Arrested tubal pregnancy

FERTILITY AND STERILITY

Vol. 48, No.6, December 1987 Printed in U.S.A.

Copyright 0 1987 The American Fertility Society

Arrested tubal pregnancy

Victor Gomel, M.D.* Shlomo Filmar, M.D. Department of Obstetrics and Gynecology, University of British Columbia, Departments of Gynecology, Shaughnessy and Health Sciences Center Hospitals, Vancouver, British Columbia, Canada

There was a 3-fold increase in the occurrence of ectopic pregnancy in the United States between 1970 and 1980. 1 The singlemost important cause for this increase has undoubtedly been the rise in the prevalence of salpingitis. 2 ,3 In addition, it has been recognized that salpingitis may have a relatively silent course, nonetheless leading to deleterious consequences. Infections of the oviduct damage the mucosa and muscularis, compromising tubal peristalsis and mucosal ciliary function. These changes predispose the occurrence of tubal pregnancy. Markedly increased numbers of reconstructive microsurgical procedures of the oviduct are additional contributing factors.3 Modern ancillary measures facilitate greatly the early diagnosis of ectopic pregnancy. These include t3-subunit human chorionic gonadotropin (t3-hCG) assay, ultrasonography, and laparoscopy. This improved ability to make the diagnosis also contributes to the reported increased prevalence of ectopic pregnancy. In the past, many tubal ectopic pregnancies that did not proceed to a catastrophic clinical event were never diagnosed. Such instances still occur, especially when the presenting symptoms are mild. The current approach to tubal pregnancy is to recognize the condition early and to treat it surgically. Lund4 demonstrated that it was possible to treat many such patients by expectant rather than sur-

Received May 15, 1987; revised and accepted July 21, 1987.

* Reprint requests: Victor Gomel, M.D., University of British Columbia, Department of Obstetrics and Gynecology, Room 2H30, Grace Hospital, 4490 Oak Street, Vancouver, B.C., Canada V6H 3V5.

Vol. 48, No.6, December 1987

gical means. It is the purpose of this communication to present five cases of tubal pregnancy where the diagnosis was not made initially, and to describe the deleterious effects of such an event upon the tube and the longevity of chorionic tissue at the ectopic implantation site. MATERIALS AND METHODS Patients

The pertinent data of these five patients, all of whom presented with secondary infertility, is summarized in Table 1. t3-hCG assays were not performed at the time ofthe surgical intervention. One of these will be described in detail to illustrate the salient points. Patient 2 was a 25-year-old woman who had undergone left salpingectomy for a ruptured tubal pregnancy 3 months earlier. In the operative report of this procedure, the ovaries and uterus were described as being normal; however, the presence of a tumor 1.5 to 2.0 cm was noted in the midampullary region of the right tube. In the preceding 5 years, she experienced several episodes of pelvic pain that were diagnosed as pelvic inflammatory disease (PID) and treated with oral antibiotics. Routine investigation of the couple's fertility parameters revealed no abnormalities. At hysterosalpingography, there was an irregular filling defect in the midampullary portion of the right tube, which was also occluded at this site. A subsequent laparoscopy revealed normal-appearing ovaries, pelvic side walls, pouch of Douglas, and uterus. The left tube was absent. The right

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Table 1 Data on Five Patients with Arrested Tubal Pregnancy Menses

cycle length/

Pa-

tient Age duration

Parity

HSG to

Pertinent previous

Previous ectopic pregnancy treatment and

Hystero-

history

findings

salpingogram

Laparoscopy

Laparotomy

Reconstructive microsurgery

Surgery to Histology

mo

33

30/5-6

Gl,PO

Possible PID associated with IUD

None

5 years earlier

Left hydrosalpinx; Pelvic and left periadnexal adright cornual hesioDs occlusion

8

dence of pregnancy; positive pregnancy test

Adhesiolysis, left sal-

right proximal isthmic segment and intramural-isthmic anastomosis

elusion with enlargement of proximal isthmus sugges-

months earlier; no histologic evi-

mo

pingostomy Excision of affected

Left hydrosalpinx Right cornual oc-

? Spontaneous abortion 22

pregnancy

Tubal segment

9

containing neerotic ectopic pregnancy;

markedly degenerating

trophoblastic cells present

tive of SIN and omental adhesions to this site; remainder

of tube appears normal

28/4

26

Gl,PO Treated for? PID in the preceding 5 years

Left tubal pregnancy and left salpingectomy 10 months prior to reconstruc· tive surgery

