Documente Academic
Documente Profesional
Documente Cultură
Ectopic pregnancy after hysterectomy is a very uncommon period after hysterectomy, early presentation, and occurred
event. Since first reported in 1895 by Wendler, 55 additional after all types of hysterectomy (130). This is presumed to
cases have been reported (155). occur because an unrecognized, preclinical pregnancy
existed at the time of hysterectomy: a preimplanted fertilized
ovum was in transit and confined to the fallopian tube, or
MATERIALS AND METHODS
sperm was present within the fallopian when the hysterec-
A search was made of the worlds literature, including multi- tomy was performed in a periovulatory period, allowing post-
ple languages, using Medline/Pubmed through the United operative fertilization and tubal implantation.
States Library of Medicine, National Institutes of Health,
identifying all reported cases of ectopic pregnancy after hys- Ectopic pregnancy has been reported to occur as late as 12
terectomy, and searching the bibliographies of all retrieved years after hysterectomy, late presentation, and 25 such
articles for additional sources of data. cases have been reported (3155) and can only develop be-
cause sperm have gained access to the peritoneal cavity
through a fistulous tract between the vagina and the perito-
RESULTS neal cavity. Although this has occurred after all types of hys-
A total of 56 ectopic pregnancies after hysterectomy have terectomy, 72% follow vaginal hysterectomy (3134, 3748,
been reported (Table 1). Thirty-one of the 56 cases of ectopic 51, 54). Although the operative narrative for the hysterec-
pregnancies after hysterectomy occurred in the immediate tomy was seldom available to the physicians treating the ec-
Received February 3, 2009; revised March 2, 2009; accepted March 6, topic pregnancy after hysterectomy, observations thought to
2009; published online April 25, 2009. increase the chance for vaginal-to-peritoneal fistula forma-
D.L.F. has nothing to disclose. tion include an open vaginal cuff closure technique, vaginal
Reprint requests: Donald L. Fylstra, M.D., Department of Obstetrics and
Gynecology, Medical University of South Carolina, 96 Jonathan Lucas
cuff infection or hematoma formation after hysterectomy,
Street, CSB 634-F, Charleston, SC 29425 (FAX: 843-792-0533; vaginal cuff granulation tissue, and a prolapsed fallopian
E-mail: fylstrad@musc.edu). tube (4751, 53, 54).
0015-0282/$36.00 Fertility and Sterility Vol. 94, No. 2, July 2010 431
doi:10.1016/j.fertnstert.2009.03.039 Copyright 2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
TABLE 1
Ectopic pregnancies after hysterectomy.
Early presentations Year published Type of hysterectomy Time to diagnosis
Knaus (1) 1937 vag 57 d
Girones (2) 1952 abd 53 d
Adams and Schreier (3) 1957 abd 86 d
Clauss (4) 1959 abd 29 d
Smythe (5) 1961 abd 40 d
Graffagnino (6) 1963 vag 59 d
Ledger and Daly (7) 1963 abd 96 d
Moayer (8) 1965 vag 35 d
McDaniel and Gullo (9) 1968 vag 59 d
Wells (10) 1970 vag 39 d
Grunberger (11) 1971 vag Unknown
Bruder and Vigilante (12) 1973 vag 54 d
Niebyl (13) 1973 vag 79 d
Alexander and Everidge (14) 1979 vag 41 d
Cocks (15) 1980 vag 26 d
Cocks (15) 1980 vag 26 d
Jackson (16) 1980 abda 36 d
Buchan (17) 1680 abd 6 wk
Zdravkovic (18) 1980 abd 5 wk
Marut and Zucker (19) 1981 vag 55 d
Williams (20) 1981 abd 7 wk
Zolli and Rocho (21) 1982 abd 15 wk
Nehry and Loginsky (22) 1982 vag 30 d
Meizner et al. (23) 1982 abd 12 wk
Arora (24) 1983 vag 47 d
Reese et al. (25) 1989 vag 24 d
Gaeta et al. (26) 1993 abd 2 mo
Allen and East (27) 1998 LAVH 6 wk
Weisenfeld and Guido (28) 2003 abd 12 wk
Binder (29) 2003 vag 13 wk
Fader et al. (30) 2007 abd 12 wk
Late presentations Year published Type of hysterectomy Time to diagnosis
Wendler (31) 1895 vag 6y
Weil (32) 1938 vag 5y
Frech (33) 1948 vag 9y
Lyle and Christianson (34) 1955 vag 11 y
Gordy and Otis (35) 1961 abd 14 mo
Zaczek (36) 1963 abd 7 mo
Hanes (37) 1963 vag 9 mo
Kornblatt (38) 1968 vag 12 mo
Sims and Letts (39) 1973 vag 2y
Sims and Letts (40) 1973 vag 2y
Schnell and Sinn (41) 1982 vag Unknown
Heidenreich et al. (42) 1983 vagb 1y
Salmi et al. (43) 1984 vag 3y
Beuthe and Wemken (44) 1985 vag Several y
Culpepper (45) 1985 vag 6y
Casco et al. (46) 1992 vag 5y
Issacs et al. (47) 1996 vag 8y
Adeyemo et al. (48) 1999 LAVH 2.5 y
Brown et al. (49) 2002 C-hyst 12 y
432 Fylstra Ectopic pregnancy after hysterectomy Vol. 94, No. 2, July 2010
TABLE 1
Continued.
