Unilateral twin tubal pregnancy successfully treated with methotrexate

Abstract

Spontaneous twin ectopic pregnancy is extremely rare. Among more than 100 reported cases of twin tubal pregnancies, successful treatment with methotrexate has yet to be reported. A 26-year-old nulliparouswomanwas admittedwith vaginal bleeding and abdominal pain. She had previously undergone infertility treatment using ovulation induction with gonadotropins and intrauterine insemination. On admission, the patient's serum level of beta-human chorionic gonadotropin (β-hCG) was 763 IU/mL. Two gestational sacs were observed in the left tube on transvaginal ultrasound. An increase in serum β-hCG level was observed on the third day of hospitalization. A multiple-dose regimen of methotrexate (1 mg/kg of methotrexate on days 1, 3, 5, and 7, and 0.1 mg/kg of folinic acid on days 2, 4, 6, and 8) was begun when the patient's β-hCG serum level reached987 IU/mL.On day1 ofmethotrexate treatment, dilatation and curettage was performed and endometrium without chorionic villi was reported by the pathologist. Serum levels of β-hCG reached 1091 IU/mL on day 2, 1219 IU/mL on day 4, and 750 IU/mL on day 6. A single dose of methotrexate (1 mg/kg) was repeated on the 14th day as the serum level of β-hCG reached 1200 IU/mL. Serum β-hCG levels declined to within the normal range 32 days after initiation of the treatment. The main risk factors in this case are infertility treatment and smoking. Marcovici et al. [1] showed that conventional methotrexate treatment was unsuccessful for spontaneous bilateral tubal ectopic pregnancies, while hemodynamically stable unruptured tubal ectopic pregnancies and heterotopic pregnancies could be successfully treated with systemic methotrexate [2]. The present case reports a unilateral twin tubal ectopic pregnancy treated successfully using systemic multiple doses of methotrexate.