Diagnosis of Ectopic Pregnancy

*Subrat Panda, Ananya Das, Kaushiki Singh, Prateeti Baruah and Anusuya Sharma*

### **Abstract**

Ectopic pregnancy is defined as the implantation of a fertilised egg outside the uterine cavity. The site of ectopic pregnancy are Fallopian tube. Cervix, ovary, peritoneal cavity, or uterine scars. Other two site of implantation are cornual pregnancy and interstitial pregnancy. Diagnostic tests for ectopic pregnancy include a urine pregnancy tests, Serum beta hcG and ultrasound. The instant result of a urine pregnancy test is a useful pointer for the clinician to suspect an ectopic pregnancy. The test is a useful triage tool for clinicians to rule out a pregnancy when the clinical situation is not clear such as a patient who is not sure of dates, does not remember or is in a state of shock and the history cannot be elicited. Ultrasound remains the mainstay of the diagnosis and high index of suspicion and a detailed history are pre-requisite of scanning. Different ultrasonography feature are diagnostic of different site of implantation. For uterine scar pregnancy ultrasonologic criteria are not validated still now.

**Keywords:** ultrasound, b HCG

### **1. Introduction**

The proverb black cat in dark night fits into the diagnosis of ectopic pregnancy. To diagnose ectopic pregnancy clinician's mind should be suspicious about ectopic pregnancy. The most common ectopic site of implantation (97%) is the fallopian tube. The most common site for tubal pregnancy is ampulla, followed by isthmus, fimbrial and interstitial. Sometimes twin tubal pregnancy with both embryos in one tube or with one in each tube has been noted [1]. The other sites of ectopic pregnancies are implantation in the cervix, ovary, peritoneal cavity, or uterine scars. A growing ectopic pregnancy in any location can make the tissue vascular, friable and eventually rupture and result in intra-abdominal bleeding. This is a life threatening medical emergency. In history the risk factors like Pelvic inflammatory disease, including pelvic tuberculosis, previous ectopic pregnancy, pregnancy with an intrauterine device, tubal surgeries (ligations, reconstructions, and reimplantations), history of STD, smoking, infertility, ovulation induction and ART procedures should be elicited. The majority of women with ectopic gestation have no identifiable risk factor.

Ectopic pregnancy should be suspected in any woman with child bearing age presenting to the clinic or emergency department with symptoms of amenorrhea, pain abdomen, and vaginal bleeding [2]. They may present with the complaint of fainting, collapse, breathlessness, or dizziness. Uncommon symptoms include diarrhoea, pain in the shoulder, rectal pressure, urinary symptoms, and anaemia. A small, undisturbed tubal pregnancy, the physical examination might be normal. In these situations, the diagnosis is dependent on investigations. On the other hand, with late presentations, there could be a disturbance of the vital signs and features of shock may be present including tachycardia, tachypnoea, hypotension, and rarely bradycardia. On abdominal examination there may be guarding, rigidity and tenderness. There could be also cervical motion tenderness, adnexal tenderness or fullness in the adnexae and pouch of Douglas. The presence of abdominal signs with altered vital parameters suggests presence of hemoperitoneum and mandates urgent resuscitation and management at a centre with appropriate facilities for blood transfusion and surgery.

Diagnostic tools for ectopic pregnancy are urine pregnancy tests, Serum beta-hCG and transvaginal or trans-abdominal ultrasound. Clinical suspicion combined with these tests plays a very important role in diagnosis and management of ectopic pregnancy. The instant result of a urine pregnancy test is a useful pointer for the practitioner to suspect an ectopic pregnancy. This kit test is easily available at low cost and is reliable. The test is a useful triage tool for clinicians to rule out a pregnancy when the clinical situation is doubtful such as a patient who is not sure of dates, does not remember or is in a state of shock and the history cannot be elicited.

