Ruptured ectopic pregnancy after hysterectomy with copper intrauterine device in place: A case report

Abstract

Introduction

Ectopic pregnancy after hysterectomy is a rare event, with 72 cases being reported since 1895. Concomitant use of reliable contraception at the time of hysterectomy makes pregnancy extremely unlikely, but, as this case illustrates, does not completely rule out the possibility of post-hysterectomy ectopic pregnancy.

Case

A 30-year-old woman experienced a ruptured fallopian tube ectopic pregnancy four weeks after a laparoscopic-assisted vaginal hysterectomy and left salpingo-oophorectomy. At the time of her hysterectomy, a copper intrauterine device was in place.

Conclusion

Women with ovaries who present with abdominal or pelvic pain should be evaluated for pregnancy regardless of contraceptive use or history of hysterectomy.

Highlights

• •We present a case of a ruptured fallopian tube ectopic pregnancy following hysterectomy with an intrauterine device in place.
• •When feasible, fallopian tubes should be removed at the time of pelvic surgery.
• •Pregnancy should always be considered in a woman with ovaries who presents with pelvic or abdominal pain.

1. Introduction

Ectopic pregnancy accounts for 2% of all pregnancies and 53% of pregnancies that occur with an intrauterine device (IUD) in situ [1]. However, ectopic pregnancy after hysterectomy is rare. There are multiple published cases of ectopic pregnancy after hysterectomy, but to our knowledge none reports the presence of an IUD at the time of surgery. Here we present the case of a woman with a ruptured fallopian tube ectopic pregnancy four weeks after laparoscopic-assisted vaginal hysterectomy and left salpingo-oophorectomy with a copper IUD in place.

2. Case

A 30-year-old woman, gravida 2 para 1, presented to the emergency room reporting sudden-onset pain in the right lower quadrant. She had a history of one term cesarean delivery and a dilation and evacuation for a fetus with anencephaly. Her other medical history was significant only for asthma. Four weeks prior, the patient had undergone a laparoscopic-assisted vaginal hysterectomy and left salpingo-oophorectomy for a history of heavy menstrual bleeding and a left dermoid cyst. She had an open umbilical hernia repair at the same time. At the time of her hysterectomy, a copper IUD was in place and strings were noted at the cervical os in the operative report. The device was also mentioned in the pathology report, which noted secretory endometrium. Her preoperative urine pregnancy test was negative on the day of her hysterectomy.

The patient reported sharp pain in the right lower quadrant several hours prior to presentation as well as several soft bowel movements, chills, and pre-syncope. Upon presentation to the emergency department, she reported diffuse abdominal pain. She denied vaginal bleeding or abnormal discharge, chest pain, palpitations, or shortness of breath. She had had a routine postoperative visit with her surgeon earlier that same week and reported intercourse two days prior without incident.

On presentation, her temperature was 36.6 degrees Celsius, blood pressure 99/55 mm Hg falling to a nadir of 69/50 mm Hg, respiratory rate 16 breaths per minute, and oxygen saturation 99% on room air. Initial labs revealed a white blood cell count of 22.5 × 10⁹ per liter, hemoglobin 10.5 g per deciliter, hematocrit 32.9%, and platelets 388 × 10³/uL. An electrocardiogram showed normal sinus rhythm. Quantitative beta-HCG was collected, but reporting of the result was delayed.

On physical exam, she was pale and in moderate distress with diffuse right-sided abdominal pain, rebound, and guarding. On speculum exam, her vaginal cuff was intact. Bimanual exam elicited peritoneal signs.

The patient had a positive focused assessment with sonography in trauma (FAST) scan, and a computed tomography (CT) scan revealed a 5.7 cm × 5.5 cm × 6.1 cm hematoma at the right adnexa obscuring the right ovary with moderate free fluid in the pelvis and abdomen, concerning for active extravasation.

The patient's hemoglobin and hematocrit fell to 7.6 g per deciliter and 23.7%, and she was transfused one unit of packed red blood cells. She consented to emergency exploratory laparotomy and was taken to the operating room. Upon entry into the peritoneum, 2000 mL of blood was evacuated. The right fallopian tube and ovary were identified. There was a 2 cm clot in the tube next to a small defect, which was actively bleeding. A salpingectomy was performed, and hemostasis was achieved. The surgery was, overall, uncomplicated. Following the case, the surgeons were alerted to the patient's beta-HCG of 14,028 m-international units per milliliter. Surgical pathology later confirmed a ruptured ectopic pregnancy.

The patient did well postoperatively and received an additional 2 units of packed red blood cells and 1 unit of plasma. She was discharged home on postoperative day three.

3. Discussion

To our knowledge, this is the first reported case of an ectopic pregnancy after a hysterectomy with an IUD in situ. Ectopic pregnancies account for 2% of all pregnancies, but ectopic pregnancy after hysterectomy is much rarer. Fylstra completed a comprehensive review of 72 cases of ectopic pregnancy after hysterectomy between 1895 and 2015. This review included all routes of hysterectomy, two of which were laparoscopic-assisted vaginal hysterectomies. Thirty of these occurred within the immediate period after hysterectomy, as in our case, which indicates that the pregnancy or potential for pregnancy existed at the time of the hysterectomy [2].

Our patient had reliable contraception in place at the time of her surgery, which makes her case even more surprising and represents rare contraceptive failure. The copper IUD is a highly effective device which creates an inflammatory response in the uterus that activates lysosomes and is ultimately spermicidal [3]. Thus, sperm traversed the patient's hostile uterine environment and was present in the fallopian tube prior to her hysterectomy. Pathology from her hysterectomy revealed secretory endometrium, so the patient must have been in the luteal phase of her cycle. A luteal phase pregnancy would not be evident by the urine pregnancy test she had immediately before her hysterectomy.

Since 2002, the use of long-acting reversible contraception, which includes IUDs and implants, has increased from 2.4% of all women using contraception to 11.6% in 2013 [4]. At 1 year, the copper IUD has a failure rate of 0.8 per 100 women, and the cumulative pregnancy risk over ten years in women who use the copper IUD is 1.9 per 100 women, similar to the risk after tubal sterilization [5]. However, of pregnancies that occur with an IUD in place, 53% are ectopic, and a tubal ectopic pregnancy in an unstable patient requires urgent surgical intervention [1]. Ectopic pregnancy is associated with significant maternal risk, and mortality estimates range from 3% to 6%, with the majority of deaths resulting from hemorrhage [6].

It is notable that the right fallopian tube was left in place during this patient's hysterectomy and left salpingo-oophorectomy. A study by Repasy et al. demonstrated that hydrosalpinx developed in 35.5% of patients with an intact fallopian tube after hysterectomy, and those authors concluded that removal of the tubes at the time of hysterectomy decreases the later incidence of pelvic masses [7]. The most compelling reason to remove fallopian tubes is the multitude of evidence suggesting that the majority of ovarian cancers arise there [8]. Nezhat and Martinelli argue that not performing opportunistic salpingectomies at the time of other pelvic surgeries is a disservice to patients [9]. Depending upon the route of hysterectomy, the fallopian tubes may not always be safely accessible, but evidence supports tube removal when possible.

Keeping a broad differential when reproductive-aged women present with abdominal pain is critical to quick and accurate diagnosis. Reliable contraception is not 100% effective, and, as this and other case reports show, ectopic pregnancy is possible even after hysterectomy. Thus, pregnancy should always be considered, particularly because ectopic pregnancy poses risk for significant morbidity and mortality.