Spontaneous bilateral tubal ectopic pregnancy

Ectopic pregnancy is still an important cause of maternal mortality. Bilateral tubal ectopic pregnancy is very rare, and is usually the result of an assisted reproduction technique.

CASE HISTORY

A woman aged 26 was admitted after experiencing severe abdominal pain. She had been amenorrhoeic for six weeks and a urine pregnancy test was positive. She and her partner had been trying for conception and this had been achieved spontaneously. There were no risk factors for ectopic pregnancy in her medical history. The pain had been present for five days and had not been associated with any vaginal discharge or bleeding. A sudden increase in pain had prompted her self-referral.

She was mildly tender in the right iliac fossa but on pelvic examination there was no cervical excitation or adnexal tenderness. An early-pregnancy ultrasound scan was requested. After 24 hours on the ward she alerted the staff to a sudden increase in her abdominal pain, and abdominal examination now revealed generalized tenderness with rebound and guarding. At diagnostic laparoscopy, extensive blood was seen within the peritoneal cavity. Neither fallopian tube was clearly visible so a ruptured ectopic pregnancy was diagnosed. Mini-laparotomy, by Pfannenstiel's incision, disclosed a large ruptured ectopic pregnancy with destruction of the left fallopian tube. There also appeared to be a small unruptured ectopic pregnancy in the right fallopian tube. Left salpingectomy and right salpingotomy were performed and histological examination confirmed synchronous bilateral ectopic pregnancy. The β-human chorionic gonadotropin, which had been raised preoperatively, became normal—confirming complete removal of the pregnancies. The patient was counselled on her high risk of ectopic pregnancy and advised to attend for an early ultrasound scan in any future pregnancies.

COMMENT

In the UK about 11 in 1000 pregnancies are ectopic.¹ The most recent Confidential Enquiry into Maternal Deaths, reports 11 deaths from this cause in the past triennium; the number has been rising since 1991–1993. Synchronous bilateral ectopic pregnancy is very rare, and in most cases results from assisted reproduction techniques. The incidence is thought to be somewhere between 1 in 125 and 1 in 1580 extrauterine pregnancies.² Of the handful of reported cases of spontaneous bilateral ectopics, one came from our own hospital.³

Comprehensive clinical guidelines for the treatment of ectopic pregnancy have been published by the Royal College of Obstetricians and Gynaecologists.⁴ Because of its rarity, synchronous ectopic pregnancy is not covered, but the principles of treatment can still be applied. Laparoscopic surgical treatment is preferred to open procedures, because the patient recovers more quickly and subsequent rates of intrauterine and ectopic pregnancy are similar.⁵ Our patient, because of her acute symptoms, was not suitable for either laparoscopic surgery or medical management with methotrexate. At the time of surgery, examination of the contralateral tube governs treatment. In the present case the left tube had been destroyed, so salpingectomy was performed. On the right, salpingotomy was performed to allow some chance of natural conception in future cycles.