Ectopic Pregnancy and Tubal Rupture After Tubal Reversal
I recently received an email from a patient who had an ectopic pregnancy subsequent to her tubal reversal. Unfortunately, the pregnancy continued to the point of tubal rupture with the loss of the fallopian tube.
Patient’s History
I was hoping you could help me understand why my ectopic pregnancy was not detected early enough to prevent the loss of my right tube. I need to know this for the future as after my surgery I have only my left tube remaining.
I went to my doctor at approximately 3 weeks pregnant and made sure that they understood the importance of checking for ectopic pregnancy. I gave them a copy of your instructions and told them my goal is to prevent losing my tube if it is ectopic, so I told them to please check and make sure it is not ectopic. They did blood work 3 times and did a vaginal ultrasound at approximately 4 weeks and said everything was normal and the sac was in the uterus, not the tube. They did not check anything again until I spotted Tuesday of this week. I went in Wednesday and they did a vaginal ultrasound and said it was ectopic with a heartbeat and I needed surgery and my tube would have to be removed.
My tube was removed because it was starting to rupture. I never expected that to happen because I took the precautions necessary.
Can you please tell me what normal pregnancy hormone levels are for each week of pregnancy versus ectopic hormone levels?
When is an ectopic visible on ultrasound? Could this have been prevented? Was there anything else that could have been done?
Role of Serum HCG in Early Pregnancy Monitoring
HCG levels alone do not differentiate between uterine and ectopic pregnancy. The HCG levels provide the earliest evidence of whether implantation has occurred successfully (but not where it has occurred) and indicate when ultrasound examination should be able to find a gestation sac if the pregnancy is in the uterine cavity. This occurs when serum HCG reaches 1500-2000 mIU/dL. If serum HCG levels are rising too slowly, or if ultrasound does not find a gestation sac in the uterus when HCG is at the level of 1500-2000, then the pregnancy is not a normal one. It could be outside of the uterus (ectopic) or it could be an abnormal pregnancy in the uterus (blighted ovum).
Role of Transvaginal Ultrasound
A careful transvaginal ultrasound exam can detect a normally developing pregnancy in the uterus very early. It is apparent in this case that the initial ultrasound findings were not interpreted correctly. How could this occur?
An intrauterine gestation sac is a dark oval shaped area of fluid surrounded by a bright white ring or halo (the trophoblastic tissue). Probably in this case there was a small amount of fluid in the uterine cavity that was mistakenly thought to be a gestation sac. This has been described as a “pseudo-sac”. A pseudo-sac does not have the distinct white halo or ring of a true gestation sac.
In a normally developing uterine pregnancy, a follow-up ultrasound exam will show the presence of a yolk sac (the small circle within the gestation sac) within a week of the appearance of the gestation sac. If the initial ultrasound exam had been followed-up with another ultrasound scan, it would have shown that this was not a normal uterine pregnancy.
Comment
There is an increased risk of ectopic pregnancy following tubal reversal surgery. Our follow-up pregnancy statistics show that the risk of ectopic pregnancy remains constant with each pregnancy. In other words, it is the same for a first, second, third, or subsequent pregnancy after tubal reversal surgery. It is important, therefore, to monitor any pregnancy after tubal reversal early and closely.
Recommendations for early pregnancy monitoring are given on our website page entitled I’m Pregnant. Although the recomended tests were performed, the most critical one - the ultrasound exam to document the location of the gestation sac - was interpreted erroneously.
An experienced ultrasonographer should be able to differentiate between a true gestation sac and a pseudo-sac by the presence or absence of the bright halo surrounding the fluid filled sac. If there is any doubt, a repeat ultrasound exam looking for the appearance of a yolk sac should be performed.
Although ectopic pregnancy is not preventable, the complication of tubal rupture always should be. In the absence of clear ultrasound evidence of an intrauterine pregnancy, early treatment with Methotrexate is recommended. It is important to monitor serum HCG levels until the HCG level returns to less than 10 mIU/dL. This will prevent a possible ectopic pregnancy from advancing to the complication of tubal rupture.