Laboratory tests of a single laboratory value of beta-hCG might not be useful to diagnose the location of a pregnancy. The typical level in a healthy intrauterine pregnancy on the day of the missed period is 50 to 100 IU/L. In a normal intrauterine pregnancy, levels of serum beta-hCG will double every 1.4 to 2.1 days and peak between 50,000 and 100,000 IU/L at 8 to 10 weeks of pregnancy. Compared to the pattern observed in healthy intrauterine pregnancies, the rate of increase between two serum-hCG levels when it is done 48 hours apart is slower.

Progesterone levels are not useful for the diagnosis of an ectopic and maybe used in the prognostication of pregnancy of unknown location.

Ultrasound remains the mainstay of the diagnosis [3]. High index of suspicion and a detailed history are pre-requisite of scanning. The majority of tubal ectopic pregnancies should be visualised on transvaginal ultrasound.

Transvaginal ultrasound has sensitivities of 87.0–99.0% and specificities of 94.0–99.9% for the diagnosis of ectopic pregnancy [4]. Usually most of the ectopic pregnancies will be visualised on the initial ultrasound examination [5]. When no intrauterine or extauterine pregnancy is seen in USG it is called pregnancy of unknown location (PUL). Ectopic pregnancies initially classified as a PUL on the initial scan may be ectopic pregnancies are just too small and too early in the disease process to be visualised on the initial ultrasound examination. Sometimes the limiting value of beta-hCG should be evaluated, below which intrauterine pregnancies cannot be seen on USG. In case of PUL serial beta-hCG level assays adone to identify pattern that indicate either a growing or failing IUP. Without clear evidence for ectopic pregnancy, serial β-hCG level is advised and a level is checked after 48 hours. This wards off unnecessary medical therapy and avoids harming an early normal pregnancy. With more concern for an ectopic gestation, D&C is another option to distinguish an ectopic from a failing IUP. Normal rise B-Hcg does not exclude normal and ectopic pregnancy [6]. Laparoscopy is no longer the gold standard for diagnosis of ectopic pregnancies.

*Diagnosis of Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.101715*

### **2. USG findings**

An inhomogeneous or non cystic adnexal mass is the most common finding, about 50–60% of cases.

An empty extra-uterine gestational sac will be present in around 20–40% [7] of cases and an extra-uterine gestational sac containing a yolk sac and/or embryonic pole that may or may not have cardiac activity will be present in around 15–20% of cases [7].

There is no specific endometrial appearance or thickness, based on which diagnosis of tubal pregnancy can be confirmed. A few of cases, in around 20%, a collection of fluid may be seen within the uterine cavity, known as 'pseudosac'. It is difficult to differentiate pseudosac from an early intrauterine gestational sac. The intradecidual and double decidual signs indicates early intrauterine pregnancy (**Figures 1** and **2**). The intradecidual sign is eccentrically located echogenic area within a markedly thickened decidua [8]. The double decidual sign is described as an intrauterine fluid collection surrounded by two hyper echogenic rings [9]. But practically, it is very difficult to distinguish a 'pseudosac' which is just a collection of fluid in the endometrial cavity from

**Figure 1.** *Double decidual sign.*

**Figure 2.** *Intradecidual sign.*

an early intrauterine sac. A small anechoic cystic structure is more likely to be an early sac rather than a 'pseudosac'. Positive pregnancy test with and a small anechoic cystic structure without adnexal mass has probability of ectopic pregnancy is 0.02% [9].

When free fluid is seen on ultrasound, it is not a pinpointing feature of ectopic pregnancy. A small amount of anechoic fluid in the pouch of Douglas may be found physiologically in normal pregnancy and may be seen with ectopic pregnancies. Which may signify tubal rupture, Most commonly the echogenic fluid has been reported is due to blood leaking from the fimbrial end of the fallopian tube but it may be tubal rupture. Culdocentesis was used in the past to diagnose hemoperitoneum. Fluid with old blood clots and blood does not clot points to hemoperitoneum. If the blood sample clots it may have been drawn from nearby blood vessel or from profound bleeding ectopic pregnancy. Nowadays culdocentesis is not advised it is replaced by usg.

