{"paper_id":"126d7f69-f6de-40bf-8af3-ea1aa2954118","body_text":"CASEREPORT\nOchsner Journal 19:178–180, 2019\n© Academic Division of Ochsner Clinic Foundation\nDOI: 10.31486/toj.17.0110\nSpontaneous Unilateral Tubal T win Ectopic Pregnancy\nHannah E. Lategan, MBBS, 1 Veronica C. Gillispie, MD, FACOG 1,2\n1The University of Queensland Faculty of Medicine, Ochsner Clinical School, New Orleans, LA2Department of Obstetrics and Gynecology,\nOchsner Clinic Foundation, New Orleans, LA\nBackground:Unilateraltubaltwinpregnanciesoccurinapproximately1ofevery125,000spontaneouspregnancies.Becauseof\nthepaucityofdata,littleguidancefortheappropriatemanagementofatwintubalectopicpregnancyisavailable.\nCase Report: A 40-year-old female presented to the emergency department (ED) with a 2-day history of vaginal bleeding asso-\nciatedwithlowerabdominalpain.Thepatientwashemodynamicallystablewithsignsofanacuteabdomen.Pelvicexamination\nelicited clinical findings consistent with potential ectopic pregnancy. Urine pregnancy test in the ED was positive. Serum beta-\nhumanchorionicgonadotropinwas23,359mIU/mL,andtransvaginalultrasoundshowedfindingsconcerningforatwinectopic\npregnancy.Diagnosticlaparoscopywithrightsalpingostomywassuccessful,andthepatienthadanuncomplicatedpostoperative\ncourse.\nConclusion: Healthcare providers should have a high index of clinical suspicion for ectopic pregnancies. Unilateral tubal twin\nectopic pregnancies, while rare, can be adequately diagnosed with transvaginal ultrasound. Laparoscopic salpingostomy pro-\nvides conservative and successful treatment of unilateral tubal twin gestation with short recovery time. Medical treatment with\nmethotrexate has not been adequately studied in this clinical scenario, but further exploration of this management modality\nshouldbeconsidered.\nKeywords: Pregnancy–ectopic, pregnancy–tubal, twin ectopic\nAddress correspondence to Veronica C. Gillispie, MD, FACOG, Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, Ochsner\nBaptist Medical Center, 4429 Clara Street, Suite 500, New Orleans, LA 70115. Tel: (504) 842-9617. Email: vgillispie@ochsner.org\nINTRODUCTION\nEctopic pregnancy accounts for approximately 1%-2%\nof first-trimester pregnancies and may be the cause of\nup to 6% of pregnancy-related deaths.1 Risk factors for\nan ectopic pregnancy include prior tubal surgery, pelvic\ninflammatorydisorder,peritubaladhesions(followingappen-\ndicitis or endometriosis), congenital tubal anomalies (ie, in\nutero diethylstilbestrol exposure), artificial reproductive ther-\napy, and smoking. Although contraceptive methods over-\nall decrease the risk of ectopic pregnancy by preventing\nall pregnancies, intrauterine devices (IUDs) may actu-\nally increase the risk.\n1 Early detection of ectopic preg-\nnancy has improved via urine/serum beta-human chorionic\ngonadotropin (bHCG) testing and transvaginal ultrasound,\nthus decreasing associated morbidity and mortality. Tubal\nectopic pregnancies comprise 95% of ectopic pregnan-\ncies. Within this incidence lies the even rarer occurrence\nof tubal twin ectopic pregnancy, with incidence rates esti-\nmated to be 1 in 725-1,580 of tubal pregnancies.\n2 Unilat-\neraltubaltwinpregnanciesoccurinapproximately1ofevery\n125,000 spontaneous pregnancies.\n3 A diagnosis of prior\nectopic pregnancy increases the risk of subsequent ectopic\npregnancy by 10%.1\nManagement options for ectopic pregnancy are medi-\ncal management via methotrexate or surgical management.