Bilateral Ectopic Pregnancy Research Articles

Dilemmas in management of bilateral ectopic pregnancies—report of two cases and a review of current practice

Simultaneous bilateral ectopic pregnancies occurring spontaneously or following assisted conception techniques, although rare, present the clinician with diagnostic uncertainty and management dilemmas which may have an implication on the patient’s future fertility. A review of available literature suggests that there is no universally accepted management strategy towards this condition, and care needs to be tailored to the needs of the patient, patient’s preferences and the clinical picture. We report two such rare cases of simultaneous bilateral ectopic pregnancies with different management and outcomes highlighting the fact that these cases not only pose diagnostic and management challenges but also has complex ethical issues associated with it.

Spontaneous Bilateral Tubal Ectopic Pregnancy

Background: Bilateral tubal pregnancy in absence of preceding induction of ovulation is a rare event, with an estimated incidence of 1/200,000 uterine pregnancies and 1/725–1/1580 ectopic pregnancies. These conditions are usually diagnosed at the time of surgery. This article reports a case of a spontaneous bilateral intact tubal multiple pregnancy associated with an ovarian cyst that was diagnosed intraoperatively and addressed with two different surgical techniques. Case: A 35-year-old woman, gravida 7, para 5+1, presented with a history of 8 weeks' amenorrhoea and intermittent vaginal bleeding; she also had mild lower abdominal pain of 1 week's duration. A urine pregnancy test taken on the day of her admission positive. This patient's abdomen was tender on palpation with a positive rebound and guarding. On pelvic examination, there was mild spotting and cervical motion tenderness were noted. A pelvic ultrasound reveled an echogenic mass lesion in the right adnexae with an ovarian cyst in the left side. A laparotomy reveled a bilateral ectopic tubal pregnancy with an ovarian cyst. Salpingectomy was performed in the unruptured right tube, and the unruptured ectopic pregnancy in the left tube was removed through salpingostomy. Results: This patient's postoperative follow-up was unevenful and histologic testing of the specimens that had been excised confirmed the diagnosis. Conclusions: Despite being rare, bilateral spontaneous ectopic pregnancy should be suspected regardless of the presence or absence of risk factors this condition, such as the use of assisted reproduction techniques. Because of its rarity, diagnosis of spontaneous ectopic pregnancy is difficult, but once the condition is diagnosed, it can be treated surgically. (J GYNECOL SURG 29:321)