### **3. Cervical pregnancy**

Cervical ectopic pregnancy is diagnosed by following usg criteria:


The 'sliding sign' distinguishes cervical ectopic pregnancies and miscarriages that are within the cervical canal. It is present in cervical miscarriage but absent in cervical ectopic gestation.

When pressure is applied to the cervix using the probe, in a miscarriage, the gestational sac slides against the endocervical canal, but does not in an cervical ectopic gestation.

Cervical Ectopic Gestation usually develops in fibrous wall of the cervix. Risk factors includes previous dilatation and curettage operation and pregnancy due to ART may be implanted in cervical canal [10, 11]. Usually the women present with painless vaginal bleeding and sometimes with massive haemorrhage [12].

Clinical criteria for diagnosis of cervical pregnancy [13].


*Diagnosis of Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.101715*

**Figure 3.** *Cervical pregnancy.*

### **4. Caesarean scar pregnancy**

The diagnosis of Caesarean scar pregnancy made by using transvaginal usg sometimes supplemented by trans-abdominal imaging if required.

Magnetic resonance imaging (MRI) can be used as a second-line investigation if the diagnosis is suspicious. Usually women with CSP present with painful bleeding PV and nearly half of women are asymptomatic.

Caesarean scar pregnancy is defined as implantation into the myometrial defect occurring at the site of the previous uterine scar.

The diagnostic criteria described for caesarean scar implantation on transvaginal ultrasound include: [14].


**Figure 4.** *Caesarean scar pregnancy.*


The true prevalence of caesarean scar pregnancies is likely to be somewhat higher than estimated in the literature as some cases end in the first trimester, either by miscarriage or termination, and go unrecorded. A few percentages of reported cases of caesarean scar pregnancy were wrongly diagnosed as intrauterine or cervical pregnancies at presentation (**Figure 4**).

### **5. Interstitial pregnancy**

When the implantation occurs in the proximal part of fallopian tube that lies within the muscular layer of uterus. Ipsilateral salpingectomy is a risk factor for interstitial pregnancy.

The following ultrasound scan criteria may be used for the diagnosis of interstitial pregnancy:


Dimensional ultrasound may be used if available to avoid misdiagnosis.

**Figure 5.** *Interstitial pregnancy.*

*Diagnosis of Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.101715*

MRI may be useful in addition to ultrasonography in the diagnosis of interstitial pregnancy (**Figure 5**).

### **6. Cornual pregnancy**

The implantation occurs in the rudimentary horn of uterus it may be communicating or non communicating. It is a confusing terminology. Some authors prefer the cornual pregnancy when implantation occurs in upper lateral part of uterine cavity of normal uterus.

Ultrasound scan criteria are used for the diagnosis of cornual pregnancy:


### **7. Ovarian pregnancy**

Findings suggestive of an ovarian ectopic pregnancy on transvaginal ultrasound with an empty uterus are:


A complex echogenic adnexal mass with free fluid in the pouch of Douglas may be the ruptured ovarian ectopic pregnancy.

Usually it is difficult to distinguish ovarian ectopic pregnancies from corpus luteal cysts, tubal ectopic pregnancy stuck to the ovary, a second corpus luteum, ovarian germ cell tumours and other ovarian pathologies and the diagnosis is confirmed surgically and histologically in most of the cases.

### **8. Abdominal pregnancy**

When the implantation occurs in intraperitoneal cavity excluding tubal,ovarian and intraligamentous pregnancy. Usually the women have vague symptoms or no symptoms. Abnormal foetal position may be palpated.

MRI might be a useful diagnostic adjunct in advanced abdominal pregnancy and can help to plan the surgical approach.


