Spontaneous Bilateral E ctopic Pregnancy: A Case Report .

1. Spontaneous Bilateral Ectopic Pregnancy: A Case Report. Dr Rahul Savant (Registrar), Sylvia Peacock (EPAU Specialist Nurse), Dr Nicola Piskorowskyj (Consultant) Department of Obstetrics and Gynaecology Glangwili General Hospital, Carmarthen, Carmarthenshire, SA31 2AF UK OPTIONALLOGO HERE The case Discussion Background Conclusions Diagnosis of ectopic pregnancy continues to be an important challenge facing emergency physicians. There has been an increase in the number of published case reports of bilateral tubal pregnancies associated with the increasing use of assisted reproductive technologies. However, without iatrogenic ovulation induction, simultaneous bilateral tubal pregnancy remains an atypical event. Most patients with bilateral tubal pregnancies present similarly to those with a unilateral ectopic pregnancy and have similar risk factors. The most frequent findings are the triad of amenorrhea, vaginal bleeding, and abdominal pain. Levels of serum βHCG and the discriminatory zone are not reliable for patients with bilateral disease. The diagnosis of bilateral tubal pregnancy is usually made intraoperative as ultrasound has not always been useful in the identification of bilateral tubal gestation. There are three possible explanations for a bilateral ectopic pregnancy: 1. Simultaneous multiple ovulation 2. Sequential impregnation 3. Transperitoneal migration of trophoblastic cells from one extrauterine pregnancy to the other tube with implantation there. Spontaneous bilateral ectopic pregnancy is the rarest form of ectopic pregnancy. Bilateral tubal pregnancies in the absence of preceding induction of ovulation are an extremely unusual occurrence and are thought to represent the rarest form of extra uterine pregnancy. More common are twin pregnancies in the same tube and heterotopic pregnancies. The incidence of simultaneous bilateral tubal pregnancies has been reported to range from 1 per 725 to 1 per 1580 ectopic pregnancies. This is thought to correspond to an occurrence of one per every 200 000 live births. only 46 cases have been reported in the English literature in the last 19 years (till 2009), 29 were listed as spontaneous. We report a case of spontaneous bilateral ectopic pregnancy that was managed medically as an outpatient. The diagnosis and management of ectopic pregnancy remains a challenge in Obstetrics and Gynaecology The easy access to Early pregnancy assessment unit (EPAU) and use of ultrasound and estimation of beta unit of human chorionic gonadotropin has helped us in improving our care to women presenting with early pregnancy complaints. Our case report has shown that bilateral tubal ectopic pregnancies can be managed effectively on outpatient basis. A Primigravida at five and half weeks gestation attended Early Pregnancy assessment Unit (EPAU) with history of vaginal spotting. It was a spontaneous conception. She was asymptomatic, heamodynamically stable and there were no significant past medical or surgical history of note. Trans vaginal ultrasound (TVS) showed an anteverted uterus with an endometrial thickness of 5.5 mm with no evidence of gestational sac. A tiny cyst of 31 mm was noted on the right ovary. No free fluid seen. Within the left adnexa an ectopic mass measuring 12×10 mm with a yolk sac was seen. Quantitative βHCG (Q βHCG) was 2082 IU. She opted for medical management and was treated with a single dose of intramuscular Methotrexate. She was followed up on day 4 and day 7 with blood tests which showed a falling trend of βHCG. The day 8 scan showed the previously noted left ectopic remaining at 11×7 mm but within the right adnexa there was a mass 22×20×44 mm highly suggestive of another ectopic pregnancy. The quantitative βHCG had dropped to 313 IU. As she was asymptomatic and QβHCG was dropping she was managed conservatively. She was followed up in EPAU on outpatient basis. Day 14 QβHCG dropped further to 31 IU, the left ectopic remained at 6×6 mm and the right ectopic measured at 26×29 mm. The cystic area on the right measured at 22 mm. The day 23 scan showed the left ectopic at 7.5 × 4mm and the right measured 32×19 mm. Her QβHCG had dropped to 3 IU. She was symptom free during the entire period and she was then discharged. References 1. Andrews J, Farell S. Spontaneous Bilateral tubal Pregnancies: A Case Report. J Obstet Gynaecol Can 2008; 30(1):51–54. 2. Martinez J, Cabistany A, Gonzalez M, Farrer M, Romero J A. Bilateral simultaneous ectopic pregnancy. Southern Medical Journal. 2009 Oct; 102(10): 1055-57. 3. Shenoy JV, Choudhary V, Giles RW. Bilateral ectopic pregnancy. J Obstet Gynecol. 2005 Aug; 25(6): 612-3.