Spontaneous bilateral tubal pregnancy following hysterosalpingography

We present a case of spontaneous bilateral tubal pregnancy in a woman following hysterosalpingography (HSG), which to our knowledge has not been reported previously. A 29-year-old woman, gravid 0, was referred to our clinic for treatment of left tubal pregnancy after 8 weeks of amenorrhea. Seven weeks prior to that, the patient underwent HSG for evaluation of tubal patency and left tubal obstruction was diagnosed. Initially, except for minimal tenderness over the left adnexa, physical examination was unremarkable. The initial result of a quantitative test for b-human chorionic gonadotropin (bhCG) was 1,584 mIU/ml, but 48 h later this value was 1,886 mIU/ml. The patient’s condition remained stable. Transvaginal ultrasound revealed no evidence of an intrauterine pregnancy, no fluid in the cul-de-sac and an approximately 3 cm-sized ovarian echo at both adnexa. The left tube had a complex structure measuring 2.8 9 1.5 9 1.8 cm. The patient was counseled, and she opted for methotrexate (MTX) therapy, 50 mg/m intramuscularly. Serum b-hCG levels were found to be 1,857 mIU/ml on day 2 after treatment, 1,500 mIU/ml on day 5, and 1,638 mIU/ml on day 7. The patient’s hCG level did not drop, and a second cycle of MTX was injected; however, b-hCG was still 1,405 mIU/ml on day 4 after the second cycle of treatment. We decided that surgical intervention was necessary. Laparoscopy revealed an approximately 3 cm-sized unruptured left ampullary pregnancy, and a left salpingostomy was performed to remove it. Inspection of the right tube revealed an approximately 1 cm-sized bulging area in the ampullary region (Fig. 1). Linear salpingostomy was performed. Pathology confirmed that conceptuses had been removed from both the right and left tubes. Followup b-hCG was 247 mIU/ml on postoperative day 1. Bilateral tubal pregnancy is a rare clinical entity. The reported instance is 1 in 2,00,000 pregnancies [1]. Bilateral tubal pregnancies are more common after assisted reproductive technology, such as ovulation induction [2], in vitro fertilization and embryo transfer (IVF-ET) [3–5], or intracytoplasmic sperm injection (ICSI) [6], than they are after spontaneous conception [1]. The risk factors related to spontaneous ectopic pregnancy are well known, such as pelvic inflammatory disease, endometriosis, previous surgery and its sequelae, and infertility. Spontaneous bilateral tubal pregnancy is also related to the factors previously mentioned, along with double spontaneous ovulation. HSG is a commonly performed diagnostic investigation to assess tubal patency in infertility patients. It has potential therapeutic effects on subfertility [7]. There is evidence for the effectiveness of tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy and live birth versus no intervention; however, there is no significant association between this procedure and miscarriage or ectopic pregnancy [7]. The diagnosis of bilateral ectopic pregnancy can be achieved by finding chorionic villi in surgical specimens obtained from both tubes [1]. There can be great difficulty in diagnosing this condition before surgery, however, in which the level of b-hCG is not particularly useful. Indeed, most often, contralateral ectopic pregnancy is asymptomatic or difficult to differentiate from pelvic pain secondary to medical treatment or to controlled ovarian hyperstimulation [6]. H.-J. Seol S.-Y. Tong (&) Department of Obstetrics and Gynecology, School of Medicine, Kyung Hee University, Seoul, South Korea e-mail: sytong@hanmail.net

Viable intrauterine pregnancy after spontaneous bilateral tubal ectopics in a multiparous woman: a case report

IntroductionBilateral ectopic pregnancies are increasing due to an increase in the incidence of pelvic inflammatory disease and increase in assisted reproductive techniques. Spontaneous conception after bilateral ectopic pregnancies is extremely rare.Case presentationA 33-year-old Indian woman presented with ruptured ectopic pregnancy associated with hemoperitoneum for which she underwent a laparotomy. The diagnosis of bilateral ectopic pregnancies was made during surgery. Salpingectomy was done on one side and the other tube was conserved with salpingostomy. Six months after surgery, she conceived spontaneously and a transvaginal ultrasound examination revealed a 5-weeks live intrauterine pregnancy.ConclusionA meticulous surgical technique conserving one fallopian tube resulted in subsequent viable intrauterine pregnancy. The approach to such a case along with steps to minimize tubal damage is presented.

Embarazo ectópico bilateral

Paciente primigestante en el primer trimestre del embarazo que consulta a urgencias por dolor abdominal y síncope. Fue estudiada en ginecología y por los hallazgos imagenológicos sugirieron embarazo ectópico derecho. Se realizó laparotomía encontrando dilatación tubárica bilateral, motivo por el cual se practicó salpingectomía bilateral. El estudio patológico demostró embarazo ectópico bilateral al encontrar vellosi­ dades coriales en ambas luces tubáricas.

M015 BILATERAL ECTOPIC PREGNANCY AFTER INTRA-UTERINE INSEMINATION (IUI) TREATMENT: A CASE REPORT AND LITERATURE REVIEW

International Journal of Gynecology & ObstetricsVolume 119, Issue S3 p. S536-S536 Poster presentations M015 BILATERAL ECTOPIC PREGNANCY AFTER INTRA-UTERINE INSEMINATION (IUI) TREATMENT: A CASE REPORT AND LITERATURE REVIEW A. Ghosh, A. GhoshSearch for more papers by this authorS. Gandham, S. GandhamSearch for more papers by this authorZ. Ibrahim, Z. IbrahimSearch for more papers by this author A. Ghosh, A. GhoshSearch for more papers by this authorS. Gandham, S. GandhamSearch for more papers by this authorZ. Ibrahim, Z. IbrahimSearch for more papers by this author First published: 22 October 2012 https://doi.org/10.1016/S0020-7292(12)61209-0AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume119, IssueS3Abstracts of XX FIGO World Congress of Gynecology and ObstetricsOctober 2012Pages S536-S536 RelatedInformation

P04.10: Ultrasound diagnosis of bilateral ectopic pregnancy: still a myth?