Sonographic diagnosis may not be useful. MRI is very much useful to confirm the diagnosis and to identify placental implantation because placenta may be implanted over vital structures, such as major blood vessels and bowel [16]. This can help to make preoperative preparedness for perioperative considerations, such as the surgical approach, requirement of blood products, preoperative angiographic embolisation, bowel preparation and insertion of ureteral catheters. Precise mapping of the location of the placenta by using ultrasound and/or MRI prior to laparotomy to avoid incising the placenta and the associated risk of uncontrollable haemorrhage is necessary.

### **9. Heterotopic pregnancy**

When there are both intrauterine and extrauterine implantation it is called heterotropic gestation it can be diagnosed with ultrasonography.

Heterotopic pregnancy should be suspected in if conception is after assisted reproductive technologies, with an intrauterine pregnancy and complaining of persistent pelvic pain and in those.

women with a persistently raised beta-hCG level following miscarriage or termination of pregnancy. A higher than expected level of serum beta-hCG in relation to gestational age may be suspicious of heterotopic pregnancy but, the presence of a complete or partial mole must be ruled out. Two corpora lutea found on laparoscopy or laparotomy. Sometimes patient may present with hemoperitoeum after termination of normal pregnancy or persistence of enlarged uterus and amenorrhoea after excision of ectopic pregnancy.

### **10. Conclusion**

Ectopic pregnancy is associated with high maternal mortality and morbidity. With early diagnosis complications can be avoided. Primary modality of diagnosis is Ultrasound Scan. Hence Obstetrician should be well trained to diagnose ectopic pregnancy, and clinician should have high index of suspicion to diagnose ectopic pregnancy. *Diagnosis of Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.101715*

### **Author details**

Subrat Panda\*, Ananya Das, Kaushiki Singh, Prateeti Baruah and Anusuya Sharma NEIGRIHMS, Shillong, Meghalaya, India

Address all correspondence to: pandadrsubrat@rediffmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[3] Kirk E, Papageorghiou AT, Condous G, Tan L, Bora S, Bourne T. The diagnostic effectiveness of an initial transvaginal scan indetecting ectopic pregnancy. Human Reproduction. 2007;**22**:2824-2828

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reliability and frequency of occurrence. Journal of Ultrasound in Medicine. 2013;**32**:1207-1214

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[14] Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. The diagnosis, treatment and follow-up of cesarean scar pregnancy. American Journal of Obstetrics and Gynecology. 2012;**207**:44e1

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[16] Aliyu LD, Ashimi AO. A multicentre study of advanced abdominal pregnancy: A review of six cases in low resource settings. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2013;**170**:33-38

### **Chapter 5**

## Ectopic Pregnancy after Ipsilateral Salpingectomy

*Afaf Felemban, Haya Aljurayfani, Fatimah Alamri, Jawaher Alsahabi, Ghadeer L. Aljahdali, Hadeel Alkheelb, Hessa Alkharif and Mohmmad Albugnah*

### **Abstract**

Ectopic pregnancy is a significant health problem for women prevalence is increase in patient with history of previous ectopic pregnancy or pelvic surgeries or pelvic inflammatory disease, and widespread treatment with assisted reproductive technologies the incidence of ectopic pregnancies has greatly increased during the past two decades and it is now estimated to occur in 2% of all pregnancies recurrent ectopic pregnancy in the remnant portion of the tube after ipsilateral salpingectomy has only rarely been reported. We present unusual cases of ipsilateral ectopic pregnancy occurring in the stump of a previous ectopic site.

**Keywords:** ectpoic pregnancy, salpingectomy, tubal stump

### **1. Introduction**

Ectopic pregnancy (EP) is the implantation of a fertilized ovum anywhere outside of the uterine cavity [1].

Ectopic pregnancy still accounts for 4–10% of pregnancy-related deaths and leads to a high incidence of ectopic site gestations in subsequent pregnancies [2]. Early intervention saves lives and reduces morbidity around 90% of ectopic pregnancies occur in one of the fallopian tubes rare sites as in the cervix, ovary, cesarean section scar defect and the abdominal cavity [2, 3].