\nBecause of the paucity of data, little guidance for the appro-\npriate management of a twin tubal ectopic pregnancy is\navailable.\nCASE REPORT\nA40-year-oldfemalegravida1para1001presentedtothe\nemergency department (ED) with a 2-day history of vaginal\nbleeding associated with lower abdominal pain. The patient\nstated that she had filled several pads with dark red blood\nandlargeclotsthatlookedlike“tissue.”Shedeniedanyvagi-\nnal pain or discharge, dysuria, and frequency or urgency\nof urination. The patient also denied constitutional symp-\ntoms, as well as gastrointestinal symptoms. Her last men-\nstrual period was 6 weeks prior to presentation. She denied\nany history of sexually transmitted disease. She had no sig-\nnificant medical history, and her surgical history was only\nsignificant for cesarean section for her first child (17 years\npreviously). The patient denied taking any medications and\nis a nonsmoker.\nOnphysicalexamination,thepatientwasafebrilewithsta-\nble vital signs. On abdominal examination, the patient was\nnontender, soft, and nondistended with no signs of rebound\ntendernessorguarding.Examinationoftheexternalgenitalia\nshowednoabnormalities.Pelvicexaminationrevealedsome\ndarkbrownbloodinthevaginalvaultwithnoactivebleeding.\n178 OchsnerJournal\n\nLategan, HE\nFigure. A: Transvaginal ultrasound sagittal view shows the right fallopian tube containing 2 discrete gestational sacs. B:\nTransvaginal ultrasound transverse view shows the right fallopian tube containing 2 discrete gestational sacs.\nThe patient had no cervical motion tenderness. Bimanual\nexamination revealed a uterus of 6-week size with a closed\ncervical os. No adnexal masses were present; however, the\npatient acknowledged tenderness on palpation of the right\nadnexa.\nIn the ED, a urine pregnancy test was positive. Blood\nwork showed serum bHCG of 23,359 mIU/mL, hemoglobin\nof 10.4 g/dL, hematocrit of 32.4%, and O positive blood\ntype.Transvaginalultrasound(Figure)revealedauterusmea-\nsuring 8.3 cm in length and 3.9 × 4 . 5c mi nt r a n s v e r s e\ndimensions with no intrauterine gestational sac; however, 2\nclosely opposed gestational sacs, each containing a fetal\npole, were seen in the right adnexal region separate from\nthe ovary. The left ovary was not identified, and no left\nadnexal abnormalities were seen. Fetal heart tones were\nnot detected at either fetal pole. No significant amount of\nfree fluid was present within the pelvis. Overall, these find-\nings indicated a right tubal ectopic twin pregnancy of aver-\nage ages of 8 weeks and 2 days and 7 weeks and 6 days,\nrespectively.\nThe patient was emergently taken to the operating room\nfor diagnostic laparoscopy with right salpingostomy. Intra-\noperative findings were consistent with the preoperative\ndiagnosis. The patient’s postoperative course was uncom-\nplicated,andshewasdischargedonpostoperativedayzero.\nHistopathology confirmed the diagnosis. Serial bHCG levels\nwere checked until the level was<5m I U / m L .\nDISCUSSION\nFrom the report in 1891 by De Ott4 through 1990, only 98\ncases of unilateral tubal twin pregnancy had been described\nin the literature, most of which were diagnosed intraop-\neratively or postoperatively.\n5 The 101st case of unilateral\ntwin ectopic pregnancy was described only in 2001.6 In\n2006, Rolle et al reported that only 8 cases of unilat-\neral tubal twin pregnancy in the literature had been diag-\nnosed preoperatively.