Persistent peritoneal trophoblastic implantation following salpingotomy, salpingectomy, and methotrexate for ectopic pregnancy

Abstract

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...

Unusual gestational choriocarcinoma arising in an interstitial pregnancy

“…Indeed, only 0.76–4% of choriocarcinomas developed in ectopic location. 8,9 Its specific occurrence in interstitial pregnancy is exceptional with, in our knowledge, three cases being reported in the literature including the present one. 2,3 …”

“… 3 At the new England trophoblastic disease center, all the women with tubal choriocarcinoma (6/6) achieved complete remission with chemotherapy even those with metastases (4/6). 9 The two cases of choriocarcinoma arising in an interstitial pregnancy reported were also successfully treated with chemotherapy based on methotrexate. 2,3 …”

Acute hemoperitoneum 6 weeks post-laparoscopic salpingectomy—a rare case of secondary peritoneal trophoblast implantation

“…None of these cases required further intervention. This is compared to 23 reported cases of secondary peritoneal implantation following salpingostomy between 1989 and 2011 [7,[10][11][12][13][14][15].…”

Ectopic choriocarcinoma in a preteen in Ogbomoso, South-West Nigeria: A case report

“…Ethical committee approved the work only after demonstrating that the patient was lost to follow up the second time with proposal for the social workers to trace the child and offer treatment at subsidized rate. Awotunde T. Olufemi, 4 Ogunlaja P. Idowu, 5 Aaron Olurotimi, 6 Idowu Ajibola, 7 Fehintola O. Funmito, 7…”

“…It's incidence is one in 533 of tubal pregnancies and one in 1.6 million normal intra uterine pregnancies (1,2). In fact, only 0.76-4% of choriocarcinomas has been reported in ectopic location (3,4).…”