Right midampul-

Left tube absent

tion of right tube associated

with a filling defect

months earlier

No histologic evidence of preg-

Right tubal preg-

ampullary anastomosis

8

containing old calcified ec· topic preg· nancy

tube at this site;

normE'1

this intervention

G2,PO ? Spontaneous abortion 24

right ampullary-

dampulla of right tube and occluding the

Segment of tube

distal ampulla and fimbria

noted during

28/5

Excision of affected tubal segment and

Obstruction in mi· 1.5 cm tumor 10dampullary porcated in mi·

Iarytumor

28

Left tube absent

nancy and right

Right tube absent Midampullary oc-

salpingectomy 6

clusion on the

years earlier

left tube

Extensive adhesiolysis Tube with hyaCauterization of en· linized scar dometriosis containing Excision of affected trophoblastic cells; old ecleft ampullary segment and left am· topic pregpullary-ampullary nancy anastomosis

Extensive pelvic adhesions, min· imal endome· triosis

Right tube absent Left midampullary blueish-yel-

nancy; positive pregnancy test

low lesion

Tubal occlusion with a small perforation at this site

4

25

28-52/ G I, PO Gonococcal infec· 4-7

None

tion 10 years earlier and spontaneous abortion

Bilateral cornual occlusion

Bilateral periad-

15

nexal adhesions Bilateral cornual occlusion

Bilateral salpingoovariolysis

Right juxta-uterine and left juxtamural

20 months earlier

anastomosis after excision of isthmic and intramural

tubal segments

Right tube con-

10

taining hyalinized deci-

dua and chorionic villi with salpingitis isthmica no· dosa

Left tube with endometrial colonization and salpingitis isthmica no· dosa

5

34

None 23-28/ G2, PI Seen first for primary infertility; 4-7 Spa 1 patent left tube live and right cornual birth occlusion; subse-

quent live birth and spontaneous abortion Presented later

with secondary infertility of 18

Right cornual occlusion, with

Performed 5 months after

HSG findings suggesRight cornual octive of SIN Left tube occluded clusion

15

At laparotomy performed 15 months after laparoscopy I

the ampullary-isthmic junction of left

small focus of

markedly atten-

calcification

1.3 cm brownish· yellow tumor at

ampulla with filling defect at

the ampullary-

uated but still ex-

isthmic junc·

hibited a brownishyellow discoloration; this section was excised and

this site

months duration

Pregnancy symptoms 3 months earlier associated with pelvic pain

sion at this site; remainder of

tube appears normal

Lost to followup

with collection ofhemosi· derin and a

tube appeared

in the region of the proximal

tion of the left tube with occlu-

Occluded segment of tube

isthmic-ampullary anastomosis was performed

lasting 5 days and positive

pregnancy test; no treatment

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Fertility and Sterility

tube appeared to be normal throughout, with the exception of a tumor of 1.5 to 2.0 cm in diameter located in the midampullary region. This lesion was blueish-yellow. There were adhesions present between this section of tube and the right ovary. In addition, there were some adhesions between the left ovary and the sigmoid colon. When chromoperturbation was performed, the dye could be seen to fill the right tube but to pass no further than the site of the described lesion. A small amount of the dye escaped from the ante mesenteric aspect of the lesion. At the time of this examination, this "tumor" was thought to be endometriotic in nature. The recommended surgery was delayed for 10 months at the request of the patient. At the time of laparotomy, the pelvic findings were identical to those previously described. Microsurgical adhesiolysis was performed and the ampullary segment containing the lesion excised. A primary ampullary-ampullary anastomosis was performed in two layers using the previously described microsurgical technique. 3 A frozen section obtained during this intervention suggested that the lesion was a calcified gestation. This was subsequently confirmed by routine formal histologic evaluation. Eight months later, the patient conceived and subsequently had a live birth. RESULTS

