Tubal ectopic pregnancy 4 years after hysterectomy : a case report

Abstract

BACKGROUND : Ectopic pregnancy after hysterectomy is a rare event. To date there are 73 definitive cases of post-hysterectomy ectopic pregnancy. The first case was reported by Wendler in 1895. CASE : A 31 year old P2G4 (one miscarriage) presented with a history of severe lower abdominal pain of three days duration. She previously had a subtotal hysterectomy four years prior her current presentation for a septic miscarriage with multiple organ dysfunction. She had a background history of being HIV reactive on antiretroviral therapy initiated two days before her presentation. Her CD4 count was 54 cells/uL, negative cryptococcal latex test. She was first diagnosed with HIV in 2015, however had not been on antiretroviral therapy since then. On clinical examination she was hemodynamically stable, normal blood pressure and pulse, afebrile and no stigmata of AIDS. She had an acute abdomen and on pelvic examination a cervical stump was palpable with no blood from the cervical os. Her haemoglobin was 13.4g/dl. Urine pregnancy test was positive. Her quantitative beta-HCG of 3979 IU/L. Pelvic ultrasound showed fluid collection in the pelvis, no definite masses seen, no uterus seen and ovaries could also not be visualised. Abdominal ultrasound did not show any abnormalities in the rest of the abdomen. The patient was counselled for surgery. Preparation with multidisciplinary consultation was done. Intraoperatively, 100ml haemoperitoneum was found. There were dense pelvic adhesions. Adhesiolysis was done and a bleeding right fallopian tube ampullary pregnancy was found. The right ovary was grossly normal. The contralateral adnexa could not be identified. A right salpingectomy was done. Total blood loss was 100ml. She recovered well post operatively and was discharged three days later to continue her antiretroviral therapy. DISCUSSION : A rare case of tubal ectopic pregnancy after hysterectomy is presented. Access to the peritoneal cavity and fallopian tube through the cervical canal, we postulated as the mechanism in this case. Ectopic pregnancies after hysterectomy are classified into early and late. The former being associated with a pregnancy (or viable gametes) that was present at the time of hysterectomy. These present soon after the hysterectomy. The latter present long after the hysterectomy. Conception can occur after hysterectomy through access via a prolapsed fallopian tube, a fistula or defect in the vault. Cervical stump pregnancy is also described. Surgical intervention is the most common intervention described amongst the case reports. CONCLUSION : Pregnancy after a hysterectomy is a rare possibility with possible adverse outcomes. Clinicians must have a strong index of suspicion for a possible ectopic pregnancy in patients that present with abdominal pain after hysterectomy.