An unusual case of bilateral tubalectopic pregnancy

We discuss here an unusual case of spontaneous bilateral tubal ectopic pregnancy. There was a ruptured tubal ectopic pregnancy on the right side and a chronic ruptured tubal ectopic pregnancy on the left side, with an organised haematoma at the site of rupture.

CASE REPORT

A 25 year old patient, Gravida 2, Para 1 with one living issue, with 2 months amenorrhoea, presented with bleeding per vaginum since 5 days and pain in the lower abdomen since 10 days. She was married since last 3 years and had one male child of 2 years. Her past menstrual cycles were regular. There was no past history of any drug taken or previous surgery.

On general examination, she had tachycardia (pulse of 110 per minute), hypotension (blood pressure of 90 mmHg systolic) and pallor.

Abdominopelvic examination revealed tenderness in the lower abdomen, tender transverse cervical movements, palpable tender right adnexal mass and fullness in all the fornices. There was haemoperitoneum on colpopuncture.

Emergency exploratory laparotomy was performed. Haemoperitoneum of approximately 400 ml was present. On the right side, there was a ruptured fimbrial ectopic pregnancy, and the patient was bleeding from this site. The left tube showed an organised haematoma of 2 x 3 cm size, protruding from the antimesenteric border in the ampullary region that was not bleeding, suggestive of an old ruptured tubal ectopic pregnancy. In view of these findings, a right salpingectomy with left salpingostomy was done. The haematoma on the left side was excised along with a thin rim of the tube and haemostasis was achieved by under-running the salpingostomy incision. The patient recovered uneventfully and was discharged on the 7th post-operative day.

Histopathology of the specimens confirmed the diagnosis of right ruptured fimbrial ectopic and left chronic ruptured tubal ectopic pregnancy.

DISCUSSION

The incidence of bilateral tubal ectopic pregnancy is reported to range from 1 in 725 to 1 in 1580 extrauterine pregnancies.[1] More than 200 cases of bilateral tubal ectopic pregnancy have been reported in the literature to date, most of which have occurred after some form of assisted reproductive treatment.[2] The case reported here is interesting, as it has occurred spontaneously.

Spontaneous bilateral ectopic pregnancy is a rare event and is difficult to diagnose preoperatively, demonstrating the limitation of both ultrasonography and laparoscopy in making such a diagnosis.[3,4] In our case also preoperative ultrasound failed to demonstrate bilateral tubal ectopic pregnancy.

Since the advent of assisted reproductive technology, concern regarding ectopic implantation of embryos has increased dramatically. Simultaneous bilateral tubal ectopic pregnancy is the least common type of ectopic implantation of two embryos, but a point to be remembered.[5]

Foster[6] reported a case of bilateral tubal ectopic pregnancy where conservative surgery in the form of a linear salpingostomy was performed, and fifteen months later the patient delivered a live infant.

This case demonstrates the importance of thoroughly examining the entire pelvis at the time of exploratory laparotomy undertaken for a suspected ectopic pregnancy. The necessity of carefully examining both the adnexae, as postulated by Sherman[7] and Suwajanakorn[8], cannot be overemphasized.

REFERENCES

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2..Abramovici D, Morfesis FA, Ally S, Bathija NR. Bilateral ectopic pregnancy. A case report. J Ky Med Assoc 1995; 93 : 295.

3'O.Brien MC, Rutherford T. Misdiagnosis of bilateral ectopic pregnancies : a caveat about operator expertise in the use of transvaginal ultrasound. J Emerg Med 1993; 11 (3) : 275-8.

4..Messore M, Angioli R, Cantuaria G, Penalver M. Spontaneous left tubal and right interstitial pregnancy. A case report. J Reprod Med 1997; 42 (7) : 445-7

5Kahraman S, Alatas C, Tasdemir M, Nuhoglu A, Aksoy S, Biberoglu K. Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection. Hum Reprod 1995; 10 (12) : 3320-1.

6.Foster HM, Lakshin AS, Taylor WF. Bilateral tubal pregnancy with vaginal delivery. Obstet Gynecol 1982; 60 (5) : 664-6.

7.Sherman SJ, Werner M, Husain M. Bilateral ectopic gestations. Int J Gynaecol Obstet 1991; 35 (3) : 255-7.

8.Suwajanakorn S, Virutamasen P, Ahnonkitpanit V, Parksamoot W. Bilateral tubal pregnancy following in vitro fertilization and embryo transfer. J Med Assoc Thai 1996; 79 (1) : 40-3.