Introduction: the first case of primary bilateral ectopic pregnancy was published by Bledsoe in 1918. Spontaneous bilateral ectopic pregnancy is difficult to diagnose preoperatively, indicating limitations of ultrasonography. Laparoscopy has always been considered as gold standard in diagnosing it. However, early diagnosis is essential to avoid potentially fatal complications and preserve future fertility. Case: we report a case of 30 year old woman who presented in A&E with abdominal pain and diarrhoea. Her serum beta hCG was > 70,000 and progesterone was 70. She was managed conservatively while awaiting ultrasound scan as it was presumed to be an intrauterine pregnancy as judged from her blood results. Scan confirmed live ectopic pregnancy on left adnexa and large haematosalpinx on right side. Although, scan findings were suggestive but strongly suspected during surgery. Bilateral salpingectomy performed and histology confirmed the presence of two gestational sac and within the gestation sac is what appears to be an anencephalic foetus 15 mm in length. Conclusion: the tube and ovary of both the side should be evaluated for woman who are having scan for suspected ectopic pregnancy. If bilateral ectopic pregnancy is suspected then preoperatively women can be counselled. The role of conservative surgery and medical management is not clear. However, after appropriate counselling conservative surgery can be offered as bilateral salpingectomy has huge impact on future reproductive outcome.

P34.12: The use of laparoscopic ultrasound in an unusual case of bilateral ectopic pregnancies: a case report

The patient was a 33 years old lady with secondary infertility. She was referred to our unit for left tubal ectopic pregnancy at six weeks of gestation. The pregnancy was conceived by ovulation induction and intrauterine insemination. She complained of small amount of vaginal bleeding. There was no abdominal pain. Clinical examination was unremarkable. Transvaginal ultrasound showed thickened endometrium. The ovaries were multicystic and enlarged, which was compatible with the history of ovarian stimulation. There was a gestational sac with fetal pole measuring 2.6 mm at the left adnexa. The diagnosis was left tubal ectopic pregnancy and the patient was counseled for laparoscopic left salpingectomy. During the operation, however, both fallopian tubes were found swollen. There was difficulty in deciding the site of the actual ectopic pregnancy and hence, the side requiring salpingectomy. Laparoscopic ultrasound has been used in our unit for detecting pelvic nodal metastasis in cervical carcinoma. The laparoscopic ultrasound probe is a multi-frequency (5.0-, 6.5-, and 7.5-MHz) probe measuring 10 mm in diameter. (Panther Ultrasound Scanner System, B&K, Denmark). Between 0.5 L and 1 L of normal saline is required to provide an acoustic window for the ultrasonography. In order to proceed with appropriate surgical treatment, we performed laparoscopic ultrasound along the bilateral swollen fallopian tubes. Scanning of the left tube showed the presence of a gestational sac with a fetal pole measuring 3.9 mm with pulsation. Unexpectedly, there was a gestational sac measuring 1.5cm in the right tube. Therefore, laparoscopic left salpingectomy and right salpingotomy were performed. Pathological examination confirmed the left tubal ectopic pregnancy and the presence of products of gestation from the right tube. Our case demonstrated the potential role of laparoscopic ultrasound in delineating the location of the ectopic pregnancy in situations with equivocal clinical findings.

Letters to Editor A of bilateral tubal ectopic pregnancy following day 5 embryo transfer

Letters to Editor A of bilateral tubal ectopic pregnancy following day 5 embryo transfer

Bilateral ectopic tubal pregnancy, following in vitro fertilisation (IVF).

