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Keywords:

  • diagnosis;
  • ectopic pregnancy;
  • hysterectomy;
  • review

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References

Ectopic pregnancy after hysterectomy is a rare but potentially life-threatening condition requiring prompt diagnosis to prevent the increased mortality associated with rupture. Twenty-seven cases of late post-hysterectomy ectopic pregnancy reported in the English literature since 1918 were reviewed and analysed for presenting symptoms, missed diagnosis rate at initial presentation, location of ectopic and rupture rate at diagnosis. The presenting symptoms were found to be non-specific. The diagnosis in this population is twice more likely to be missed than in women with intact uteri. The rupture rate is 63%, compared with 37% in women with intact uteri. The majority of late post-hysterectomy ectopic pregnancies (62%) were located in the fallopian tubes. Because of the potential risk of mortality, emergency physicians should always consider the possibility of ectopic pregnancy in childbearing women whose surgical history includes hysterectomy without oophorectomy. Evaluation of abdominal pain in this population should include a pregnancy test to ensure prompt diagnosis when the possibility of pregnancy exists clinically.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References

Ectopic pregnancy after hysterectomy is an extremely rare event that is often not considered in woman with histories of prior hysterectomy who present with abdominal or pelvic pain, vomiting or vaginal bleeding. Yet, missing the diagnosis puts the patient in danger of life-threatening complications that could be easily avoided by timely diagnosis. Many case reports exist in the literature of post-hysterectomy ectopic pregnancies. In an article by Fylstra in 2010,1 he cited 56 cases of post-hysterectomy ectopic pregnancies in the literature. Thirty-one of those cases, termed early post-hysterectomy ectopic pregnancies, were explained by fertilization taking place immediately before hysterectomy. Twenty-five cases were termed late post-hysterectomy ectopic pregnancies. Such cases were explained by the presence of fistulous tracts between the vagina and the peritoneal cavity or the presence of fallopian tube prolapse, facilitating the passage of sperm into the peritoneal cavity or to the fallopian tube, where fertilization could take place.

In this article, we review all the cases of late post-hysterectomy ectopic pregnancies reported in the English literature, focusing on the nature of presenting symptoms, latency between presentation and diagnosis, rate of rupture on diagnosis and location of ectopic.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References

A comprehensive literature review was carried out to identify all the published peer-reviewed case reports of late post-hysterectomy ectopic pregnancy, as well as any prior review articles on the topic. As mentioned previously, late ectopic pregnancy after hysterectomy is defined as ectopic pregnancy taking place months to years after hysterectomy and is not due to previously undiagnosed ectopic pregnancy immediately before the hysterectomy.

Literature search

A PubMed search was conducted, using the following search details: ‘pregnancy, ectopic’[MeSH Terms] OR ‘ectopic pregnancy’[All Fields]. The search revealed 13 873 articles. Another search was conducted using the following search details: ‘hysterectomy’[MeSH Terms] OR ‘hysterectomy’[All fields], and the result was a total of 32 524 articles. The two search results were joined by ‘AND’ and the search result was a total of 546 articles. The abstracts of all these articles were reviewed and articles were included if they described subjects who had late post-hysterectomy ectopics as defined in the Method section. Non-English articles, as well as case reports about early ectopic pregnancy after hysterectomy, were excluded from this review.

Through the abovementioned PubMed search, 20 English-language articles on late post-hysterectomy articles were identified. The bibliographies of these articles were further examined to identify additional publications of relevance, yielding a total of 27 case reports on late ectopic pregnancy following hysterectomy in the English literature. The first case was in 1918, and the most recent was in 2010.

The identified articles were then reviewed in detail, and the following data were collected on each case: time from hysterectomy to presentation with ectopic, type of hysterectomy, age of subject at presentation, presenting symptoms, time from onset of symptoms of ectopic to diagnosis of ectopic, presence of rupture on diagnosis, location of ectopic, mortality and recurrence. Descriptive analysis was then carried out using the number and per cent for categorical variables.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References

Table 1 lists the characteristics of the cases reviewed, the time from undergoing hysterectomy to presentation, type of hysterectomy, rupture status upon diagnosis, location of ectopic and recurrence.

Table 1.  Characteristics of the cases reviewed
CasesTime from hysterectomy to presentationType of hysterectomyRuptured upon surgeryMortalityRecurrenceLocation
  • History of tubal ligation before incidence.

