excised and hemostasis was attained. Palpation revealed normal kidneys. The wall of the rudimentary horn was 1.0 cm thick. Attached to the extruded placenta was a male fetus with
a crown-rump diameter of 11 cm. During the operation the patient received 5 units of whole blood. Her postoperative hemoglobin concentration was 13.4 g/dL. Recovery was uneventful and she was discharged 8 days later.
Discussion This case has several interesting points for speculation. Because the embryo was developing in a rudimentary horn a functioning endometrium must have existed. Since there was no communication of the horn with the vagina, what happened to the menstrual flow? There was no evidence of hematometra, hematosalpinx or pelvic endometriosis, and no history of dysmenorrhea. The fertilizing spermatozoon must have entered the peritoneal cavity via the left uterine horn, travelled transperitoneally to the right fallopian tube, where fertilization occurred, then implanted itself in the right uterine horn. In June 1977, after an uneventful pregnancy, the patient was delivered vaginally of a healthy boy weighing 3200 g. My thanks to Dr. M. Kirby for his assistance in the management of this patient.
References 1. ROLEN AC, CHOQUErrE AJ, SEMMENS
JP: Rudimentary uterine horn: obstetric and gynecologic implications. Obstet Gynecol 27: 807, 1966 2. LATTO D, NORMAN R: Pregnancy in a rudimentary horn of a bicornuate uterus. Br Med J 2: 926, 1950 3. ZERvoUDAKIs IA, LAUER5EN NH, SAARY Z: Unusual twin pregnancy in a double uterus. Am J Obstet Gynecol
124: 659, 1976
CMA JOURNAL/JULY 22, 1978/VOL. 119 157
We undertook a retrospective clinical study to evaluate evidence suggesting that tubal sterilization is a causative factor in ectopic pregnancy. We also noted the procedures used for tubal sterilization. Although more definitive correlation between the occurrence of ectopic pregnancy and tubal sterilization may require wider sampling, our findings are notable. Equally relevant is the nexus of ectopic pregnancy to the procedure used in tubal sterilization. During a 3-year period, 1974 through 1976, 92 cases of tubal pregnancy were dealt with at the Ottawa Civic Hospital; 11 of the ectopic pregnancies occurred in 10 women who had undergone tubal sterilization. In our review of the cases we tried to evaluate the possible sequelae of tubal sterilization procedures and their relation to ectopic pregnancy. We concluded that the diagnosis of ectopic pregnancy must be considered carefully in a woman with signs or symptoms of pregnancy, lower abdominal pain or abnormal uterine bleeding regardless of previous tubal sterilization. 1-3
Findings Study group and sterilization procedures Ninety-two cases of ectopic pregnancy dealt with at the Ottawa Civic Hospital from 1974 through 1976 were studied. Eleven of the pregnancies occurred in 10 women who had undergone tubal sterilization. Information on the sterilization procedure was obtained from hospital records and from the surgeons involved. The procedure had been performed at the Ottawa Civic Hospital in five instances and elsewhere in the other five. Three women underwent transvaginal procedures, performed by the same surgeon, in which 2 to 3 cm From the department of obstetrics and gynecology, University of Ottawa and Ottawa Civic Hospital Reprint requests to: Dr. Harry Oxorn, Department of obstetrics and gynecology, Ottawa Civic Hospital, 1053 Caning Ave., Ottawa, Ont. KLY 4E9
of the midsegment of the fallopian tubes was resected with a cutting knife or an electrocautery.4 In five women the Pomeroy procedure5 was used; the surgeons were different in each case. Two of these five operations were performed at the Ottawa Civic Hospital; segments of the fallopian tubes were removed and confirmed as such by histologic study. One patient underwent tubal sterilization by the Ushida technique6 at another hospital, and one underwent dilatation and curettage with laparoscopic tubal cauterization at the Ottawa Civic Hospital. Details of pregnancy and management The interval between tubal sterilization and ectopic pregnancy was more than 24 months in 8 of 10 cases; one woman had two tubal pregnancies after sterilization at intervals of 24 and 48 months. In one woman who underwent transvaginal tubal sterilization the interval was 4 months, and in one woman who underwent laparoscopic tubal cauterization the interval was only 3 weeks; probably the fertilized ovum was in the distal portion of the fallopian tube, free or implanted, when the laparoscopic procedure was performed. All the women presented with abdominal pain, variable periods of amenorrhea and vaginal spotting. A tender adnexal mass was palpable in five. Of the 10 women 9 had hemoperitoneum, the volume of blood ranging from 500 to 1500 mL. In all cases the pregnancy was noted in either the ampulla or the distal segment of the fallopian tube. One patient presented because of chronic pelvic pain that had been worse for 3 weeks. A left adnexal mass was palpable. Surgical exploration showed a tubo-ovarian mass thought to be endometriosis; total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. In addition to removal of the affected fallopian tube, salpingectomy or fimbriectomy of the opposite tube was carried out in seven women. A