Late presentations Year published Type of hysterectomy Time to diagnosis
Pasic et al. (50) 2004 LSH 4 mo
Nnochiri and Warwick (51) 2007 vag 1y
Tagore et al. (52) 2007 abd 9y
Babikian S et al. (53) 2008 abd SC 3y
Rosa et al. (54) 2009 vag 5y
Fylstra (55) 2009 C-hyst 6y
Note: vag vaginal hysterectomy; abd abdominal hysterectomy; abd SC abdominal supracervical hysterectomy;
LAVH laparoscopic-assisted vaginal hysterectomy; LSH laparoscopic supracervical hysterectomy; C-hyst cesar-
ean hysterectomy.
a
Diagnosed at 23 weeks and delivered electively a healthy infant at 36 weeks.
b
Supracervical hysterectomy later followed by trachelectomy.
Fylstra. Ectopic pregnancy after hysterectomy. Fertil Steril 2010.
Ectopic pregnancy after supracervical hysterectomy has Ectopic pregnancy as the etiology of a womans abdominal
been reported (50, 53, 55), raising the concern that sperm pain who has had a hysterectomy is seldom considered, and is
can access the peritoneal cavity through a patent cervical ca- frequently made in the operating room or on final pathologic
nal. Pathologic identification of such a communication examination of a removed surgical specimen. This must occur
through a residual cervix has been documented (53). Cautery because sperm have gained access into the peritoneal cavity,
of the cervical canal and cervical stump at the time of laparo- and ovulated ova, through a communication between the va-
scopic supracervical hysterectomy has also failed to prevent gina and the peritoneal cavity. Two-thirds of all hysterectomies
a patent cervical canal and an ectopic pregnancy after hyster- performed in the United States are abdominal hystectomies,
ectomy (50). with only one-third performed vaginally, with or without lapa-
roscopic assistance (56, 57). Because 72% of late presenta-
DISCUSSION tion ectopic pregnancies occur after vaginal hysterectomy,
there is a disproportionate number of ectopic pregnancies after
Fifty-five percent of ectopic pregnancies after hysterectomy
vaginal hysterectomy, suggesting a causal relationship.
have been diagnosed and treated in the immediate period after
hysterectomy, suggesting that a pregnancy, or a potential for The usual method of vaginal cuff closure differs between
pregnancy, existed at the time the hysterectomy was per- vaginal hysterectomy and abdominal hysterectomy. The ad-
formed. An immediate prehysterectomy pregnancy test would nexal structures are brought into closer proximity of the vag-
not be expected to be positive under such circumstances, and an inal cuff with vaginal hysterectomy cuff closure, and can
early ectopic pregnancy diagnosis would be unlikely. even be incorporated into the peritoneal closure, increasing
the change for a prolapsed fallopian tube into the vaginal
Because the symptoms of ectopic pregnancy can be mim-
cuff or the development of a vaginal-to-peritoneal or tubal-
icked by common immediate complications after hysterec-
to-vaginal fistula (47, 49). Late presentation ectopic preg-
tomy, such as protracted abdominal pain, pelvic hematoma
nancies after total abdominal hysterectomy have been
formation, vaginal cuff infection, and vaginal bleeding, ectopic
reported, indicating that vaginal-to-peritoneal fistula can
pregnancy is rarely expected in most cases until additional im-
even develop after this procedure. However, the small num-
aging or repeat operation confirms the diagnosis (22, 26, 27, 29,
ber of such cases would suggest that it is less likely to occur,
30). Therefore, the prevention of early presentation ectopic
presumably because the residual fallopian tubes and ovaries
pregnancy after hysterectomy is the prevention of pregnancy
are more distant from the vaginal cuff during abdominal hys-
before hysterectomy. Hysterectomy, like tubal sterilization,
terectomy cuff closure, and the commonly used technique of
should be avoided in the luteal phase of the menstrual cycle
closure of the pelvic floor parietal peritoneum over the vagi-
in those women not previously sterilized or not using reliable
nal cuff isolates the vagina from the peritoneal cavity (47).
