A well recognized complication of conservative surgical treatment for tubal ectopic pregnancy, salpingotomy, is incomplete removal of trophoblastic tissue. Secondary trophoblastic implantation needs to be considered especially in cases of persistent disease following salpingectomy. We report an unusual and rare case of persistent peritoneal trophoblastic implantation following salpingotomy, salpingectomy and methotrexate for tubal ectopic pregnancy. This case illustrates that the treatment of ectopic pregnancy can prove to be difficult, even if the initial diagnosis is ''obvious''. It shows that persistent trophoblastic disease can occur not only after salpingotomy but also after salpingectomy and methotrexate, hence the need for postoperative serum beta human chorionic gonadotrophin (Bhcg) in all cases. It also demonstrates that secondary implantation is a possibility in persistent disease and thorough examination of the pelvis, the peritoneal and serosal surfaces is mandatory.A 33-year-old woman, gravida 2, para 1, presented at 6 weeks' gestation with a 1-day history of right iliac fossa pain and light vaginal bleeding. It was a planned and very much wanted pregnancy. Ultrasound examination showed an empty uterus. In the left adnexa, between the uterus and the left ovary, there was a gestational sac with a yolk sac present, an appearance suggestive of a left tubal ectopic pregnancy. The woman was asymptomatic and haemodynamically stable, and a laparoscopic procedure was arranged.At laparoscopy, a 2·2-cm left isthmic unruptured ectopic pregnancy was seen. The fimbrial end of the right fallopian tube was not seen, as it was abnormally ''tucked'' behind the right ovary. In view of the possibility of a contralateral unhealthy fallopian tube and the patient's desire for future fertility, a left salpingotomy was performed. The histology from the product removed from the left fallopian tube confirmed an ectopic pregnancy.Postoperative surveillance of serum beta human chorionic gonadotrophin (Bhcg) showed high and rising levels (see Table 1). An ultrasound scan was arranged on the 15th postoperative day, which showed thin endometrium with no evidence of pelvic mass.A second laparoscopy was performed 19 days after the first one. The left fallopian tube was noted to be opened from previous surgery and adherent to the back of the uterus. A left salpingectomy was performed, and the histology confirmed the presence of trophoblastic villi. Laparoscopic examination revealed a partially organised haematoma at the base of the appendix. This was removed, but the histology revealed no evidence of fetal parts or trophoblastic villi.The patient presented 5 days after the salpingectomy (25 days after the salpingotomy) with abdominal pain. She was haemodynamically stable, and there were no abdominal signs. Serial serum Bhcg showed high and rising levels (see Table 1).The treatment options of laparotomy or methotrexate injection were discussed with the patient, and she chose the medical option. An injection of methotrexate at the dose...

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Relaxin has been postulated to be a modulator of the expression of the endometrial secretory proteins, insulin-like growth factor binding protein (IGFBP-1) and placental protein 14 (PP14). This study evaluated the expression of relaxin in relation to concentrations of these secretory proteins along with oestradiol, progesterone and human chorionic gonadotrophin in groups of pregnant and non-pregnant patients who underwent differing assisted conception treatments. Serum samples were taken from 88 patients at 8 and 12 days after embryo transfer. At 12 days after embryo transfer, relaxin concentrations in the pregnant patients who had undergone in-vitro fertilization (IVF) or natural cycle frozen embryo transfer were significantly higher than those who did not conceive in these groups (mean concentrations 8334 versus 28 and 2608 versus 62 pg/ml respectively, P<0.001). However concentrations in the pregnant patients who had hormone support and transfer of frozen embryos were not significantly different from the patients who did not conceive after the same treatment. Although relaxin expression was associated with corpus luteum activity, it was not related to the number of corpora lutea in IVF patients. A wide range of relaxin concentrations was seen to be compatible with a healthy pregnancy. These serum relaxin concentrations were not found to be directly related to the serum concentrations of IGFBP-1, PP14 or the other factors assessed in this study.

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