156 CMA JOURNAL/JULY 22, 1978/VOL. 119
second tubal pregnancy occurred 18 months after the first in one woman whose opposite fallopian tube had been left intact. Discussion In this series of 92 tubal pregnancies, 11 occurred after tubal sterilization, a frequency of 12%. Brenner, Benedetti and MishelP reported seven such occurrences in a series of 100 cases. Conception after tubal sterilization can be explained by fistula formation and recanalization.7'8 There is evidence that recanalization occurs more readily if the tubal stumps are apposed or if the distance between the stumps is minimal. When partial recanalization results in a constricted tubal lumen the rate of subsequent ectopic pregnancy is higher than that of subsequent intrauterine pregnancy because migration of the large fertilized ovum is blocked by the reduced lumen though the much smaller spermatozoa can pass readily. So that tubal sterilization would be more effective the technique of transvaginal tubal resection was modified in 1974; after removal of the midsegment of the fallopian tube the transected ends are now coagulated. Likewise, in the Pomeroy procedure the stumps are cauterized after a loop of the fallopian tube has been resected. Conclusions Every method of tubal sterilization has its share of failures, but the direct relations shown in this study, as well as in earlier ones, provide evidence that the frequency of failure varies with the method. Ectopic pregnancy must be considered, irrespective of a previous sterilizing procedure, in any woman with signs or symptoms of pregnancy, lower abdominal pain or abnormal uterine bleeding. References 1. BRENNER PF, BENEDETTI T, MISHELL DR .JR: Ectopic pregnancy following tubal sterilization surgery. Obstet
Gynecol 49: 323, 1977 2. HARRALSON JD, VAN NAGELL JR JR, RoDDIcK JW JR: Operative manage-
ment of ruptured tubal pregnancy. Am I Obstet Gynecol 115: 995, 1973 3. THELIN TJ, VAN NAGELL JR JR: Rup-
tured ectopic pregnancy after bilateral tubal ligation. Obstet Gynecol 39: 589, 1972 4. SHUTE WB: Transvaginal sterilization:
use of a new uterine retroverter and method. Am J Obstet Gynecol 115: 998, 1973 5. MATTINGLY RF: Te Linde's Operative Gynecology, 5th ed, Lippincott, Philadelphia, 1977, p 339 6. Ibid, p 343
7. SThPTOE PC: Recent advances in surgical methods of control of fertility and infertility. Br Med Bull 26: 60, 1970 8. SHEIKR HH: Hysterosalpingographic follow-up of laparoscopic sterilization. Am J Obstet Gynecol 126: 181, 1976
A rare cause of massive intraperitoneal hemorrhage JOHN T. BATE, MD, FRCSIIC]
In the human female, failure of development or lack of fusion of the paired miillerian ducts gives rise to a variety of genitourinary anomalies. When implantation occurs in a rudimentary horn of a uterus didelphys that does not communicate with the vagina, nonoperative delivery is impossible and serious complications may ensue. As early as 1699 Mauriceau and Vassal reported such a case.1 Unfortunately most of the early cases were diagnosed at autopsy when maternal death had resulted from intraperitoneal hemorrhage. In 1900 Kehrer reported a maternal mortality of 47.6% associated with this condition.1 Currently, with prompt surgical intervention and availability of blood transfusion, death should be prevented in such cases. In 1965 Rolen, Choquette and Semmens1 noted that in the past 50 years 65 cases had been reported in the English and American literature. Ninety percent of the patients present with spontaneous rupture early in the second trimester, around the 16th week of gestation.2 In 1976 Zervoudakis, Lauersen and Saary' reported a case of twin pregnancy occurring in the two horns of a uterus didelphys; the rudimentary horn did not communicate with the vagina or with the other horn. Below is described a case of massive intraperitoneal hemorrhage secondary to spontaneous rupture of a From the department of obstetrics and gynecology, York Central Hospital, Richmond Hill Reprint requests to: Dr. John T. Bate, Department of obstetrics and gynecology, York Central Hospital, 10 Trench St., Richmond Hill, Ont. L4C 4Z3
rudimentary uterine horn containing a developing embryo.