This is a case report of a 33 year-old-woman who underwent in vitro fertilization, because of primary infertility caused by fallopian tube factor. The patient underwent three trials of frozen embryo transfers (ET-CRYO). On the 26th day after the third probe of ET-CRYO she suffered from pelvic pain and vaginal bleeding. Transvaginal ultrasonographic scan revealed bilateral tubal ectopic pregnancy without fluid in the Douglas pouch and no gestational sac in the uterus. Laparoscopic bilateral salpingectomy was performed on the next day after admission. The postoperative course was uneventful.

Embarazo ectópico bilateral con embrión vivo en la trompa izquierda

Bilateral ectopic pregnancy with a live embryo is a rare occurrence. We report a case of bilateral ectopic pregnancy with live embryo in one tube and an interrupted gestation in the other tube, in a patient with no risk factors. When there is a unilateral ectopic pregnancy, even without risk factors, the other adnexal area and abdominal cavity should also be examined.

Bilateral Simultaneous Ectopic Pregnancy

Spontaneous bilateral ectopic pregnancy is the rarest form of ectopic pregnancy. A 31-year-old patient with spontaneous bilateral tubal pregnancy was admitted after light vaginal bleeding, 42 days after her last menstruation. Ultrasonography showed a bilateral tubal ectopic pregnancy. A bilateral laparoscopic salpingectomy was performed without complication and the pathology report confirmed the diagnosis. This is an unusual case of early diagnosis.

Concurrent bilateral ectopic pregnancy after recurrent miscarriages in a fertile woman

Bilateral ectopic pregnancy is the occurrence of bilateral extrauterine pregnancies on the same menstrual cycle. This is a very rare\rquote clinical condition with an estimated incidence of 1:1,580...

Cases of ectopic pregnancies as seen in Lagos State University Teaching Hospital, Ikeja, Nigeria

Objective : To determine the prevalence rate, the major forms of ectopic pregnancy and to correct some of the inadequacies in filling of the laboratory forms. Materials and Methods : Relevant data on 91 ectopic pregnancy specimens received at the Lagos State University Teaching Hospital (LASUTH), Ikeja between May 1 2001 and 30 November 2004 were collected from the laboratory forms and analyzed. Results>/b>: A total of 91 ectopic pregnancy cases were received during the 3 year period. The total gynaecological and pregnancy-related specimens were 613 and 472 respectively. Ectopic pregnancy accounted for 14.4% of all the gynaecological and 19.28% of pregnancy-related specimens received in the laboratory. The ages of the patients presenting with ectopic pregnancies ranged from 17 to 36 years with the age group 25 – 29 years representing the highest percentage of 51.6%. The ages of the patient studied were not recorded in 62.2% of cases. 96.70% of the pregnancy specimens were tubal while ovarian occurred in 3.3% of cases. Each of the fallopian tubes had 50% chance of being involved. The sites of the tubal ectopic pregnancy were not specified in 73.2% of cases. A case of bilateral ectopic pregnancy was received. The tubes were recorded as having ruptured in 37.8% of cases. Results showed that lymphocytes are the commonest inflammatory cells seen in the fibro-muscular wall of the fallopian tubes. Conclusion : The rate of ectopic pregnancy is on the increase in Lagos(1). The high rate of tubal rupture associated with ectopic pregnancy can be reduced through the creation of better awareness of this condition in the society, as this will ensure early presentation and referral of cases to hospital. Doctors should be encouraged to fill the relevant portions of the laboratory forms correctly before sending specimens to the laboratories. Keywords : Ectopic pregnancy, Incidence rate, Histopathological laboratory forms Nigerian Journal of Health and Biomedical Sciences Vol. 5 (2) 2006: 79-82

Bromocriptine-Induced Heterotopic Triplet Pregnancy: Bilateral Tubal and Intrauterine Pregnancy in a Patient with Pituitary Adenoma

A heterotopic pregnancy is the coexistence of one or more ectopic and a single or multiple eutopic pregnancy. Heterotopic pregnancy currently occurs in approximately 1 of 7000 spontaneous pregnancies. However, artificial reproductive techniques increase the incidence to 1%. Coexisting bilateral tubal and an intrauterine pregnancy is a rare condition. We present a case of a combined bilateral ectopic and intrauterine pregnancy in a patient with a pituitary adenoma who was managed with bromocriptine. (J GYNECOL SURG 22:123)

