Live twin tubal ectopic pregnancy

Abstract

Twin tubal ectopic pregnancy is a rare diagnosis, with an incidence of 1:200 ectopic pregnancies [1]. The incidence of live tubal twin ectopic pregnancy is even rarer, and has been calculated to be 1:125,000 pregnancies [2]. This report describes a unilateral live twin ectopic pregnancy with the highest level of serum quantitative human chorionic gonadotropin (Q-hCG) reported in the medical literature to date. A 41 year old, gravida 7, para 4, presented with a 1-day history of abdominal pain. Her last menstrual period was 7 weeks prior to presentation. The patient had received no infertility therapies and had no risk factors for ectopic pregnancy. On physical examination, the patient's vital signs were stable, and her abdomen was tender. The serum Q-hCG was 31,672 mIU/mL. A pelvic ultrasound revealed a right tubal pregnancy that had two fetuses, both with detectable cardiac activity (Fig. 1). At the time of laparoscopy, the ampulla of the right fallopian tube was found to be ruptured and portions of the two gestations were extruding from the fallopian tube (Fig. 1). Two gestational sacs were clearly identifiable, each containing a fetus. There was active bleeding from the ruptured fallopian tube. A laparoscopic right salpingectomy was then performed. Her postoperative course was uncomplicated. (A) The fetal heart activity identified by color flow Doppler using transvaginal sonography. (B) Transvaginal sonogram image depicting the membrane separating the two gestational sacs. (C) The M-mode used to detect the fetal heart rate of twin A in this twin tubal ectopic. (D) The M-mode used to detect the fetal heart rate of twin B in this twin tubal ectopic. (E) Twin tubal gestation at the time of laparoscopy. In the medical literature published in English, there have been only seven other cases of live twin tubal ectopic pregnancies diagnosed by transvaginal ultrasonography. The Q-hCG of this case was 31,672 mIU/mL, only four of the other seven reported cases have had Q-hCG reported; the mean Q-hCG of those cases were 9846 mIU/mL. It may be that the Q-hCG at presentation for twin ectopic pregnancies is higher than that of a singleton ectopic pregnancy, in which more than half present with Q-hCG less than 3000 mIU/mL [2]. This case concurs with a report by Ash et al. [3] that, in the absence of an intrauterine gestational sac in the presence of a normally rising Q-hCG titer, a diagnosis of multiple ectopic gestation should be considered, among the other rare differential diagnoses. This case underscores the need of early recognition and accurate diagnosis of ectopic pregnancy. An accurate diagnosis in twin ectopic pregnancies is even more helpful, as such pregnancies may grow larger and, therefore, have higher risk of rupture. This case supports the hypotheses that live twin ectopic pregnancies present with higher Q-hCG levels and that surgical treatment of these cases is appropriate.