Discussion
Ectopic pregnancy is a common emergency but life-threatening condition that obstetricians and gynecologists face and requires fast and careful management. In the past 30 years, the incidence of EP has raised in developed countries [1]. Approximately 1% to 2% of all pregnancies are ectopic pregnancies and over 98% of implantations occur in the fallopian tube (7). The leading risk factors of EP in women are Pelvic inflammatory disease, previous pelvic surgery, tubal infertility, and congenital uterine abnormalities. (2, 3)
Bilateral tubal pregnancy (BTP) is considered an extremely rare form of extra-uterine pregnancy [4]. It is difficult to estimate the accurate frequency which is based on case reports, however, the highest reported incidence was 1 in 200,000 pregnancies [5]. This demonstrates 1/750 - 1,500 of all EPs [6]. BTP is commonly associated with infertility treatment. Multiple ovulations either spontaneously or with ovulation induction have elevated the risk of bilateral EP [8]. In addition, the incidence has increased due to the high rates of endo salpinx damages following sexually transmitted infections, tubal sterilizations, assisted reproductive technologies, tobacco smoking, polygamy, and more precise methods for early detection of ectopic pregnancy. The highest risk factor for ectopic pregnancy is previous fallopian tube damage [9, 10, 11].
Complications such as severe bleeding and hypovolemic shock associated with maternal morbidity and mortality are the results of misdiagnosis or delayed diagnosis of EP (2, 3). In this case, we report a patient with bilateral tubal pregnancy, and the presentations were not at the same time which makes it more life-threatening and harder to diagnose.
In cases of unilateral EP, early diagnosis can be successfully achieved with the use of TVUS and the accessibility of β-hcg kits. Transvaginal ultrasonography has a high sensitivity and specificity for detecting EP and Color Doppler sonography increases the rate of transvaginal ultrasound for early detection of small ectopic masses, preoperatively. [7, 12] However, ultrasound has a weak role in the diagnosis of bilateral EP, and almost all cases are diagnosed intraoperatively, because even the most expert sonographers may encounter a handful in their life career. [13] The literature review has shown it as an operative diagnosis, except for only a few reports. Commonly, clinicians fail to recognize the diagnosis during the surgery as well as our patient. [12]
In our case, we didn’t visualize any abnormal findings on the contralateral tube during the laparoscopic surgery. During the post-operative follow-up due to the rise of β-hcg level and evaluating other possibilities, we found out about the other ectopic pregnancy in the contralateral tube. We consumed that during the laparoscopic surgery, the other tubal pregnancy was too small to be seen then.
BTP treatment is controversial in most clinical guidelines for the management of EP, Because of the rare cases of BTP [14]. Treatment options for EP management are surgery, medical therapy, and expectant management. Systemic MTX therapy is considered a cost-effective choice rather than laparoscopy for patients who have stable hemodynamics. Periodic β-hCG measurements are useful to diagnose EP and to assess the efficacy of MTX. [15]
Clinicians should know about various therapeutical alternatives. Like unilateral EP, choices depend on the patient’s condition, the extent of damage to the fallopian tubes, the desire to preserve fertility, the size and location of the EP mass, and the β-hCG level. [16]
Therapeutic options for spontaneous BTP cases are essentially similar to unilateral EP. The type of surgical procedure may be different between spontaneous BTP and those following ART. In spontaneous BTP, if the tube appears benign, the procedure is to perform a salpingostomy. This is the only successful pregnancy in the series [17].
Yao and Tolandi, [18] compared fertility rates between salpingotomy versus salpingectomy, showing that both approaches were the same. Femke et al [19] demonstrated a similar cumulative rate of natural pregnancy among mentioned approaches.
Conservative management using methotrexate (MTX) does not satisfactory therapeutic effect due to the high hCG level (the hCG concentration level for MTX treatment was <5000IU/L). [20], salpingotomy should be considered if the patient has a strong desire to save fertility. However, patients should be aware of the possibility of trophoblast tissue remnant and persistent trophoblast, Complementary treatment with systemic MTX, and EP recurrence. [19, 21]
In our case, first, we did a laparoscopic salpingostomy and after the diagnosis of BTP, we treated the patient with MTX therapy which needed a second dosage.
Recent reports demonstrated delayed diagnosis of contralateral tubal pregnancy days to weeks after the first surgery in BTP, so clinicians should always keep in mind such an alternative, particularly, in patients for whom multiple embryo transfers have been performed. Bilateral fallopian tubes should always be checked, and inconsistent β-hCG values may delay accurate diagnosis. [15] In our case, we were able to diagnose it after the surgery and the rise of β-hCG level to search for other possible locations of pregnancy.
Surgical procedures vary from salpingectomy for one tube and linear salpingostomy for a contralateral tube to bilateral salpingostomy or bilateral salpingectomy [21]. If present, laparoscopy may be the best choice for diagnosis and management of BTP [22] because the diagnosis can be easily missed even at laparoscopy so a high index of suspicion should be kept. [22]. But in our case, as we inspected the contra lateral tube thoroughly we didn’t observe any abnormal findings due to the possibility of a small ectopic pregnancy in the right tube.
In hemodynamically unstable patients, laparotomy is the choice treatment and is equally impressive. However, it should be noted that serial β-hCG monitoring should be performed because there is a possibility of ongoing ectopic pregnancy, especially if a conservative surgery such as salpingostomy or tubal milking has been chosen [16]. There are reports of intrauterine pregnancy after conservative surgical management of BTP [23], but the reality is that these patients are at high risk of recurrent ectopic pregnancy subsequently [16].
The unusual part of this case is the chronology of the bilateral ectopic pregnancy. Most reported bilateral ectopic pregnancies occurred and developed simultaneously, so the diagnoses were made at the same time on both sides. In this case, even the mindful exploration of the contralateral fallopian tube did not show any signs of a developing ectopic pregnancy. At the first exploration, the contralateral implanted embryo was too underdeveloped to be seen by laparoscopy, which contributed to the consequently delayed diagnosis of ectopic pregnancy. In this paper, we present an unusual case of bilateral ectopic pregnancy, in which there has been a substantial delay of 2 weeks between the diagnoses of both sides of the ectopic pregnancies.
Conclusion :
First of all, we should have this diagnosis in mind. Evaluation of both adnexa by TVUS is equally important. A watchful inspection of the abdomen and pelvis should always be performed during the surgery for an ectopic pregnancy, particularly the contralateral fallopian tube even when unilateral EP is diagnosed preoperatively. In some cases, contra-lateral pregnancy was shown days to weeks after the first surgery. This paper accentuates that diagnosis and treatment of one ectopic pregnancy do not rule out the happening of a second ectopic pregnancy in the same patient at the same time, especially if the patient has rising β-hCG and persistent symptoms.
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