ECTOPIC PREGNANCY

Ectopic pregnancy after hysterectomy: a review and

insight into etiology and prevention
Donald L. Fylstra, M.D.
Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina

Objective: To review all reported cases of ectopic pregnancy after hysterectomy.

Design: Medline literature search 1966 to Jan 2009. Search terms included ectopic pregnancy, post hysterec-
tomy ectopic pregnancy, pregnancy after hysterectomy. The bibliography of all retrieved articles was searched
for additional sources of data.
Setting: Academic medical center.
Patient(s): Women with ectopic pregnancies following hysterectomy.
Intervention(s): Surgical removal.
Main Outcome Measure(s): To review all reported cases of ectopic pregnancy after hysterectomy.
Result(s): Fifty-six cases of ectopic pregnancies after hysterectomy have been reported. Thirty-one such cases
were diagnosed and treated in the immediate period after hysterectomy, early presentation, and were pregnancies
presumed to have been present at the time the hysterectomy was performed. Twenty-five cases of late presenta-
tion ectopic pregnancy after hysterectomy have been reported, certainly developing as a result of a communication
between the vagina and the peritoneal cavity.
Conclusion(s): Every woman with intact ovaries, despite previous hysterectomy, who presents with abdominal
pain, should be screened for pregnancy. Early presentation ectopic pregnancies can be prevented with adequate
contraception before hysterectomy or by avoiding operating in the periovulatory or luteal phase of the menstrual
cycle. Late presentation ectopic pregnancies after hysterectomy are likely dependent on the type of hysterec-
tomy performed and the presence or a residual cervix. (Fertil Steril 2010;94:4315. 2010 by American Society
for Reproductive Medicine.)
Key Words: Ectopic pregnancy, ectopic pregnancy after hysterectomy, early presentation, late presentation