It will be noted from Table 1 that two of the five patients had prior surgical interventions for tubal pregnancy. The other three patients and one of those who had a tubal gestation had a prior history of pregnancy or possible pregnancy which was not proven absolutely to be intrauterine, but was not treated further. In the fifth patient, described previously (patient 2 in Table 1) the ampullary tumor, which proved to be a calcified ectopic pregnancy, was present at the time of the intervention for the ectopic pregnancy in the contralateral tube. In all five patients, the tube was occluded at the site of the arrested gestation. The initial diagnosis of tubal occlusion was made by hysterosalpingography. The site ofthe occlusion was cornual in two, near the ampullary-isthmic junction (AIJ) in one, and in the midampulla in two. In four of the five patients, the gestational site in the tube demonstrated clear histologic evidence of chorionic villi. The time from hysterosalpingography to laparotomy in these four patients varied from a minimum

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Figure 1 Sections through old tubal ectopic pregnancy. (a) Large nest of partly degenerated syncytiotrophoblastic cells (hematoxylin and eosin, was X250). (b) Ghost outline of degenerate and hyalinized trophoblastic villi (long arrow), and partly degenerate trophoblastic cells (short arrow) (hematoxylin and eosin, was X100).

of 7 to a maximum of 15 months. In patient 2, the tumor was present during a prior intervention, which preceded the reconstructive surgery by 10 months. In one patient (patient 5), although a tumor of 1.3 cm was noted at laparoscopy in the proximal ampulla near the AIJ, at the time of laparotomy some 10 months later, the tumor had disappeared and its site instead was noted to be thin and attenuated, forming a solid cord of tissue that resembled the lesion noted in patients submitted to tubal electrocauterization; however, the brownishyellow discoloration was still present. The histology demonstrated evidence of hemosiderin and a small focus of calcification, but chorionic villi were not seen. While it is clear that the four previously described patients had definitive histologic evidence of ectopic pregnancy, this patient is included with a presumptive diagnosis, based on the history and laparoscopic findings only. The histologic appearance of the chorionic villi noted in four of the cases is as follows: one was calcified; one was degenerating (Fig. lA); one showed evidence of hyalinization (Fig. IB); and the final one showed a

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combination of hyalinized decidua, chorionic villi, and salpingitis isthmica nodosa. Subsequent to excision of the affected occluded segment and tubotubal anastomosis, four of the five women became pregnant and one was lost to follow-up. The conceptions occurred within 10 months of the time of the reconstructive surgery. All resulted in live births. There were no ectopic pregnancies. DISCUSSION It is not possible to determine the frequency of tubal ectopic pregnancies that do not progress to a catastrophic clinical event if left untreated. However, the phenomenon does occur, as demonstrated clearly by four of these cases, and highly suspected by the fifth. Lund4 reported a large series of ectopic pregnancies; 119 of these patients, in whom the clinical diagnosis of "subacute tubal pregnancy" was made, were treated by observation. While in 68 patients the symptoms subsided without surgical treatment, subsequent surgical intervention proved necessary in 51 patients. This observation demonstrates that, in a large number of patients with the diagnosis of ectopic pregnancy, surgical intervention will be required even if the symptoms are subacute initially. The management of selected cases of ectopic pregnancy by observation was of course more reasonable in the past (before the era of j3-hCG assay, ultrasound, and laparoscopy) when it was much more difficult to reach a diagnosis. It is also likely that a certain percentage of the patients in whom spontaneous resolution occurred did not in fact have an ectopic pregnancy. The small series presented herein demonstrates clearly that a tubal gestation may arrest and that associated symptoms may subside spontaneously. There is a paucity of information with regards to the natural evolution of such phenomena. The findings in four of the patients indicate that chorionic villi are capable of surviving in a histologically recognizable form for at least 15 months after the demise of a pregnancy. While one of the patients did not show evidence of chorionic villi, her clinical history and the successive observations that were made strongly support the diagnosis. In this patient, a 1.3-cm tumor was noted at laparoscopy. This proximal ampullary tumor was also the site of the tubal occlusion. When a laparotomy was undertaken 10 months later, the tumor was no longer present; the same section of tube was instead thin and attenuated, but was still occluded and main-