The fallopian tubes length about 8–10 cm extend from the uterine cornus. The sites of tubal implantation in descending order of frequency are; ampulla (73.3%), isthmus (12.5%), fimbrial (11.6%), and interstitial (2.6%) [4]. If a woman with a previous ectopic gets pregnant, the risk of a recurrent EP is increased four-fold [5].

Recently, literature review reported rare cases of recurrent ectopic pregnancy in the remnant portion of the tube after a previous ipsilateral salpingectomy [6]. Ipsilateral recurrent ectopic pregnancy may occur in the proximal or distal remnant of the operated tube [7, 8].

Ectopic pregnancy in the remnant tube is difficult to diagnose due to the unique anatomic location of the pregnancy sometimes results in delayed diagnosis [6]. Although complete tubal resection cannot prevent cornual pregnancy, it might

reduce the risk of recurrent ectopic pregnancy in the remnant tube [6] while the exact incidence of ectopic pregnancy occurred in the remnant tube after ipsilateral adnexectomy is not known [6].

Tubal pregnancy associated with high risk of rupture and severe bleeding [9], due to the poor ability of this portion of the tube to distend as well as the increased vascularity of the area (anastomosis of the uterine and ovarian vessels) [10].

### **2. Pathophysiology**

The mechanism of recurrent ipsilateral ectopic pregnancy is not clear. But there is many hypotheses including contralateral transmigrate of fertilized ovum from the intact fallopian tube across the endometrial cavity to contralateral tubal stump. And another hypotheses transperitoneal migration of the egg or embryo to the contralateral tubal stump or passage of the spermatozoa to fertilize the ovum in the proximal tubal remnant with some degree of patency or recanalization may occur in the tubal stump [6].

Another explanation for the anatomical location of the ectopic pregnancy may be through transperitoneal migration of an ovum from the contralateral ovary to the opposite tube via the pouch of Douglas. This was explained previously, that embryo or ovum migration has been described animals [11]. These findings suggest that normal tubo-ovarian integrity is not essential for pregnancy to occur. The possible paths that the gametes or the fertilized ovum can travel are illustrated in **Figure 1**.

### **Figure 1.**

*Laparoscopic appearance of rupture ectopic pregnancy in the proximal remnant of the right Fallopian tube.*

A rare case of transperitoneal ovum migration resulting in an intra-uterine pregnancy is presented. A woman with left congenital ovarian absence and a surgically removed right oviduct, conceived following microsurgical repair of left tubal occlusion [12].

### **3. Diagnosis**

Ultrasonographic examination is effective for the diagnosis of tubal stump pregnancy. However, in some cases, the diagnosis of tubal stump pregnancy is difficult because the tubal stump portion is near the ovary (**Figure 2**).

*Ectopic Pregnancy after Ipsilateral Salpingectomy DOI: http://dx.doi.org/10.5772/intechopen.103146*

### **Figure 2.**

*Proposed hypothesis for reurrect ectopic pregnancy post isplitaeral salpingectomy A: recanalization in the tubal stump B: contralatera transmigrate of fertilized ovum from the intact fallopian tube across the endometrial cavity to contralateral tubal stump.*

Ectopic pregnancy occurring in tubal stump after tubectomy is extremely rare, and the frequency of tubal stump pregnancy is approximately 0.4% of all pregnancies [13].

Due to unique anatomic location of the tubal stump pregnancy sometimes results in delayed diagnosis and it will carry high risk of rupture of the uterus in some case increase beyond 12 weeks of amenorrhea, and the rupture of the ectopic part occurs in 20% of ectopic pregnancies beyond 12 weeks of gestational age. Earlier diagnosis would decrease morbidity and increase the chance of successful minimal invasive surgery [13].