Ectopic pregnancy after hysterectomy is a very uncommon
event. Since first reported in 1895 by Wendler, 55 additional
cases have been reported (155).
MATERIALS AND METHODS
A search was made of the worlds literature, including multi-
ple languages, using Medline/Pubmed through the United
States Library of Medicine, National Institutes of Health,
identifying all reported cases of ectopic pregnancy after hys-
terectomy, and searching the bibliographies of all retrieved
articles for additional sources of data.
RESULTS
A total of 56 ectopic pregnancies after hysterectomy have
been reported (Table 1). Thirty-one of the 56 cases of ectopic
pregnancies after hysterectomy occurred in the immediate
Received February 3, 2009; revised March 2, 2009; accepted March 6,
2009; published online April 25, 2009.
D.L.F. has nothing to disclose.
Reprint requests: Donald L. Fylstra, M.D., Department of Obstetrics and
Gynecology, Medical University of South Carolina, 96 Jonathan Lucas
Street, CSB 634-F, Charleston, SC 29425 (FAX: 843-792-0533;
E-mail: fylstrad@musc.edu).
period after hysterectomy, early presentation, and occurred
after all types of hysterectomy (130). This is presumed to
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
sperm was present within the fallopian when the hysterec-
tomy was performed in a periovulatory period, allowing post-
operative fertilization and tubal implantation.
Ectopic pregnancy has been reported to occur as late as 12
years after hysterectomy, late presentation, and 25 such
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-
neal cavity. Although this has occurred after all types of hys-
terectomy, 72% follow vaginal hysterectomy (3134, 3748,
51, 54). Although the operative narrative for the hysterec-
tomy was seldom available to the physicians treating the ec-
topic pregnancy after hysterectomy, observations thought to
increase the chance for vaginal-to-peritoneal fistula forma-
tion include an open vaginal cuff closure technique, vaginal
cuff infection or hematoma formation after hysterectomy,
vaginal cuff granulation tissue, and a prolapsed fallopian
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
Pasic et al. (50) 2004
Nnochiri and Warwick (51) 2007
Tagore et al. (52) 2007
Babikian S et al. (53) 2008
Rosa et al. (54) 2009
Fylstra (55) 2009
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
been reported (50, 53, 55), raising the concern that sperm
can access the peritoneal cavity through a patent cervical ca-
nal. Pathologic identification of such a communication
through a residual cervix has been documented (53). Cautery
of the cervical canal and cervical stump at the time of laparo-
scopic supracervical hysterectomy has also failed to prevent
a patent cervical canal and an ectopic pregnancy after hyster-
ectomy (50).
DISCUSSION
Fifty-five percent of ectopic pregnancies after hysterectomy
have been diagnosed and treated in the immediate period after
hysterectomy, suggesting that a pregnancy, or a potential for
pregnancy, existed at the time the hysterectomy was per-
formed. An immediate prehysterectomy pregnancy test would
not be expected to be positive under such circumstances, and an
early ectopic pregnancy diagnosis would be unlikely.
Because the symptoms of ectopic pregnancy can be mim-
icked by common immediate complications after hysterec-
tomy, such as protracted abdominal pain, pelvic hematoma
formation, vaginal cuff infection, and vaginal bleeding, ectopic
pregnancy is rarely expected in most cases until additional im-
aging or repeat operation confirms the diagnosis (22, 26, 27, 29,
30). Therefore, the prevention of early presentation ectopic
pregnancy after hysterectomy is the prevention of pregnancy
before hysterectomy. Hysterectomy, like tubal sterilization,
should be avoided in the luteal phase of the menstrual cycle
in those women not previously sterilized or not using reliable
contraception, unless no vaginal intercourse has occurred dur-
ing the preoperative period. Women should be preoperatively
counseled as such. Any woman who has undergone hysterec-
tomy and had not previously undergone tubal sterilization or
had a partner vasectomy, or was not using reliable contempora-
neous contraception, should be considered at risk for this diag-
nosis, should otherwise unexplained postoperative pain or
bleeding occur.
Fertility and Sterility
Type of hysterectomy Time to diagnosis
LSH 4 mo
vag 1y
abd 9y
abd SC 3y
vag 5y
C-hyst 6y
Ectopic pregnancy as the etiology of a womans abdominal
pain who has had a hysterectomy is seldom considered, and is
frequently made in the operating room or on final pathologic
examination of a removed surgical specimen. This must occur
because sperm have gained access into the peritoneal cavity,
and ovulated ova, through a communication between the va-
gina and the peritoneal cavity. Two-thirds of all hysterectomies
performed in the United States are abdominal hystectomies,
with only one-third performed vaginally, with or without lapa-
roscopic assistance (56, 57). Because 72% of late presenta-
tion ectopic pregnancies occur after vaginal hysterectomy,
there is a disproportionate number of ectopic pregnancies after
vaginal hysterectomy, suggesting a causal relationship.
The usual method of vaginal cuff closure differs between
vaginal hysterectomy and abdominal hysterectomy. The ad-
nexal structures are brought into closer proximity of the vag-
inal cuff with vaginal hysterectomy cuff closure, and can
even be incorporated into the peritoneal closure, increasing
the change for a prolapsed fallopian tube into the vaginal
cuff or the development of a vaginal-to-peritoneal or tubal-
to-vaginal fistula (47, 49). Late presentation ectopic preg-
nancies after total abdominal hysterectomy have been
reported, indicating that vaginal-to-peritoneal fistula can
even develop after this procedure. However, the small num-
ber of such cases would suggest that it is less likely to occur,
presumably because the residual fallopian tubes and ovaries
are more distant from the vaginal cuff during abdominal hys-
terectomy cuff closure, and the commonly used technique of
closure of the pelvic floor parietal peritoneum over the vagi-
nal cuff isolates the vagina from the peritoneal cavity (47).
These numbers of ectopic pregnancies and the hysterectomy
method differences are suggestive that the risk would be
greater after vaginal hysterectomy, but this is not based on
any proven medical evidence.
Subtotal hysterectomy has increased in the United States in
the past decade, estimated to now make up 7.5% of all hyster-
ectomies performed (58). Two cases of late presentation
433
ectopic pregnancy have followed supracervical cesarean hys-
terectomy (49, 55). Leaving a remnant of cervix or the epithi-
alization of a much larger vaginal cuff closure area because of
cervical dilation at the time of cesarean hysterectomy may in-
crease fistulous tract formation (49).
With the now more commonly performed laparoscopic
supracervical hysterectomy, this author and other investiga-
tors are concerned about a potential increase in the incidence
of ectopic pregnancy after hysterectomy (50, 53, 55). The
commonly used technique of cauterizing the residual proxi-
mal cervical canal to prevent cyclic vaginal bleeding after
hysterectomy at the time of laparoscopic supracervical
hysterectomy may not be adequate to prevent patency of
the cervical canal.
It may not be possible to prevent all late presentation ec-
topic pregnancies after hysterectomy, but its prevention is the
prevention of vaginal-to-peritoneal cavity communication.
Vaginal cuff closure, regardless of operative technique,
should be sure not to incorporate the fallopian tube into the
vaginal cuff, and postoperative vaginal cuff granulation tis-
sue, a very common finding, must be differentiated from
a portion of prolapsed fallopian tube, with biopsy, if neces-
sary (59). When the cervix is left in situ, techniques should
be used to obliterate or isolate the residual cervical canal,
thus preventing a patent cervical canal allowing sperm access
to the peritoneal cavity.
Ectopic pregnancy after hysterectomy is very rare. An es-
timated 600,000 hysterectomies are performed each year in
the United States, and one-third of all US women will have
had a hysterectomy by age 60 years (57). Only 56 cases of ec-
topic pregnancy after hysterectomy have been reported in the
worlds literature since 1895. This incidence is infinitesimal.
However, this author recommends that any woman, even af-
ter hysterectomy but with ovaries in situ, who presents with
an acute abdomen or abdominalpelvic pain should be
screened for pregnancy. A urine pregnancy test is readily
available and inexpensive, and although ectopic pregnancy
after hysterectomy has been very uncommon until now,
only a high index of suspicion will make the diagnosis.
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