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?

The intrauterine gestation sac has a white ring or halo around a dark center as seen with ultrasound examination..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.

Gestation sac and yolk sac seen in early pregnancy by ultrasound examination.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.

39 thoughts on “Ectopic Pregnancy and Tubal Rupture After Tubal Reversal”

  1. Netria says:

    I am 37 years old. I had an ectopic pregnancy in August 2008. I still have the tube and was wondering if it could be repaired to increase my chances of conceiving.

    1. Dr. Berger says:

      Netria – I would need to review your records regarding any tubal surgery you have had in order to respond. You can send them to me at the address below:

      Gary S. Berger, M.D.
      Medical Director
      Chapel Hill Tubal Reversal Center
      109 Conner Drive
      Suite 2200
      Chapel Hill, NC 27514
      (919) 967-8637 fax

  2. Janelle Burgess says:

    I followed your rules perfectly but it doesn’t matter because all of the Physicians I saw had the wrong answers to everything.

    My first HCG count was 750. Two days later it was 1500. I started spotting the next day. Was in Vegas and went to the ER. The doctor there sent me for an abdominal ultrasound which showed no baby. Then the vaginal ultrasound showed no baby but my HCG count was 2300. Dr said that the problem is that people go off of the date of a girls last period which I had tracked along with ovulation. She said I may not be the six weeks that the chart said and may only be 4 weeks. She said at 4 wks, the ultrasound machines would not even show a sac. She said the spotting was because of sex which we said we hadn’t had.

    Then got home to Oklahoma City and went to the ER because I was in so much pain that I couldn’t do anything but scream and cry. 7 doctors were by my side because they couldn’t keep my blood pressure stable it was 70/40 and I had 3 IVs running. They told me flat out that they thought I was going to die. Since there was only one OBGYN Surgeon on call, we had to wait til she got there. I cried and told the doctors that I didn’t want to die. They said that they understand and would want to go to a different hospital also but they were afraid that I would die on route if I didn’t have the ER care that I needed. They did an abdominal ultrasound and vaginal ultrasound and neither showed a baby. I did have an HCG of 3200. I told them that I must have an ectopic pregnancy. I asked for the drug that aborts the baby and they laughed and said that is not possible with tubal pregnancies. They said, once the baby attaches to the tube that the tube must be removed. I’m certain they are wrong. They finally decided to believe because of my blood pressure and they were giving me enough morphine to take down an elephant and I was still screaming and I mean SCREAMING.

    Well, the OBGYN showed up 6 hours later. She tried to get me to sign a consent for a hysterectomy which I refused. Then she tried to get me to sign a consent to remove one ovary and the tube if needed. I refused on the ovary. I was rushed into surgery and the surgeon removed my right fallopian tube. I was given a c-section type surgery and am still in recovery. (btw she butchered my beautiful scar line that Dr. Berger did) It’s been 6 wks. So how can this be prevented again? It can’t.

    I couldn’t find an OBGYN that would agree to see patients before 10 weeks. They said it is because of the high risk of miscarriages. Instead of waiting, I decided to go to a family urgent care clinic for my counts.

    The only thing I can say is be prepared for the worst and hope for the best. I can tell you that I am now having some type of panic problems. I keep reliving the pain and horrible experience over and over again. I have a hard time trying to forget what happened. The pain of an ectopic pregnancy is indescribable. I’m not trying to scare you. I only want you to find a way to prepare yourself.

    If the doctor does not see the baby, then maybe you may consider aborting. However, if the doctor says that you may only be 4 wks when your chart says 6 wks, and they can’t see the baby, you may need to get another ultrasound quick.

    Just one more thing. Yes, I know I can probably get pregnant on the left side but now my chances are only every other month which is now going to take twice as long. Plus, I’m so scared about having the same thing happen again but I really want a baby.

    My understanding is that my baby got caught in the scar tissue of the right fallopian tube. Is there not a way to prevent scar tissue on the tube? Or better yet, is there a test to see if I have scar tissue covering my left tube?

    1. Dr. Berger says:

      Janelle – I am distressed to learn about what happened. I cannot understand why some doctors do not follow our recommendations for early pregnancy monitoring since they can prevent the complication of a possible ruptured tubal pregnancy. You could have an HSG to assess your left tube. If you do have this done in the future, please instruct the radiologist to send your HSG images to us to review. An HSG would have to be ordered by your local physician.

  3. Jenny says:

    Is there a time frame to wait after having a tubal reversal to become pregnant to reduce the chances of an ectopic pregnancy?

    1. Dr. Berger says:

      Jenny – There is no arbitrary period that you need to wait after tubal reversal to reduce the chances of an ectopic pregnancy.

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