Grigg (1919–1920)21 yearAbdominal supracervical hysterectomyNot rupturedNoNoUnknown
McMillan and Dunn (1921)31st ectopic: 1 yearAbdominal supracervical hysterectomy1st ectopic: not rupturedYesYes1st ectopic: under spleen
2nd ectopic: 2 years2nd ectopic: ruptured2nd ectopic: fallopian tube
Weil (1938)45 yearsVaginal hysterectomyUnknownNoNoUnknown
Frech (1938)59 yearsVaginal hysterectomyRupturedNoNoFallopian tube
Connors et al. (1948)64 yearsSupravaginal hysterectomyNot rupturedYesNoUnknown
Brown and Shields (1944)71 yearSupracervical hysterectomyNot rupturedNoNoCervix
Lyle and Christianson (1955)811 yearsVaginal hysterectomyUnknownNoNoCul-de-sac
Grody and Otis (1961)914 monthsAbdominal hysterectomyRupturedNoNoUnknown
Zaczek (1963)107 monthsAbdominal hysterectomyNot rupturedNoNoFallopian tube
Hanes (1963)119 monthsVaginal hysterectomyRupturedNoNoAdnexa
Kornblatt (1968)1212 monthsVaginal hysterectomyRupturedNoNoAdnexa
Sims and Letts (1974)1322 monthsVaginal hysterectomyRupturedNoNoFallopian tube
Salmi et al. (1984)143 years and 7 monthsVaginal hysterectomyRupturedNoNoFallopian tube
Culpepper (1985)156 yearsVaginal hysterectomyRupturedNoNoVagina
Isaacs et al. (1996)168 yearsVaginal hysterectomyNot rupturedNoNoFallopian tube
Adeyemo et al. (1999)172.5 yearsLaparoscopic-assisted vaginal hysterectomyRupturedNoNoFallopian tube
Brown et al. (2002)1812 yearsCesarean hysterectomyRupturedNoNoFallopian tube
Pasic et al. (2004)194 monthsLaparoscopic supracervical hysterectomyNot rupturedNoNoFallopian tube
Nnochiri and Warwick (2007)201 yearVaginal hysterectomyRupturedNoNoFallopian tube
Tagore et al. (2007)219 yearsAbdominal hysterectomyNot rupturedNoNoUnknown
Babikian et al. (2008)223 yearsAbdominal supracervical hysterectomyRupturedNoNoAdnexa
Rosa et al. (2009)235 yearsVaginal hysterectomyRupturedNoNoOvary
Fylstra (2009)246 yearsCesarean supracervical hysterectomyRupturedNoNoOvary
Barhate et al. (2009)252 yearsVaginal hysterectomyRupturedNoNoUnknown
Bansal et al. (2009)264 yearsCesarean supracervical hysterectomyRuptured during operationNoNoFallopian tube
Ramos et al. (2010)275 monthsVaginal hysterectomyNot rupturedNoNoFallopian tube
Hitti et al. (2010)281st ectopic: 2 yearsCesarean supracervical hysterectomy1st ectopic: unknownNoYes1st ectopic: unknown
2nd ectopic: 7 years2nd ectopic: ruptured2nd ectopic: fallopian tube

Of the 27 case reports reviewed, the average age at which ectopic pregnancy took place was about 35 years. The earliest presentation was 4 months after hysterectomy, and the latest was 12 years. The mean time between undergoing hysterectomy and being diagnosed with an ectopic pregnancy was around 47 months.

The most common presentation was some form of abdominal or pelvic pain, present in approximately 85% of reported cases, ranging from indolent vague discomfort lasting days to weeks, to sudden onset severe stabbing pain with no previous warnings. Nausea and/or vomiting was seen in about 33% of cases. About 26% of cases presented with a form of vaginal discharge of varying duration, ranging from increased amounts of the normal vaginal fluids to the presence of bloody vaginal discharge. Other presenting symptoms are listed in Table 2.