The ovarian corpus luteum is mistaken for a tubal stump pregnancy. Moreover, it is thought that many doctors pay less attention to the tube in which patients have already undergone salpingectomy because of ectopic pregnancy.

three sonographic criteria for interstitial and tubal stump pregnancies proposed by Lau and Tulandi:


Another authors Timor-Tritsch et al., advocate an "interstitial line sign" the diagnosis of interstitial and tubal stump pregnancies [11].

In small-sized interstitial pregnancies, the line may represent the interstitial lesion of the tube. In large-sized interstitial pregnancies, it likely represents the endometrial canal. This sign represents the visualization of an echogenic line extending into the abutting interstitial ectopic mass of the tubal mid-portion. The diagnosis of interstitial pregnancy is 80% sensitive and 98% specific with the "interstitial line sign"

technique [13]. Spontaneous interstitial pregnancy on a tubal stump after unilateral salpingectomy followed by vaginal Doppler ultrasound [14].

Per-vaginal color and angio Doppler blood flow analysis combined with serial measurement of human chorionic gonadotrophin (HCG) level is reported here for the first time to study the local vascularity of a cornual pregnancy and to monitor the effectiveness of medical therapy. They found, a strong relationship between morphological changes of trophoblastic tissue and the intensity of neovascularization was noted. Methotrexate (MTX) therapy as systemic single-dose allowed successful treatment of an interstitial ectopic pregnancy involving part of the proximal portion of a tubal stump. Conventional transvaginal ultrasonography Compound color Doppler, the outpatient surveillance of ectopic pregnancy evolution following MTX therapy is greatly enhanced. This is of particular value in cornual pregnancies which are highly likely to develop harmful complications during surgical intervention or even during puncture for local MTX injection [15].

### **4. Treatment**

Lau and Tulandi reported, The main treatment for tubal stump pregnancy is surgery and conservative management using methotrexate that the overall success rates in surgical treatment reached 100% and that of methotrexate management was 83% [16].

### **Figure 3.**

*Sonographic appearance: (A) absence of an intrauterine pregnancy (B) free fluid in the cul de sac (C) a twin ectopic pregnancy in the right adnexa.*

*Ectopic Pregnancy after Ipsilateral Salpingectomy DOI: http://dx.doi.org/10.5772/intechopen.103146*

The difficulty level of laparoscopic operation for interstitial and tubal stump pregnancy is higher than that of common laparoscopic salpingectomy. The operation method for tubal stump pregnancy is almost the same as that of interstitial pregnancy, and hence, the selection of operative method depends on the surgeon's preference and expertise (**Figure 3**).

There is a lot of successful laparoscopic surgery for interstitial and tubal stump pregnancy using an advanced bipolar device and injecting diluted vasopressin into the uterus [2, 7, 8]. Sherer et al. before incising the cornua, he recommend clamping the adjacent uterine wall to the interstitial pregnancy with long-jaw forceps [17]. Some authors, they are reports of using hysteroscopic surgery for interstitial and tubal stump ectopic pregnancy [12]. However, long-term prognosis for selecting hysteroscopic surgery are unknown.

Any subsequent pregnancy after operation for tubal stump pregnancy should be followed up carefully and cesarean delivery at term may be safer and help decrease the risks of uterine rupture during labor.

In summary, Laparoscopic surgery can be account first-line treatment for a hemodynamically stable patient with interstitial pregnancy of a small size. Sometimes, the accurate diagnosis for this type of ectopic pregnancy is difficult; therefore, we have to pay much attention to the possibility of tubal stump pregnancy when we diagnose the ectopic pregnancy [13, 18].

### **5. Prevention**

There is no certain nature of the mechanism, selecting a method for prevention is difficult. However, there is some options may be suggested to decrease the probability of recurrence of ipsilateral ectopic pregnancy. When performing the tubectomy, care should be taken not to leave a long stump [16] and this remnant portion should be minimized. Additionally, using diathermy or ligation with clips of the proximal portion may be necessary components to decrease the risk of recurrent implantation [9].