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tained brownish-yellow discoloration. The pregnancy and the resorption of gestational products must have led to the segmental atrophic tubal changes noted in this instance. We have observed similar focal unilateral atrophy associated with occlusion (near the AIJ) on several previous occasions. Such anomalies may be congenital; however, the successive observation in this case suggests that they may be a sequela to a tubal pregnancy. Methotrexate has been employed for the treatment of tubal pregnancy. In a series of six cases reported by Ory et a1. 5-despite the strict selection criteria employed for inclusion in the treatment group-two patients had significant bleeding necessitating blood transfusion and one additional patient required subsequent surgical intervention to excise the tubal gestation. The efficacy of this treatment modality on tubal pregnancy and its subsequent effects on tubal function are yet to be determined. One might have argued in favor of "observation" of patients with the clinical diagnosis of tubal pregnancy having mild symptoms in an era when early and accurate diagnosis of this condition was not possible. The availability of j3-hCG assay and ultrasound has greatly facilitated this task. Early surgical intervention remains the approach of choice once the diagnosis of tubal pregnancy is reached. This approach avoids the progression of the condition to a catastrophic clinical event and facilitates the conservation of the affected tube when maintenance of fertility is desired. The validity of this approach is also supported by the observation that spontaneous resolution of tubal pregnancy may lead to tubal occlusion. The close association between salpingitis isthmica nodosa and tubal pregnancy reported earlier6 is also noted in this series either by histology or hysterosalpingography. In three ofthe five patients submitted to microsurgical tubotubal anastomosis after the resection of the affected tubal segment, the reconstructive procedure was performed on the single remaining tube. The fact that two of these three women achieved viable pregnancies attests to the value of reconstructive tubal microsurgery (excision of affected segment and tubotubal anastomosis) in arrested tubal pregnancies. SUMMARY

This communication presents a small series of patients operated on for tubal occlusion resulting from undiagnosed tubal pregnancy.

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In three of the five patients, tubotubal anastomosis after the resection of the affected tubal segment was performed on a single tube. Two of these three patients achieved viable pregnancies. This fact supports the value of reconstructive tubal microsurgery in arrested tubal pregnancy. The histopathologic findings suggest that chorionic villi are capable of surviving in a recognizable form for at least 15 months after the demise of the tubal pregnancy.

Acknowledgment. We thank Peter McComb, M.D., for the inclusion of two of his patients in this study.

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REFERENCES 1. Dorfman SF: Deaths from ectopic pregnancy, United

States, 1979 to 1980. Obstet Gynecol 62:334, 1983 2. Westrom L, Bengtsson LPH, Mardh P A: Incidence, trends and risks of ectopic pregnancy in a population of women. Br Med J 282:15, 1981 3. Gomel V: Microsurgery in Female Infertility. Boston, Little, Brown and Company, 1983, p 183, 225 4. Lund JJ: Early ectopic pregnancy. J Obstet Gynaecol Br Commnw 62:70, 1955 5. Ory SJ, Villaneuva LA, Sand PK, Tamura RK: Conservative treatment of ectopic pregnancy with methotrexate. Am J Obstet GynecoI154:1299, 1986 6. Majmudar B, Henderson PH, Semple E: Salpingitis isthmica nodosa: a high-risk factor of tubal pregnancy. Obstet Gynecol 62:73, 1983

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