# ectopic pregnancy with hysterectomy?



## Lifeguards For Life (Aug 4, 2009)

you have a 28 y/o female patient with a cc of abdominopelvic pain. Pain came on suddenly and is stabbing in origin. Patient claims to have missed her period about 7 weeks ago and has vaginal bleeding not associated with menstruation. Patient also reports N+V and fatigue. Pt also has reffered shoulder pain. Past Medical history includes a hysterectomy a 7 years ago. Pt. denies possibility of preganacy due to the hysterectomy.
Even though the uterus has been removed can she still have an ectopic pregnancy?


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## Foxbat (Aug 5, 2009)

http://yourtotalhealth.ivillage.com/pregnancy-an-ectopic-pregnancy-possible-after-hysterectomy.html

_An ectopic pregnancy may occur after hysterectomy, but it is incredibly uncommon. There are only 36 reports in the world's literature; in the United States alone, more than 400,000 hysterectomies are performed annually. Most of the reported cases (24 of the 36 described cases) happened immediately after the hysterectomy, apparently because an already fertilized egg was in transit down the fallopian tubes at the time of the surgery. Because pregnancy tests do not register until the fertilized egg has implanted (6-10 days after conception), even a pregnancy test done immediately before a hysterectomy will not pick up such cases._

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1947893
_A patient with ectopic pregnancy occurring a considerable interval after vaginal hysterectomy is reported. She presented with recurrent lower abdominal pain and the correct diagnosis was only established at laparotomy. Although 14 cases of this late complication of hysterectomy have been reported in the literature no fatalities have been recorded._

http://www.journals.elsevierhealth.com/periodicals/aagl/article/PIIS1074380405600217/abstract
_Although it is an easy diagnosis to eliminate, pregnancy is rarely considered in a woman with acute abdominopelvic pain and history of hysterectomy. A 37-year-old woman was seen because of acute onset of pelvic pain. Her history was significant for laparoscopic supracervical hysterectomy performed 4 months previously. A urine pregnancy test was positive. At diagnostic laparoscopy, an area in the right tube was consistent with ectopic pregnancy. Bilateral salpingectomy was performed, and pathology confirmed an ectopic pregnancy in the right tube. A diagnosis of ectopic pregnancy should be entertained in any woman with pain and intact ovaries._


I wonder how it can happen considerable time after surgery. From what I read, even after partial hysterectomy there should be no passage between vagina and ovaries.


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## Lifeguards For Life (Aug 5, 2009)

thanks fox, i figured it could happen just looking for some additional info


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## usafmedic45 (Aug 5, 2009)

> I wonder how it can happen considerable time after surgery. From what I read, even after partial hysterectomy there should be no passage between vagina and ovaries.



It's been documented a few times in the literature where an opening exists at the distal end of the vagina (where the uterus would normally be attached) through surgical staple or suture failure and the patient has developed peritonitis as a result.  This could possibly explain how sperm could get into the abdominal cavity and then possibly find their way into the remaining fallopian tubes.   That would be my theory behind the slim chance of this occuring.


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## Hal9000 (Aug 5, 2009)

Crazy!  It's weird some of the odd things you encounter. I had a patient with abdominal epilepsy.  Neither my medic nor I had heard of it.  Turns out that there were only 36 documented cases of it.


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## Medic744 (Aug 5, 2009)

Lifeguards For Life said:


> you have a 28 y/o female patient with a cc of abdominopelvic pain. Pain came on suddenly and is stabbing in origin. Patient claims to have missed her period about 7 weeks ago and has vaginal bleeding not associated with menstruation. Patient also reports N+V and fatigue. Pt also has reffered shoulder pain. Past Medical history includes a hysterectomy a 7 years ago. Pt. denies possibility of preganacy due to the hysterectomy.
> Even though the uterus has been removed can she still have an ectopic pregnancy?



I had a patient with similar complaint when I did my ER rotations and she had a ruptured ovary.  It is possible to have a ruptured ovary or ovarian cyst.  Although if she is still having a period I would question if it was a full or partial hysterectomy and why it was done.  A period is a shedding of the lining of the uterus and if you don't have a uterus there is no period to miss.


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## Lifeguards For Life (Aug 5, 2009)

I remember reading somewhere that  5-20% of women who had the subtotal procedure continued to have genital bleeding, although this can be avoided with endocervical electro-coagulation or resection.


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## Medic744 (Aug 5, 2009)

Could be an ectopic, but I wouldn't rule out an internal rupture of some kind including the appendix, which side was she having pain on?  Just on the information you presented I wouldn't rule out ectopic but may lean towards a rupture of another organ in the area.  Ultrasound should be able to confirm.


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## LucidResq (Aug 5, 2009)

Lifeguards For Life said:


> you have a 28 y/o female patient with a cc of abdominopelvic pain. Pain came on suddenly and is stabbing in origin. Patient claims to have missed her period about 7 weeks ago and has vaginal bleeding not associated with menstruation. Patient also reports N+V and fatigue. Pt also has reffered shoulder pain. Past Medical history includes a hysterectomy a 7 years ago. Pt. denies possibility of preganacy due to the hysterectomy.
> Even though the uterus has been removed can she still have an ectopic pregnancy?



Why did a 21 yo have a hysterectomy? May or may not be relevant, but I would like to know why someone so young would have this surgery.


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## Lifeguards For Life (Aug 5, 2009)

many reasons to have a partial or totaly hysterectomy. cancer,fibroid, disfunctional uterine bleeding, chronic pelvic pain, uterine prolapse, endometriosis. just to name a few. I don not know if there is any age requirement for the surgery but girls much younger than 21 can have some of the above listed conditions


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## LucidResq (Aug 5, 2009)

I work in an OB-GYN clinic... I'm quite aware of these conditions and the fact that a female of any age can have a hysterectomy, however a doctor is going to be extremely reluctant to resort to this option in someone so young, so I'm assuming that some extremely significant and potentially relevant medical history is present. 

What's the G & P of this pt?


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## Lifeguards For Life (Aug 5, 2009)

LucidResq said:


> I work in an OB-GYN clinic... I'm quite aware of these conditions and the fact that a female of any age can have a hysterectomy, however a doctor is going to be extremely reluctant to resort to this option in someone so young, so I'm assuming that some extremely significant and potentially relevant medical history is present.
> 
> What's the G & P of this pt?



sorry for any confusion. this was in regards to a patient with a CC of nausea dizzyness and extreme migraines, who had a hysterectomy, and the RN was joking with her about sending her blood to the lab to test for a pregnancy. some time after the fact the question of could someone with a hysterectomy have an ectopic pregnancy came to me. This was just a scenario and was posted in the scenario section as such. if there is a next time i will specify if a hypothetical question.


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## FFMedic75 (Aug 16, 2009)

*similar circumstances*

I once responded to a mid 30's yr old female with chief complaint of Abd pain X 2 days.  Pt had a Hx of P0 G1 and recently found out she was pregnant.  We later learned the pt had used fertility drugs to get pregnant.  The pregnancy was early on however do to all the issues conceiving an ultrasound had already been performed.  The patient presented cool, clammy, diaphoretic, hypotensive, and tachycardic.  The patient's family stated the doctor said the baby was in the uterus on the ultrasound.  After the patient was transported emergently to the nearest ED we found out there was a twin that was missed on the first ultrasound that grew in the tube and ruptured.


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