Tubal ectopic pregnancy on a patient with two previous consecutive laparoscopic tubal sterilisation techniques
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CASE REPORT
Tubal ectopic pregnancy on a patient with two previous consecutive laparoscopic tubal sterilisation techniques Costas Panayotidis & Richard Husicka
Received: 20 October 2012 / Accepted: 31 December 2012 / Published online: 18 January 2013 # Springer-Verlag Berlin Heidelberg 2013
Introduction The article discusses the challenges of laparoscopic management of failed sterilisation techniques, the difficulty of further laparoscopic tubal sterilisation techniques using diathermy and the limitations of future hysteroscopic sterilisation when the proximal tubal end is missing. Case study A 35-year-old patient gravida 6 para 3 had an uncomplicated laparoscopic sterilisation where two Filshie clips were applied on both tubes (Fig. 1). Four years later, she has been referred to the gynaecological clinic with 18 months history of deteriorating abdominal pain, described as lower pelvic dull ache, predominantly on the right iliac fossa side. The patient did not have dysmenorrhoea or other clinical symptoms suggestive of endometriosis Diagnostic laparoscopy was performed and three migrated clips, all attached curiously together, where removed from the right upper part of the vesico-uterine peritoneum (Fig. 2). At this point, both the right and left cornual ends of uterus were of normal appearance with a very short proximal tubal end. The right tube had an impregnation of the previously applied clips presenting as a very small intermediate part and a longer distal part (Fig. 3). The laparoscopy did not detect any other pelvic abnormality, no endometriosis, or adhesions were depicted. The fourth clip was not detected despite a thorough inspection of the pelvis and the left distal tubal end was intact. Bipolar diathermy at 20 W C. Panayotidis (*) : R. Husicka Gynecology, Withybush General Hospital, Haverfordwest, Wales, UK e-mail: [email protected]
was applied on the remaining proximal tubal ends at their whole length in order to secure tubal blockage and the right intermediate tubal part was removed simultaneously (Fig. 4). Neither was possible to apply any type of sterilisation clip on such short tubal ends. Any attempt to excise the proximal tubal ends with scissors/monopolar energy would involve excision of part of the uterine cornua and hence could lead to complications and conversion to laparotomy. Patient had an excellent recovery and her previously described pains were quickly resolved. Seven months later, she had an unexpectedly positive pregnancy test after missing her period for more than a month. Although the patient was asymptomatic, she came to the early pregnancy unit for a transvaginal ultrasound scan which was strongly suggestive of right tubal ectopic pregnancy (4 cm “doughnut” like structure in the right adnexal area, demarkable from the ovary) and her serum beta HCG was 22,959 IU/l. Patient was fully consented for diagnostic laparoscopy and bilateral salpingectomy. The diagnostic laparoscopy confirmed the ectopic pregnancy in the remained distal right end of fallopian tube which was treated with
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