P15.05: Bilateral ectopic pregnancy

Spontaneous bilateral ectopic pregnancy is extremely rare (1 in 125–1580 ectopic pregnancies). An unusual case of ectopic pregnancy in which a patient had spontaneous, bilateral tubal pregnancy is presented. A 27 year old, pram gravida woman with history of recurrent miscarriages, complaining of abdominal pain, nausea and vaginal bleeding at 8th week of amenorrhea referred to our hospital. The patient had no history of pelvic inflammatory disease (PID), no prior use of intrauterine contraceptive device (IUD) and no use of fertility drugs. The HCG level was 19.500 IU/L. Transvaginal ultrasound showed no intrauterine pregnancy and was able to diagnose a right ectopic pregnancy, with accumulation of fluid in cul-de-sac and Morrison's pouch. On general examination, she had tachycardia and hypotension. Abdominopelvic examination revealed tenderness in the lower abdomen, tender transverse cervical movements, palpable tender right adnexal mass and fullness in all the fornices. Emergency exploratory laparotomy was performed. Hemoperitoneum of approximately 500 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 enlarge with an unsuspected isthmic pregnancy in the left. In view of these findings, a right salpingectomy with left salpingostomy was done. The patient recovered uneventfully and was discharged on the 5th post-operative day. Histopathology showed the presence of chorionic villi in each tube. 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. 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 ultrasonography in making such a diagnosis.

Unrecognized spontaneous bilateral ampullary pregnancy treated by laparoscopy

We report on a 35-year-old woman with spontaneous bilateral tubal pregnancy. This is a rare and complex condition with uncertain etiology. Despite preoperative work-up that included clinical examination, serial ultrasound investigation, and serial quantitative beta human chorionic gonadotropin testing, the bilateral disease was not accurately diagnosed until laparoscopy. A bilateral laparoscopic linear salpingostomy was performed along with extraction of the conception products from both tubes. There were no intraoperative or postoperative complications, and the patient was discharged on the 1st postoperative day. Subsequent histopathology confirmed bilateral ectopic pregnancy. To avoid misdiagnosing bilateral ectopic pregnancy, we emphasize the need to combine clinical, sonographic, and laparoscopic investigation when the clinical picture is confusing.

Embarazo ectópico bilateral espontáneo

Spontaneous bilateral ectopic pregnancy is a rare event and is difficult to diagnose preoperatively. We report a case diagnosed by transvaginal ultrasonography in a patient without risk factors. Laparoscopic left salpingectomy and right linear salpingostomy were performed. This case illustrates the importance of carefully examining both adnexa when ultrasound examination or surgery are performed.

Salpingostomía lineal por laparoscopia para el tratamiento de un embarazo ectópico bilateral espontáneo: reporte de caso

El embarazo ectópico bilateral espontáneo es una condición clínica infrecuente que ocurre en 1 de cada 1.580 embarazos ectópicos. En los últimos 25 años se han reportado 72 casos de embarazo ectópico bilateral, 31 de los cuales han sido espontáneos y en ninguno de ellos se ha logrado hacer un correcto diagnóstico preoperatorio. Su tratamiento, al igual que en los ectópicos unilaterales depende de la expectativa reproductiva de la paciente y del estado de las trompas. Existen seis reportes en la literatura de salpingostomía lineal por laparoscopia en pacientes con embarazo ectópico tubárico bilateral. Sólo uno de ellos informa el estado de ambas trompas después de este tipo de intervención. En este trabajo se reporta el primer caso descrito en la literatura colombiana de un embarazo ectópico bilateral espontáneo, en el que se practica manejo conservador por laparoscopia y además, cuatro meses después, se confirma la permeabilidad de ambas trompas por medio de una sonohisterosalpingografía.

Combined intrauterine and bilateral ectopic pregnancies managed laparoscopically

Combined intrauterine and bilateral ectopic pregnancies managed laparoscopically