Page 4 - Jcog-July 2016
P. 4
rnal of Cases in
Ob s te tri cs & G yn e co l o g y
pingogram at 8 weeks post surgery to assess left tubal pa- techniques, after tubal surgeries and ovarian hyperstimu-
tency. Histology confirmed a right tubal ectopic pregnancy. lation cycles. The exact etiology of spontaneous bilateral
She was admitted 3 weeks later in haemorrhagic shock tubal pregnancy, as in our case, remains an enigma. Ta-
with severe acute lower abdominal and significant shoul- bachnikoff et al. [8] suggested three possible mechanisms
der tip pain. The patient did not have sexual intercourse for spontaneous bilateral tubal pregnancies. Firstly, si-
before re-presentation. Her pulse rate was 120 beats/min multaneous ovulations from both ovaries resulting in two
with a blood pressure of 50/30mmHg; there was general- synchronous tubal pregnancies, but due to unequal growth
ized abdominal distension, marked guarding and rebound the larger ectopic tend to present first. The second expla-
tenderness. The urinary pregnancy test was still positive nation is after superfetation, but this is extremely rare in
and urgent haemoglobin check was 8.0 g/dL. Transvag- humans and lastly transperitoneal trophoblastic migration
inal pelvic examination suggested ruptured left ectopic from one tubal pregnancy with implantation in the con-
pregnancy with significant intraabdominal fluid collection. tralateral tube or third cause as sequential impregnation.
Findings at emergency exploratory laparotomy includ- In our case with no obvious evidence of corpus lutea in
ed 3000 ml of haemoperitoneum and a ruptured left tub- both ovaries, simultaneous ovulation is the least likely
al ectopic pregnancy. Left salpingectomy was carried out cause of the spontaneous bilateral tubal ectopic pregnancy.
and she was adequately resuscitated with 4 units of blood Diagnosis of bilateral tubal ectopic pregnancy by ultra-
and 2 units of fresh frozen plasma transfusion. Preopera- sonography is a challenge and had its limitations in this
tive serum beta human chorionic gonadotrophin sample case; most diagnosis are made at the time of surgery and
level was 23,651 IU/L. The patient made an uneventful this is supported by medical literature [9,10]. At initial
recovery and post-transfusion haemoglobin was 11.3 g/dL. presentation, medical therapy with methotrexate is a suit-
Two weeks after surgery the serum beta human chorion- able treatment option as she was hemodynamically stable,
ic gonadotrophin level was <5 IU/L confirming complete had minimal symptoms and serum beta human chorionic
removal of ectopic pregnancy. She was counselled on the gonadotrophin level was less than 3,000 IU/L. Outpatient
need for assisted reproductive techniques for future concep- treatment with methotrexate therapy is as effective as sur-
tions. Histology confirmed a left tubal ectopic pregnancy. gery with potential for considerable savings in direct and
indirect treatment costs when compared with laparoscopy.
Discussion Laparoscopic salpingectomy and exploratory laparatomy
with salpingectomy carried out in our patient at the time
Spontaneous bilateral tubal ectopic pregnancy is a rare of both presentations are recognized surgical interventions.
This case emphasises the importance of careful examination
gynaecological emergency. In the United Kingdom ap- of contralateral adnexa during surgery for ectopic pregnan-
proximately 11 in 1000 pregnancies are ectopic. Ectopic cy to assess the state of the contralateral tube, decide on the
pregnancy is still the leading cause of pregnancy-related type of tubal surgery and to also exclude the likelihood of
death in the first trimester. The frequency of bilateral tubal bilateral tubal ectopic pregnancy. Appropriate follow-up in
pregnancy is estimated at 1 in 200,000 intrauterine preg- patients with suspicious contralateral adnexa will aid earlier
nancies [1, 2] and 1 in 725 to 1 in 1580 ectopic pregnancies diagnosis and limit mortality and morbidity associated with
[3, 4]. There has been a gradual increase in incidence of bilateral tubal ectopic pregnancy and it should be suspected
both ectopic and bilateral tubal ectopic pregnancies in the in symptomatic patients representing after recent treatment
last 20 years due to increase in use of assisted reproductive for ectopic pregnancy. For now, it is accepted practice to
techniques, sexually transmitted diseases and greater use of apply the same principles of management to both singleton
intrauterine contraceptive devices [5, 6, 7]. Bilateral tubal and bilateral ectopic pregnancies; however, with the recent
ectopic pregnancy impacts negatively on future fertility as surge in incidences, uncertainty in the pattern of serum beta
a proportion of patients can end up with bilateral salpingec- human chorionic gonadotrophin changes and multiplier ef-
tomy as in our case, preventing further natural conception. fect of associated morbidity and mortality of bilateral ec-
The reported case occurred after a spontaneous menstru- topics, it is reasonable to have a different agreed guideline
al cycle, which is not common as most cases of bilateral for the management of bilateral tubal ectopic pregnancy.
