Summary: A 24-year-old gravida 3, para 2 + 1 presented to the emergency room with 2 days of severe lower abdominal pain of increasing intensity. She was 9 weeks 3 days pregnant by date. There was no associated vaginal bleeding. There was no significant past medical or surgical history.
Summary: Physical examination revealed that her vital signs were:
- Blood presure 114/95
- Pulse rate 94/minute
- Respiratory rate 20/minute.
Summary: Systemic review was unremarkable except for mild tenderness with guarding in the right lower quadrant. The hemoglobin level was 9.0 g/dL. The other blood chemistry levels were normal. She was then referred for transabdominal and endovaginal ultrasound, which revealed an empty uterus and 2 live fetuses with cardiac activities in the right adnexa. The left ovary and adnexa was normal. A mild amount of fluid was noted in the cul de sac. The patient was then taken to the operating room where she had abdominal laparotomy and right salpingectomy.
Live right-tubal twin-ectopic pregnancy. Differential diagnosis: abdominal pregnancy.
Endovaginal ultrasound revealed an empty uterus (Figure 1) and 2 live fetuses with cardiac activities in the right adnexa (Figures 2 and 3).
Live twin-ectopic gestations are extremely rare. More than 100 twin-tubal pregnancies have been reported, but <10 have cardiac activities demonstrated in both fetuses.2
Unilateral twin-ectopic pregnancies occur in 1:200 ectopic pregnancies. Most cases are monochorionic and monozygotic.3
Ectopic pregnancies account for 2% of all pregnancies and represent a major health risk for women of childbearing capacity, which can result in life-threatening complications if not treated properly. They result from the abnormal implantation and maturation of the conceptus outside of the endometrial cavity.
The incidence of ectopic pregnancies has been increasing since the 1970s. The first case of live twin-ectopic pregnancy was described in 1994.4 The classic clinical triad of ectopic pregnancy is pain, amenorrhea and vaginal bleeding.
Multiple risk factors contributing to the incidence of ectopic pregnancy include: Pelvic inflammatory disease, previous ectopic pregnancy, history of tubal surgery and conception after tubal ligation, and use of fertility drugs or assisted reproductive technology. Other risk factors include use of an intrauterine contraceptive device, increasing age, smoking and variant anatomy of the uterus (T-shaped uterus).
Live twin-ectopic gestations are extremely rare but there are treatment options. These have typically been classified as either conservative or surgical.
Patients are typically sent for surgical intervention if they are at high risk of tubal rupture, hypotension, anemia or if they have anectopic pregnancy >3 cm in diameter. Those eligible for conservative treatment typically receive a chemo- therapeutic agent like methotrexate, which is less invasive and has a significantly lower risk and cost compared with surgery. The success rate with methotrexate ranges from 70%to 100%.5
- Atye, Lam SL. Viable left tubal twin ectopic pregnancy.Singapore Med J. 2005;46:651-655.
- Parker J, Hewson AD, Calder-Mason T, Lai J. Transvaginal ultrasound diagnosis of a live twin tubal ectopic pregnancy. Australas Radiol. 1999;43:95-97.
- Storch MP, Petrie RH. Unilateral tubal twin gestation. Am J Obstet Gynecol. 1976;125:1148-1150.
- Gualandi M, Steemers N, de Keyser JL. First reported case of preoperative ultrasonic diagnosis and laparoscopic treatment of unilateral, twin tubal pregnancy. Rev Fr Gynecol Obstet. 1994;89:134-136. in French.
- Luciano AA, Roy G, Solima E. Ectopic pregnancy from surgical emergency to medical management. Ann N Y Acad Sci. 2001;943:235-254.