Bilateral tubal pregnancy : A diagnostic dilemma

Bilateral tubal ectopic pregnancy is very rare and usually occurs following ovulation stimulation. Moreover preoperative diagnosis is very difficult. We are presenting a case of bilateral tubal ectopic pregnancy occurring spontaneously. Hence careful follow-up with combination of color Doppler and serum beta HCG estimation of patients after laparoscopic or open surgery for ectopic pregnancies is needed to avoid such unusual event.


INTRODUCTION
Ruptured extra-uterine pregnancy is still an important cause of maternal mortality.97% of extra-uterine pregnancy is tubal.Unilateral tubal ectopic pregnancy is common but bilateral tubal ectopic pregnancy is very rare, and usually follows ovulation stimulation.There are no cases reported in which preoperative diagnosis of bilateral ectopic pregnancy was made [1].The case reported here has occurred spontaneously.

CASE REPORT
A 32-year-old mother Gravida 3, Para 2 presented with 2 months amenorrhea followed by bleeding per vagina and pain in the lower abdomen since 2 days.She had bilateral tubal ligation 13 years back.Her past menstrual cycles were regular.She had tachycardia (110 per minute), hypotension (blood pressure of 90/50 mm Hg) and severe pallor at the time of admission.Abdominopelvic examination revealed tenderness in the lower abdomen, tender cervical movements, palpable tender right adnexal mass and fullness in all the fornices.There was haemoperito-neum on colpopuncture.Emergency exploratory laparotomy was performed.Haemoperitoneum of approximately 400 ml was present.On the right side, there was a ruptured tubal ectopic pregnancy, and the patient was bleeding from this site (Figure 1).The left tube showed an organized hematoma of 2 × 3 cm size, protruding from the tubal ostium and fixed posterior to uterus (Figure 1).That was not bleeding, suggestive of an ectopic pregnancy in the process of abortion.In view of these findings, both sided salpingectomy was done and both tubes were sent for histopathology.The patient recovered uneventfully and was discharged on the 7th post-operative day.Histopathology of the specimens showing chorionic villi and trophoblasts in both tubes confirmed the diagnosis of bilateral tubal ectopic (Figures 2 and 3).

DISCUSSION
Incidence of bilateral ectopic is thought to be somewhere between 1 in 125 and 1 in 1580 extrauterine pregnancies [2].More than 200 cases of bilateral tubal ectopic pregnancy have been reported in the literature to date [3].
Various theories that include twining, superfetation and second pregnancy following tubal abortion of first one have been put forward to explain its occurrence [4,5].Thankfully after a century of rapid technological advances, the diagnosis and management of ectopic have been dramatically improved.But bilateral ectopic pregnancy is difficult to diagnose preoperatively, indicating limitations of ultrasonography [6].A high index of suspicion for pregnancy despite a history of bilateral salpingectomies in a woman of reproductive age presenting with a period of amenorrhoea is thus prudent in order to avoid missing an ectopic.Laparoscopy remains the main cornerstone of diagnosis and treatment in majority of women especially true in bilateral tubal pregnancy because of its conservative approach and the patient recovers more quickly [7].
Moreover a case has been reported in which consecu-   tive right and left salpingectomy were performed in seven weeks gap for ruptured ectopic despite left tube appeared normal during first surgery and the patient did not have coitus between the two salpingectomies [8].
Hence failure to recognize bilateral tubal ectopic even intra-operatively arises worsening of conditions.Colour Doppler capacities further enhance the diagnostic sensitivity of transvaginal ultrasound for the early recognition of abnormal and normal intrauterine pregnancy, and small extrauterine masses preoperatively [6].
Careful attention should be directed to follow-up tests.A serial measurement of serum concentrations of human chorionic gonadotrophin is necessary to rule out the risk of persistent trophoblast until complete resolution is necessary [9].
Our patient, because of her acute symptoms, was not suitable for either laparoscopic surgery or medical management.At the time of surgery, examination of the contralateral tube governs treatment [4].

CONCLUSION
Hence we give emphasis not only to look at both adnexas during surgery for ectopic pregnancy but also to the careful follow-up with combination of color Doppler and serum beta HCG estimation of patients after laparoscopic or open surgery for ectopic pregnancies.

Figure 1 .
Figure 1.On the right side, there was a ruptured tubal ectopic pregnancy, and the left tube showed an organized hematoma of 2 × 3 cm size, protruding from the tubal ostium.

Figure 2 .
Figure 2. Histopathology of right tube showing chorionic villi and trophoblasts.