tubal ectopic pregnancy arise from assisted reproductive
78 July 2016
www.jcasesobstetgynecol.com
Ob s te tri cs & G yn e co l o g y
pingogram at 8 weeks post surgery to assess left tubal pa- techniques, after tubal surgeries and ovarian hyperstimu-
tency. Histology confirmed a right tubal ectopic pregnancy. lation cycles. The exact etiology of spontaneous bilateral
She was admitted 3 weeks later in haemorrhagic shock tubal pregnancy, as in our case, remains an enigma. Ta-
with severe acute lower abdominal and significant shoul- bachnikoff et al. [8] suggested three possible mechanisms
der tip pain. The patient did not have sexual intercourse for spontaneous bilateral tubal pregnancies. Firstly, si-
before re-presentation. Her pulse rate was 120 beats/min multaneous ovulations from both ovaries resulting in two
with a blood pressure of 50/30mmHg; there was general- synchronous tubal pregnancies, but due to unequal growth
ized abdominal distension, marked guarding and rebound the larger ectopic tend to present first. The second expla-
tenderness. The urinary pregnancy test was still positive nation is after superfetation, but this is extremely rare in
and urgent haemoglobin check was 8.0 g/dL. Transvag- humans and lastly transperitoneal trophoblastic migration
inal pelvic examination suggested ruptured left ectopic from one tubal pregnancy with implantation in the con-
pregnancy with significant intraabdominal fluid collection. tralateral tube or third cause as sequential impregnation.
Findings at emergency exploratory laparotomy includ- In our case with no obvious evidence of corpus lutea in
ed 3000 ml of haemoperitoneum and a ruptured left tub- both ovaries, simultaneous ovulation is the least likely
al ectopic pregnancy. Left salpingectomy was carried out cause of the spontaneous bilateral tubal ectopic pregnancy.
and she was adequately resuscitated with 4 units of blood Diagnosis of bilateral tubal ectopic pregnancy by ultra-
and 2 units of fresh frozen plasma transfusion. Preopera- sonography is a challenge and had its limitations in this
tive serum beta human chorionic gonadotrophin sample case; most diagnosis are made at the time of surgery and
level was 23,651 IU/L. The patient made an uneventful this is supported by medical literature [9,10]. At initial
recovery and post-transfusion haemoglobin was 11.3 g/dL. presentation, medical therapy with methotrexate is a suit-
Two weeks after surgery the serum beta human chorion- able treatment option as she was hemodynamically stable,
ic gonadotrophin level was <5 IU/L confirming complete had minimal symptoms and serum beta human chorionic
removal of ectopic pregnancy. She was counselled on the gonadotrophin level was less than 3,000 IU/L. Outpatient
need for assisted reproductive techniques for future concep- treatment with methotrexate therapy is as effective as sur-
tions. Histology confirmed a left tubal ectopic pregnancy. gery with potential for considerable savings in direct and
indirect treatment costs when compared with laparoscopy.
Discussion Laparoscopic salpingectomy and exploratory laparatomy
with salpingectomy carried out in our patient at the time
Spontaneous bilateral tubal ectopic pregnancy is a rare of both presentations are recognized surgical interventions.
This case emphasises the importance of careful examination
gynaecological emergency. In the United Kingdom ap- of contralateral adnexa during surgery for ectopic pregnan-
proximately 11 in 1000 pregnancies are ectopic. Ectopic cy to assess the state of the contralateral tube, decide on the
pregnancy is still the leading cause of pregnancy-related type of tubal surgery and to also exclude the likelihood of
death in the first trimester. The frequency of bilateral tubal bilateral tubal ectopic pregnancy. Appropriate follow-up in
pregnancy is estimated at 1 in 200,000 intrauterine preg- patients with suspicious contralateral adnexa will aid earlier
nancies [1, 2] and 1 in 725 to 1 in 1580 ectopic pregnancies diagnosis and limit mortality and morbidity associated with
[3, 4]. There has been a gradual increase in incidence of bilateral tubal ectopic pregnancy and it should be suspected
both ectopic and bilateral tubal ectopic pregnancies in the in symptomatic patients representing after recent treatment
last 20 years due to increase in use of assisted reproductive for ectopic pregnancy. For now, it is accepted practice to
techniques, sexually transmitted diseases and greater use of apply the same principles of management to both singleton
intrauterine contraceptive devices [5, 6, 7]. Bilateral tubal and bilateral ectopic pregnancies; however, with the recent
ectopic pregnancy impacts negatively on future fertility as surge in incidences, uncertainty in the pattern of serum beta
a proportion of patients can end up with bilateral salpingec- human chorionic gonadotrophin changes and multiplier ef-
tomy as in our case, preventing further natural conception. fect of associated morbidity and mortality of bilateral ec-
The reported case occurred after a spontaneous menstru- topics, it is reasonable to have a different agreed guideline
al cycle, which is not common as most cases of bilateral for the management of bilateral tubal ectopic pregnancy.
tubal ectopic pregnancy arise from assisted reproductive
78 July 2016
www.jcasesobstetgynecol.com