Table 2.  Summary of the presenting symptoms and their frequency
Chief complaintPatient numberPercentage
Abdominal or pelvic pain2385.0
Nausea and/or vomiting933.0
Vaginal discharge726.0
Urgency, frequency, dysuria311.0
Dyspareunia27.4
Fever and/or chills27.4
Diarrhoea27.4
Hot flushes13.7
Mastalgia13.7

Of the 27 case reports of late post-hysterectomy ectopic pregnancies reviewed, 15 patients (56%) had undergone vaginal hysterectomies, 1 of which was supracervical, as opposed to 12 (44%) patients who had undergone abdominal hysterectomies, 8 of which were supracervical. Three patients developed ectopic hysterectomy after both hysterectomy and tubal ligation.

The location of the ectopic was described in 21 of the 27 case reports. The ectopic pregnancy was in the fallopian tube in the majority of the cases (62%). Three of the cases (14%) were described to be in the adnexa, two (9.5%) in the ovary, two (9.5%) in the vagina and one (4.7%) in the cervix. At least 8 cases out of the 27 case reports reviewed were missed on first visit to a physician, with a miss rate of approximately 31%. The rate of rupture upon diagnosis was found to be approximately 63%, with 17 out of 27 cases being ruptured upon surgical exploration, as opposed to 8 cases of unruptured ectopic pregnancies and 2 cases where the presence of rupture was indiscernible from the report.

With respect to mortality, there are two fatality cases, representing a fatality rate of approximately 7.4%. Two case reports (7.4%) involved recurrent late post-hysterectomy ectopic pregnancies.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References

An Australian-wide study suggests that between 17%29 and 22%30 of women have undergone a hysterectomy by their mid-50s. In the USA, the prevalence of hysterectomy over the reproductive years (ages 18–44 years) reached about 18%.31 Despite evidence of a drop in the rates of hysterectomies in the past few years, the incidence of hysterectomies remains high. As such, primary care physicians, gynaecologists and emergency physicians must be aware of the short-term and long-term complications of hysterectomies.

Even though abdominal hysterectomies have been more common historically than vaginal hysterectomies,32,33 our review found that the majority (56%) of late post-hysterectomy ectopics reported were following vaginal hysterectomies compared with 44% following abdominal hysterectomies. This disproportionate number of late ectopic pregnancies following vaginal hysterectomies reflects the hypothesis that vaginal hysterectomies are associated with greater risk of developing fistulous tracts between the vaginal canal and the remnants of the fallopian tube than abdominal hysterectomies. As vaginal hysterectomies become increasingly popular in regions, such as Western Australia,33 late post-hysterectomy ectopics might become more common.

Our review found that the most common location for late post-hysterectomy ectopic pregnancies is the fallopian tube (62%). This might be an underestimate as three additional cases were described to be in the adnexa, which encompasses the fallopian tubes in addition to the ovary and surrounding ligaments. This finding suggests that patients who undergo hysterectomy with bilateral salpingectomies might be at lower risk for late post-hysterectomy ectopic pregnancies.

In the 27 cases reviewed, the presenting signs and symptoms were non-specific. Approximately 85% complained of abdominal or pelvic pain, 33% complained of nausea and/or vomiting, and about 26% complained of increased vaginal discharge. The diagnosis was missed in approximately 31% of cases, as opposed to 12% in women with intact uteri.34 This might account for the high rate we found of rupture upon diagnosis of 63%, compared with about 37% in cases of tubal ectopic pregnancy in patients with intact uteri.35 Rupture on presentation is believed to increase the patient's risk of morbidity and mortality, and every effort should be made to diagnose patients before they present with signs and symptoms of rupture.

Compared with the average mortality rate of ectopic pregnancy in patients with intact uteri of 0.3% (9),36 the mortality rate of late post-hysterectomy ectopic pregnancy is higher at 7.4%. This likely reflects the higher rupture rates at diagnosis but might still be an underestimation of the true mortality, as many such cases might go unreported and attributed to other causes.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References

Ectopic pregnancy should be on the differential diagnosis of any woman of childbearing age presenting with acute abdominal or pelvic pain, vaginal bleeding, or nausea of a few days' duration, even in women who have undergone prior hysterectomy. To avoid delays in diagnosis and treatment, this population should be screened for pregnancy when presenting with such complaints, and a clinical possibility of pregnancy exists. Our findings suggest that removal of the fallopian tubes at the time of the hysterectomy might reduce the risk of late post-hysterectomy ectopic pregnancy, although further research is required to support this as a recommendation.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References

Thanks for Mrs Aida Farha, librarian at the Saab Medical Library, for her help and support in retrieving the case reports.

Competing interests

None declared.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgement
  9. References
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