contraception, unless no vaginal intercourse has occurred dur-
These numbers of ectopic pregnancies and the hysterectomy
ing the preoperative period. Women should be preoperatively
method differences are suggestive that the risk would be
counseled as such. Any woman who has undergone hysterec-
greater after vaginal hysterectomy, but this is not based on
tomy and had not previously undergone tubal sterilization or
any proven medical evidence.
had a partner vasectomy, or was not using reliable contempora-
neous contraception, should be considered at risk for this diag- Subtotal hysterectomy has increased in the United States in
nosis, should otherwise unexplained postoperative pain or the past decade, estimated to now make up 7.5% of all hyster-
bleeding occur. ectomies performed (58). Two cases of late presentation
434 Fylstra Ectopic pregnancy after hysterectomy Vol. 94, No. 2, July 2010
42. Heidenreich W, Hartge R, Burhert W. Tubal pregnancy following hyster- 52. Tagore KR, Krishna R, Charyulu PA, Latha PP, Narayana LK. A case of
ectomy. Geburtshilfe Frauenheilkd 1983;43:2457. post-hysterectomy ectopic tubal pregnancy. Indian J Pathol Microbiol
43. Salmi T, Punnonen R, Gronross M. Tubal pregnancy after vaginal hyster- 2007;50:5589.
ectomy. Obstet Gynecol 1984;64:8267. 53. Babikian S, Thoma DC, Berkey BD. Ruptured ectopic pregnancy pres-
44. Beuthe D, Wemken K. Tubal pregnancy after a previous tubal ligation ents 3 years after supracervical hysterectomy. J Ultrasound Med
and hysterectomy. Geburtshilfe Frauenheilkd 1985;45:188. 2008;27:108790.
45. Culpepper JP. Ruptured tubal pregnancy six years after total vaginal hys- 54. Rosa M, Mohammadi A, Monteiro C. Ectopic tubal pregnancy after hys-
terectomy. J Miss State Med Assoc 1985;26:3412. terectomy and tubal ligation. Arch Gynecol Obstet 2009;279:835.
46. Casco M, Anonini E, Battigelli G, Patat D, Scavazza MG. Tubal preg- 55. Fylstra DL. Ovarian ectopic pregnancy six years after supracervical
nancy after vaginal hysterectomy. Minerva Ginecol 1992;44:12931. cesarean hysterectomy: a case report. So, what about the cervix? Fertil
47. Isaacs JD, Casare CD, Cowan BD. Ectopic pregnancy following hyster- Steril 2009. DOI:10.1016/j.fertnstert.2009.03.039.
ectomy: an update for the 1990s. Obstet Gynecol 1996;88:732. 56. Whiteman MK, Hillis SD, Jamieson DJ, Morrow B, Podgoril MN,
48. Adeyemo D, Qureshi M, Butler C. Tubal ectopic pregnancy-cause of Brett KM, et al. Inpatient hysterectomy surveillance in the United States,
acute abdomen following hysterectomy. J Obstet Gynaecol 1999;19:328. 20002004. Am J Obstet Gynecol 2008;198:34.e17.
49. Brown WD, Burrows L, Todd CS. Ectopic pregnancy after cesarean hys- 57. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical
terectomy. Obstet Gynecol 2002;99:9334. approach to hysterectomy for benign gynaecological disease. Cochrane
50. Pasic R, Scobee J, Tolar B. Ectopic pregnancy months after laparoscopic Database Syst Rev 2006;2:CD003677.
supracervical hysterectomy. JAmAssoc GynecolLaparosc2004;11:945. 58. Merrill RM. Hysterectomy surveillance in the United States, 1997
51. Nnochiri A, Warwick AP. Tubal pregnancy four months after cauteriza- through 2005. Medical Science Monitor 2008;14:CR2431.
tion of the vaginal vault; one year following a vaginal hysterectomy. 59. Novendstern J. Prolapsed fallopian tube after abdominal hysterectomy.
J Obstet Gynaecol 2007;27:86372. Am J Obstet Gynecol 1979;135:1120.