January 6th, 2008 at 4:38 pm
It is reassuring for patients who come to Dr. Berger for tubal reversal surgery to know that he puts the patients safety first. Early pregnancy monitoring is very important since there is a risk for ectopic pregnancy after surgery. We like to be informed of each and every pregnancy following surgery. We also like to be informed of the HCG levels until it is been identified where the pregnancy is. We wish that every pregnancy could be a normal one for all pateints but we have seen patients go on to have a healthy uterine pregnancy following an ectopic. There is hope and early pregnancy monitoring is recommended to help women receive treatment as early as possible. Staff members are available 24/7 not only to answer questions about tubal reversal but also to answer questions about early pregnancy monitoring. This is just one way that Dr. Berger goes above and beyond to help his patients.
January 6th, 2008 at 11:31 pm
Patient education is something that Dr. Berger and our entire staff work hard to promote. Nothing is more frustrating or heartbreaking than when we hear that a patient has experienced a tubal pregnancy that has ruptured or required surgery. We hope that the information posted here and on our website - as well as the information given at the time of surgery - will help to reduce or eliminate this situation.
January 7th, 2008 at 11:30 am
This story re-emphasizes the importance of following Dr. Berger’s recommended pregnancy protocol after tubal reversal surgery. It is always so upsetting to hear that a patient has lost both a pregnancy and tube and that the loss of the tube could have been prevented. We always encourage patients to take a copy of the pregnancy protocol with them to their appointments and to make sure that they have an OB-Gyn who will comply with Dr. Berger’s recommendations.
January 7th, 2008 at 2:28 pm
I’d have to agree with both Julia and Rhonda. Nothing is more frustrating or heartbreaking to learn that a patient has experienced a tubal pregnancy. I hope that any patient that has experienced this type of situation, reads this thread and is encouraged by the fact that she can still conceive with one tube!
January 8th, 2008 at 9:44 am
Many of the patients I schedule for reversal surgery have already had an ectopic pregnancy prior to having any surgery on their fallopian tubes! I have talked with a few women that have had all of their children with only one fallopian tube. A lot of people think a women needs both fallopian tubes in order to conceive, but they only need one. It is also encouraging to see most of our patients that have had an ectopic pregnancy go on to have a normal pregnancy and often more than one normal pregnancy.
January 9th, 2008 at 8:23 am
I think this also brings up a good point about patient doctor relationships. It is important for the patient to be well informed and to do so they must ask questions if something is not quite clear. This also takes a doctor who is willing to address any concerns of the patient. That is why I think Chapel Hill Tubal Reversal Center is unique in that it is made up of an entire staff dedicated to patient care and follow-up.
January 10th, 2008 at 12:34 am
Yes, I must agree with all that has been stated here. It is very rare to find one surgeon this committed to his patients and their outcome. The relationship Dr. Berger shares with each and ever patient is sincere and true. He will strive for the best outcome, and he requires that of his staff. No one will give better insihgt about this procedure and how the procedure works. Know that all concerns in relation to the tubal reversal are his top priority. His study and information provided on the website is very helpful, and they are reflections of how much he cares about the outcome of every procedure he does.
April 5th, 2008 at 1:29 pm
[...] most significant risk associated with tubal ligation reversal is the long term risk of having an ectopic pregnancy. This risk is increased from approximately 2% of pregnancies in the general population to [...]
September 18th, 2008 at 5:55 pm
I had a ruptured tubal pregnancy last thanksgiving. I was 3 months along. i had complications from the very beginning. I asked the doctors over and over if there was any chance that it could have been atubal pregnancy. they checked everything and told me everything was fine. Then the day after thanksgiving I got so sick I had to call my mother to come take me to the hospital. we went to the emergency room. They told me that I was misscarring the baby. they gave me a shot and sent me home. My mother was concerned so she took me to her house. There I kept passing out and vomiting. So she called the hospital THey told her that that was from the shot that they gave me. 9 hours later I couldn’t take the pain any more. My mom decided to take me to another hospital. When we arrived they knew exactly what was wrong. They did a vaginal ultrasound and sure enough it was a ruptured tubal pregnancy. I lost 1800cc of blood and they had to remove my left tube. They said that if I wouldn’t have come in I would have died during the night. I think God everyday and pray that I will someday have a baby.
September 18th, 2008 at 6:06 pm
Brittney -
It is disturbing that ruptured tubal pregnancy was allowed to occur, since it is preventable by following the protocol described in this blog article. Serum HCG assays and ultrasound are available in any community and should be used appropriately by doctors caring for women early in pregnancy.