\n7 In the current case, the treatment\nteam was able to establish with reasonable certainty that\nthe patient had a unilateral twin ectopic pregnancy prior to\nsurgery.\nThe literature includes case reports describing twin\nectopic gestations following salpingectomies and other\ntubalsurgeries,aswellasothersfollowingahistoryofpelvic\ninfection or artificial reproductive therapy. This patient, how-\never, had no history of tubal surgery, pelvic infection, artifi-\ncial insemination, tubal anomalies, IUDs, or smoking. In all\nwomen of reproductive age, even those with no known risk\nfactors, physicians should operate with high clinical suspi-\ncion of potential ectopic pregnancy.\nBecause of the low incidence of spontaneous unilateral\ntubal twin pregnancies, no consensus has been reached as\nto the best option for management. In cases similar to ours,\nlaparotomyandlaparoscopicsalpingectomyhavebeensuc-\ncessfully performed.\n8 Only one other case report describes\nmanagement via laparoscopic salpingostomy as achieved\nin our case. Only 2 cases of medical management with\nmethotrexate have been documented in hemodynamically\nstablepatientswithunrupturedunilateraltubaltwinpregnan-\ncies, and both were successful.\n9,10\nCONCLUSION\nEven in the absence of the accepted risk factors, the\npossibility of unilateral twin ectopic pregnancy should be\nconsidered. Retrospectively in this case, treatment with\nmethotrexate may have been an option; however, with\nextremely limited data on the use of medical management,\nmethotrexatemaynothave beenappropriate,but thisques-\ntion is an imperative for future study.\nACKNOWLEDGMENTS\nThe authors have no financial or proprietary interest in the\nsubject matter of this article.\nVolume19,Number2,Summer2019 179\n\nSpontaneous Unilateral Tubal Twin Ectopic Pregnancy\nREFERENCES\n1. CunninghamFG,LevenoKJ,BloomSL,etal.Ectopic\npregnancy.In:CunninghamFG,LevenoKJ,BloomSL,etal,\neds. Williams Obstetrics.24thed.NewYork,NY:McGraw-Hill\nEducation;2014:377-395.\n2. SvirskyR,MaymonR,VakninZ,etal.Twintubalpregnancy:a\nrisingcomplication? Fertil Steril.2010Oct;94(5):\n1910.e13-1910.e16.doi:10.1016/j.fertnstert.2010.03.017.\n3. DedeM,GezginçK,YenenM,etal.Unilateraltubalectopic\ntwinpregnancy. Taiwan J Obstet Gynecol.2008\nJun;47(2):226-228.doi: 10.1016/S1028-4559(08)60089-3.\n4. DeOttD.Acaseofunilateraltubaltwingestation. Ann\nGynécol Obstét.1891;36:304.\n5. ShererDM,LibertoL,WoodsJRJr.Preoperativesonographic\ndiagnosisofaunilateraltubaltwingestationwith\ndocumentedfetalheartactivity. J Ultrasound Med.1990\nDec;9(12):729-731.\n6. GökerEN,T avmergenE,OzçakirHT,LeviR,AdakanS.\nUnilateralectopictwinpregnancyfollowinganIVFcycle. J\nObstet Gynaecol Res.2001Aug;27(4):213-215.\n7. RolleCJ,WaiCY,BawdonR,Santos-RamosR,HoffmanB.\nUnilateraltwinectopicpregnancyinapatientwithahistory\nofmultiplesexuallytransmittedinfections. Infect Dis Obstet\nGynecol.2006;2006:10306.\n8. SurSD,ReddyK.Spontaneousunilateraltubaltwin\npregnancy. JRS o cM e d.2005Jun;98(6):276.\n9. KaradenizRS,DilbazS,OzkanSD.Unilateraltwintubal\npregnancysuccessfullytreatedwithmethotrexate. Int J\nGynaecol Obstet.2008Aug;102(2):171.\ndoi:10.1016/j.ijgo.2008.03.012.\n10. ArikanDC,KiranG,CoskunA,KostuB.Unilateraltubaltwin\nectopicpregnancytreatedwithsingle-dosemethotrexate.\nArch Gynecol Obstet.2011Feb;283(2):397-399.\ndoi:10.1007/s00404-010-1449-6.\nThis article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical\nSpecialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.\n180 OchsnerJournal","source_license":"CC-BY-4.0","license_restricted":false}