G.O. Obajimi1, F.O. Balogun2, U. Nwose3 and O.M. Obajimi4
- Department of Obstetrics and Gynaecology, University College Hospital, Ibadan.
- Department of Obstetrics and Gynaecology, Reddington Multi-Specialist Hospital, Lagos.
- Department of Anaesthesia, Reddington Multi-Specialist Hospital, Lagos.
- Department of Family Medicine, University College Hospital, Ibadan.
Pregnancy is unlikely to occur in women who have undergone sterilization. However when it occurs, there is a substantial risk that it will be an ectopic pregnancy. We report a case of right unruptured ampullary ectopic gestation following tubal sterilization with spring clips 6 years prior to presentation. The likely aetiology may be spontaneous reanastomosis.
Keywords: Ectopic, Bilateral Tubal ligation, Spring Clips.
Dr. G.O. Obajimi
Dept. of Obstetrics & Gynaecology,
University College Hospital,
Ibadan, Oyo state.
Tubal sterilization is highly effective but can fail. Available evidence suggests that sterilization fails in 0.13-1.3% of sterilization procedures and of these, 15-33% will be ectopic pregnancies.1
In August, 2011, a 35 year old woman, gravida 5, para 3+1 (4 alive) presented at the gynaecology clinic with a complaint of lower abdominal pain of 1 week duration and bleeding per vaginaam of 3 days duration. The abdominal pain was of sudden onset, localized to the right lower quadrant, intermittent and of dull intensity. The bleeding was irregular, moderate with passage of minimal blood clots. She was unsure of her last menstrual period and denied missing any period.
She had 3 previous caesarean sections in 2000, 2002 and 2005 respectively. A bilateral tubal ligation was done in 2005 using spring clips at caesarean section. There was no history of intercurrent medical illness. Examination revealed a young lady, in stable clinical condition. She was neither pale nor icteric. Her pulse rate was 84 beats per min and blood pressure was 110/80 mmhg. Abdominal examination revealed right iliac fossa tenderness with significant rebound tenderness. There was an old pfannesteil scar from previous surgeries.
A vaginal examination revealed a posterior, soft cervix with a closed external os. There was marked cervical excitation tenderness on the right. The uterus was marginally bulky measuring about 12 week’s size. The pouch of douglas was flat and tender.
A blood pregnancy test done was positive and a pelvic scan revealed an anteverted bulky uterus measuring AP 47mm and LS 116mm. The endometrial stripe was thickened measuring 8.9mm with no defined intrauterine gestational sac. There was a complex echogenic mass seen in the Pouch of Douglas. The left ovary had a solitary, simple cyst measuring 68 x 52mm. Her packed cell volume was 34%, Retroviral screening for HIV 1 & 2 was non-reactive and urinalysis was essentially normal.
A diagnosis of right unruptured ectopic gestation was made and she was counseled for exploratory laparotomy. Consent was obtained for right total salpingectomy, repeat left tubal ligation and ovarian cystectomy.
She had exploratory laparotomy and intra-operative findings were: right unruptured ampullary ectopic gestation, normal looking right ovary, left simple ovarian cyst measuring about 70 x 60 mm, bilateral spring clips at the isthmus of both tubes. A right total salphingectomy was done; repeat left tubal ligation using the Pomeroy technique was carried out alongside left ovarian cystectomy.
Her post operative condition was satisfactory and she was discharged on the 3rd post operative day on antibiotics and analgesics. Her packed cell volume on discharge was 33%. She was seen for follow up 1 week after the surgery. A review of the procedure was done with the couple and she was discharged from follow up.