Case report On July 1, 1976 a 24-year-old woman, gravida 1, para 0, was seen in the emergency department with severe abdominal pain of 2 hours' duration. Her last menstrual period had begun Mar. 8, 1976. Early in June her family physician had palpated a mass adjacent to the enlarged uterus, which was assumed to be a corpus luteal cyst. She had been well until the evening of admission, when she experienced severe midabdominal pain; signs of clinical shock - restlessness, air hunger, marked pallor and a rapid thready pulse developed rapidly. The blood pressure was 80/60 mm Hg. The abdomen was rigid and distended, and pelvic examination revealed a tender mass arising from the right side of the pelvis. Movement of the cervix produced extreme pain. A diagnosis of intraperitoneal hemorrhage of unknown cause was proposed and emergency laparotomy arranged. The abdomen was entered through a paramedian incision in the right lower quadrant, and 2000 mL of blood was removed by suction and sponging. A uterus didelphys was enlarged to a size compatible with 15 weeks' gestation. Profusely bleeding placental tissue was protruding through a rupture 6 cm long in the superior surface of the enlarged rudimentary right horn. This horn did not communicate with the left horn or the vagina. The left uterine horn was connected to the cervix, and the left fallopian tube and ovary were normal. The ruptured uterine horn and the right tube and ovary were excised and hemostasis was attained. Palpation revealed normal kidneys. The wall of the rudimentary horn was 1.0 cm thick. Attached to the extruded placenta was a male fetus with
a crown-rump diameter of 11 cm. During the operation the patient received 5 units of whole blood. Her postoperative hemoglobin concentration was 13.4 g/dL. Recovery was uneventful and she was discharged 8 days later.
Discussion This case has several interesting points for speculation. Because the embryo was developing in a rudimentary horn a functioning endometrium must have existed. Since there was no communication of the horn with the vagina, what happened to the menstrual flow? There was no evidence of hematometra, hematosalpinx or pelvic endometriosis, and no history of dysmenorrhea. The fertilizing spermatozoon must have entered the peritoneal cavity via the left uterine horn, travelled transperitoneally to the right fallopian tube, where fertilization occurred, then implanted itself in the right uterine horn. In June 1977, after an uneventful pregnancy, the patient was delivered vaginally of a healthy boy weighing 3200 g. My thanks to Dr. M. Kirby for his assistance in the management of this patient.
References 1. ROLEN AC, CHOQUErrE AJ, SEMMENS
JP: Rudimentary uterine horn: obstetric and gynecologic implications. Obstet Gynecol 27: 807, 1966 2. LATTO D, NORMAN R: Pregnancy in a rudimentary horn of a bicornuate uterus. Br Med J 2: 926, 1950 3. ZERvoUDAKIs IA, LAUER5EN NH, SAARY Z: Unusual twin pregnancy in a double uterus. Am J Obstet Gynecol
124: 659, 1976
CMA JOURNAL/JULY 22, 1978/VOL. 119 157
