Archives of International Surgery

CASE REPORT
Year
: 2019  |  Volume : 9  |  Issue : 2  |  Page : 46--49

Spontaneous unilateral twin tubal ectopic pregnancy: A case report


Hajara Umaru-Sule1, John M Bakut2, Abiodun J Babajide2, Adebiyi G Adesiyun1, Modupeola O A. Samaila3,  
1 Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medical Sciences, Ahmadu Bello University and Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Pathology, Faculty of Basic Clinical Sciences, College of Medical Sciences, Ahmadu Bello University and Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Correspondence Address:
Dr. Hajara Umaru-Sule
Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Shika, Zaria
Nigeria

Abstract

Unilateral tubal twin pregnancy is rare with an incidence of 1: 125,000 spontaneous pregnancies. Majority of cases that occur follow ovulation induction and assisted reproductive technology. A 38-year-old single primipara with a 9-week history of amenorrhea, 2-week history of lower abdominal pain, and a 3-day history of vaginal bleeding. Previous history of ectopic gestation with surgery, as well as repeated elective abortions and pelvic infections, was elicited. She was hemodynamically unstable with features of an acute abdomen. Pelvic examination revealed features suggestive of ectopic gestation. Spot serum pregnancy test was positive and the pelvic ultrasound revealed left tubal twin ectopic gestation with the significant peritoneal fluid collection. An emergency laparotomy with left salpingectomy was performed, with an un-complicated post operation course. The diagnosis was confirmed with histology. A high index of suspicion is required in the diagnosis of ectopic gestation in order to reduce the morbidity associated with it. Unilateral twin tubal ectopic gestation, although rare, has been reported with higher frequencies, and as such, the occurrence should be carefully sought on ultrasound in order to reduce its potential morbidity and mortality.



How to cite this article:
Umaru-Sule H, Bakut JM, Babajide AJ, Adesiyun AG, Samaila MO. Spontaneous unilateral twin tubal ectopic pregnancy: A case report.Arch Int Surg 2019;9:46-49


How to cite this URL:
Umaru-Sule H, Bakut JM, Babajide AJ, Adesiyun AG, Samaila MO. Spontaneous unilateral twin tubal ectopic pregnancy: A case report. Arch Int Surg [serial online] 2019 [cited 2020 Sep 19 ];9:46-49
Available from: http://www.archintsurg.org/text.asp?2019/9/2/46/291751


Full Text



 Introduction



An ectopic gestation occurs when a blastocyst gets implanted in a location other than the endometrial lining of the uterus. The incidence of ectopic gestations has increased since the advent of assisted reproductive techniques (ART) and tubal surgeries.[1] It occurs in 1–2% of first trimester pregnancies in the general population but increases to 2–5% in patients who have utilized ART.[2],[3] Spontaneous unilateral twin tubal ectopic pregnancy is a very rare occurrence. It is estimated to have an incidence of 1:20,000–1:125,000 spontaneous pregnancies and 1:200 ectopic pregnancies.[4],[5] This is a case of ruptured unilateral twin tubal ectopic gestation which was diagnosed prior to emergency surgery via transabdominal pelvic ultrasonography and confirmed with histology.

 Case Report



We present a 38-year-old single primary school teacher, Para 1+3, with the last menstrual period 9 weeks prior to presentation. She presented to the accident and emergency unit with a 2-week history of lower abdominal pain and bleeding per vaginam of 3 days duration with preceding amenorrhea of 9 weeks. The abdominal pain was initially colicky in nature but became sharp and persistent 3 days prior to presentation. She had vaginal spotting which minimally stained her undergarment but eventually increased necessitating the use of four sanitary pads each day in the last 3 days prior to presentation. She had generalized body weakness and dizziness but no syncope.

There was a history of exploratory laparotomy 1 year prior to presentation on account of a right ectopic pregnancy. She also had two previous abortions via dilation and curettage 14 years and 10 years prior, respectively. She also had a history of previous pelvic infections treated with over-the-counter medications; no history of menstrual disturbances. No history of use of ovulation induction drugs. She had a term pregnancy 17 years prior with spontaneous vaginal delivery (SVD) of a female baby who died at 4 months of age following a febrile illness. She had multiple sexual partners and was diagnosed with HIV 18 years prior. She commenced highly active antiretroviral therapy (HAART) 12 years prior to presentation and was changed to second-line HAART 4 years later on account of clinical drug resistance. She had no other comorbidities; she had no family history of twinning, she ingests alcoholic beverages but does not smoke cigarettes. She was allergic to acetaminophen.

Examination revealed a young woman in painful distress, pale, with tachycardia of 110/min, blood pressure of 90/60 mmHg; the abdomen was full, moved with respiration but tender with guarding. The vulva and vagina were stained with blood. The uterus was of normal size with a tender left adnexal mass and fullness in the pouch of Douglas. The serum pregnancy test was positive and hematocrit 26%. Pelvic ultrasound revealed an empty uterus that measured 5.01 cm in maximal anteroposterior diameter with two gestational sacs with a thick dividing membrane in the left fallopian tube. They measured 1.50 cm and 1.48 cm with an average estimated gestational age of 7 weeks 6 days. There was also a significant peritoneal fluid collection.