Another author, suggest performing hysterosalpingography to evaluate the patency of the fallopian tubes after salpingectomy and ligation [19]. In addition to salpingectomy, he suggests insertion of flexible microinserts (commercial products are available) into the remnant tube. These devices are considered to be effective in occluding the fallopian tubes [11] This can be provided if greater protection left from proximal tube.

In case of the woman has completed her family and has a history of ectopic pregnancy, effective contraception counseling may be given, or permanent contraceptive measures implemented [9].

Clinicians should be aware that one ectopic is a risk factor for future ectopic and that salpingectomy does not exclude ipsilateral ectopic pregnancy.

Ectopic pregnancy on the ipsilateral tube is rare, but we should be aware that history of salpingectomy is a risk factor for future ectopic pregnancy in ipsilateral remnant tube.

### **6. Discussion**

Recurrent ectopic pregnancy in the remnant portion of the tube after ipsilateral salpingectomy has only rarely been reported, The exact incidence of ectopic



### **Table 1.**

*The results of a literature review of previously reported cases with a history of the previous salpingectomy which diagnosed as a case of ectopic pregnancy in ipsilateral remnant tube with spontaneous conception.*


### **Table 2.**

*The reported cases of ectopic pregnancy in the remnant tube after ipsilateral salpingectomy induced by ovulation induction intrauterine insemination.*

pregnancy occurred in the remnant tube after ipsilateral adnexectomy is not known, Ko et al. reported that tubal stump pregnancy after salpingectomy is extremely rare, with a prevalence of about 0.4% [20]. Takeda et al. reported an incidence of 1.16% in their department from January 1994 to August 2005 [21], with mortality 10–15 times higher compared to other forms of ectopic [22].

**Table 1** shows the results of a literature review of previously reported cases with a history of previous salpingectomy which were diagnosed as a ectopic pregnancy in ipsilateral remnant tube with spontaneous conception.

**Table 2** shows findings associated with reported cases of ectopic pregnancy in the remnant tube after ipsilateral salpingectomy induced by ovulation induction and intrauterine insemination. Agarwal et al. [30], these authors reported seven cornual and tubal stump pregnancies in patients with prior salpingectomy undergoing IVF. Also, two literature reported cases of ectopic pregnancy in the remnant tube after ipsilateral salpingectomy conceived after IVF, [20] he report Six cases of tubal stump pregnancy, four of six conceived with IVF and all managed surgically, Only one of the cases managed successfully by methotrexate and the remaining six were treated surgically.

The mechanism of recurrent ipsilateral ectopic pregnancy is not clear. But there is many hypotheses including Transperitoneal migration of the egg or embryo to the contralateral tubal stump or Passage of the spermatozoa to fertilize the ovum in the proximal tubal remnant with some degree of patency or recanalization may occur in the tubal stump or contralateral fertilization occurred and the fertilized ovum transmigrate from the intact fallopian tube across the endometrial cavity to contralateral tubal stump.

In The literature review, there are some of the suggestions to decrease the risk of recurrence of ectopic pregnancy in a remnant tube after tubectomy, the length of the remnant tube should be minimized and adequate closer to the tip of the remnant tube achieved by diathermy or using clip.

### **Author details**

Afaf Felemban1 \*, Haya Aljurayfani1 , Fatimah Alamri1 , Jawaher Alsahabi1 , Ghadeer L. Aljahdali1 , Hadeel Alkheelb1 , Hessa Alkharif<sup>1</sup> and Mohmmad Albugnah2

1 King Abdulaziz Medical City, Riyadh, Saudi Arabia

2 Dr. Suliman Alhabeb Hospital, Riyadh, Saudi Arabia

\*Address all correspondence to: fillimbana@ngha.med.sa

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Ectopic Pregnancy after Ipsilateral Salpingectomy DOI: http://dx.doi.org/10.5772/intechopen.103146*

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