She had an exploratory laparotomy with left total salpingectomy and findings included 600 mL hemoperitoneum and an enlarged slow leaking ruptured left tubal ectopic pregnancy [Figure 1]. The tube measured 12 cm × 5 cm × 4 cm in its largest diameter, absent right fallopian tube, normal ovaries bilaterally. The total blood loss was 900 mL. She had two pints of blood transfused in the perioperative period. The postoperative period was uneventful and she was counseled about safe sex practices, contraception and future reproductive career before discharge. The patient was well on a 1-month follow-up visit.{Figure 1}

Histology revealed a ruptured fallopian tube with two gestational sacs, each containing a fetus with crown-rump-length 22 mm and 21 mm corresponding to 2 lunar months [Figure 2]. Microscopy sections showed expanded ruptured tubal wall, chorionic villi of varying sizes, deciduas, and hemorrhage, other areas showed paratubalwalthard cell nests and squamous metaplastic nests [Figure 3].{Figure 2}{Figure 3}

 Discussion



Many risk factors exist for ectopic pregnancies and include genital tract infections, tubal surgeries, previous ectopic gestations (with history of recurrence of 12–18%), use of fertility drugs and ART, increasing maternal age, smoking, and congenital uterine anomalies.[1],[6] Identified risk factors in the index case are increased maternal age, history of recurrent genital infections, history of elective abortions, and previous history of ectopic pregnancy. HIV is associated with a higher incidence of genital infections because of the negative effect it has on the immune system,[7],[8] especially when the viral load is high. The viral load in the index patient was unknown to her and access to that knowledge could not be gotten as her care was at another facility. The index patient also had high-risk behavior of multiple sexual partners with a history of unprotected coitus.

Unilateral tubal twin ectopic gestation is a very rare condition and was first described by De Ott in 1891.[1] Most cases occur following ART,[4],[5] with very few cases occurring spontaneously as in this case. She had no family history of twinning but her age and nationality could have increased her risk for a twin gestation. The incidence of naturally conceived dizygotic twins increases two-to threefold between ages 15 and age 35, and maybe related to increases in follicle-stimulating hormone (FSH) with age. Also, Nigerians have the highest rate of dizygotic twinning worldwide.[8],[9] Anything that interferes with ovum transport in the fallopian tube increases the risk for ectopic gestation. Also, a delay in ovum transport and implantation in monozygotic twinning may increase the risk for ectopic gestation. The size of the twin cell mass has been hypothesized to cause retardation in transport. As such, about 95% of twin ectopic gestations reported have been monochorionic and monoamniotic.[5],[10] The index case was dichorionic and diamniotic, which is very rare.

The classical triad of presentation of ectopic gestation is abdominal pain, amenorrhea, and vaginal bleeding, which was seen in this case.[6] This classic triad is however only present in half of the previously reported cases of unilateral twin tubal ectopics.[5] The gestational age at presentation is in keeping with previously reported cases, with 6.9 ± 1.9 weeks for unruptured and 7.2 ± 2.2 weeks for ruptured cases.[11] The advent of transvaginal ultrasonography and correlation with quantitative serum β-hCG evaluation has improved the detection rates of ectopic gestations.[1],[3],[4] The unstable hemodynamic status of the patient in the index case did not allow time for quantitative evaluation of serum β-hCG, hence, a spot pregnancy test was done. The diagnosis was also arrived at via trans-abdominal pelvic ultrasonography and confirmed postoperatively with histology.

Despite declining rates of morbidity and mortality following ectopic gestations due to improved diagnosis and treatment modalities, it still remains a potentially life-threatening condition. Complication rates are increased in twin tubal pregnancies because of higher volume, with rates of acute abdomen and hypovolaemic shock from the rupture of the tubes of 30–50%.[4] This patient had an acute abdomen from tubal rupture. Treatment was with laparotomy and Left salpingectomy as opposed to the laparoscopic approach employed in most of the recent literature. This was due to the unavailability of facilities for laparoscopic surgery in the center. Treatment of twin tubal ectopic pregnancies using systemic methotrexate has been largely unsuccessful, but two cases of unruptured tubal twin ectopic gestation were treated with success.[2],[4],[12] The index patient may have benefitted from this modality of management if she had presented earlier, before the rupture of the tube, as she had already lost the contralateral tube in the previous surgery. Future conceptions would only be possible via ART in this specific case. The major differentiating factor in the index case is the spontaneous occurrence of the unilateral tubal twin ectopic gestation as well as the diamniotic and dichorionic nature of the twinning. This was, however, not confirmed with DNA studies.

The incidence of unilateral twin tubal pregnancy may not be as low as earlier perceived. Early diagnosis and prompt management would forestall the morbidity associated with this condition and as such meticulous and detailed ultrasonography (preferably transvaginal ultrasound) should be employed early in the first trimester to aid diagnosis. This could lead to the use of other less invasive forms of treatment as well as reducing morbidity associated with it.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

Dr. Idris Mohammed El-Amin of the department of anesthesia for technical support during patient resuscitation and surgery; and Dr. Philip Kurah of the pathology department for sample preparation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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