|Year : 2014 | Volume
| Issue : 1 | Page : 45-47
Bilateral tubal ectopic gestation: A case report
Matthew I Nwali1, Brown N Ejikeme1, Azubike K Onyebuchi1, Robinson C Onoh1, Felix O Edegbe2
1 Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
2 Department of Morbid Anatomy, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
|Date of Web Publication||18-Sep-2014|
Matthew I Nwali
Department of Obstetrics and Gynaecology, Federal Teaching Hospital, PMB 102, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Spontaneous bilateral tubal ectopic pregnancy is a rare occurrence. A case of a recently managed spontaneous bilateral tubal ectopic pregnancy is discussed. A 37-year-old grand multiparous farmer, who had been amenorrhoeic for 12 weeks, presented with lower abdominal pain, bleeding per vaginam, and dizziness. Other clinical and ultrasonographic findings were suggestive of ruptured ectopic gestation. Intra-operative findings included ruptured right tubal and unruptured left tubal ectopic pregnancies. Bilateral partial salpingectomy was performed with uneventful recovery. Intra-operative diagnosis of bilateral tubal ectopic pregnancy was confirmed by histology of the specimens.
Keywords: Bilateral, salpingectomy, spontaneous, tubal ectopic pregnancy
|How to cite this article:|
Nwali MI, Ejikeme BN, Onyebuchi AK, Onoh RC, Edegbe FO. Bilateral tubal ectopic gestation: A case report. Ann Nigerian Med 2014;8:45-7
| Introduction|| |
Spontaneous bilateral tubal ectopic pregnancy is rare. The first case of bilateral ectopic gestation was reported in the literature by Bledsoe in 1918.  The incidence of 1 in 200,000 pregnancies has been quoted in the literature.  The incidence however is on the increase especially with the use of artificial reproductive technology.  The incidence after in vitro fertilization was reported as ranging from 2.1-9.4% of all clinical pregnancies.  Other predisposing factors include increased maternal age, early age at coitarche, pelvic infection, multiple sexual partners, history of infertility, previous ectopic pregnancy, and pelvic surgeries.  The clinical scenario may vary from incidental discovery to acute emergency; and management depends on the condition of the affected tubes, parity and desire for further reproduction, available resources, and experience of the surgical team.
We present a case of bilateral tubal ectopic pregnancy following a spontaneous conception that we recently managed in our hospital. Consent to publish the report was obtained from the patient, and ethical approval was acquired from the Ethics Committee of the Hospital.
| Case Report|| |
A 37-year-old farmer who hails from and lives with the husband, a farmer, at Iboko Izzi, Ebonyi state; was brought to the gynaecological emergency unit of the Federal Teaching Hospital, Abakaliki, on 18 th July, 2013, after 12 weeks of amenorrhea. Her complaints were lower abdominal pain and bleeding per vaginam both of 3 days duration, and dizziness of 4 hours duration. The pain was initially a continuous dull ache in the lower abdomen, which later became sharp and severe; radiating to the shoulder and made worse on movement. There was history of dizziness but no loss of consciousness. There was associated brownish bloody vaginal discharge but no passage of vesicles or fleshy materials. There was no history of fever or vomiting.
She was para 5 + 4 with five living children (3 males, 2 females). Her last confinement was in 2008 and since then she had 4 spontaneous miscarriages with no complications. Her last menstrual period was on the 20 th April, 2013. She had no history of sexually transmitted infection or use of contraception. She is married in a polygamous family setting and there was no family history of twinning.
On examination, she was in painful distress, pale, afebrile and anicteric. Her radial pulse rate was 120 beats per minute and thready. Blood pressure was 90/60 mmHg. She was tachypneic, but chest was clinically clear. Her abdomen was distended and did not move with respiration; associated with generalized tenderness. Vaginal examination revealed a blood stained vulva, bulging posterior fornix and blood trickling from the cervical os. Bimanual could not be done because of severe tenderness. A diagnosis of ruptured ectopic pregnancy was made and resuscitation with fluids commenced; and analgesics and prophylactic antibiotics given. The woman was counseled for surgery for which she consented. Investigations carried out included an ultrasound scan which showed massive peritoneal fluid collection, hemoglobin concentration (6.1 g/dl), packed cell volume (18%), and serum and urea/ electrolyte/ creatinine which were within normal limits.
Intraoperatively, findings included a hemoperitoneum of about 1.5 litres, ruptured right tubal and unruptured left tubal ectopic pregnancies. A bulky uterus and healthy looking ovaries were noted. A diagnosis of bilateral tubal ectopic pregnancies with rupture right tube was made. Bilateral partial salpingectomy was done, the hemoperitoneum was evacuated and peritoneal lavage done with warm normal saline. The abdomen was closed in layers. Two units of blood were transfused and the immediate post-operative period was satisfactory. The specimens were sent for histopathological evaluation. Her post-operative period was uneventful and her recovery was good. Hemoglobin estimation done on the third day post op was 8.0g/dl. On the seventh post-operative day, her sutures were removed and there was good apposition of the wound. Repeat hemoglobin estimation was 9.3g/dl. She was counseled once more on the surgery and discharged home on hematinics. Four weeks later she came for her follow-up visit and her clinical state was stable and her packed cell volume was 30%. Histopathology reports indicated pregnancy in both salpingectomy specimens, confirming the diagnosis [Figure 1] and [Figure 2].
|Figure 1: Shows ruptured right tube with fi mbria (F), blood clots (B) and|
chorionic villi (V)
Click here to view
| Discussion|| |
Bilateral tubal ectopic pregnancy is a rare condition. The incidence is however on the increase especially with the increasing use of ovulation induction or fertility enhancing drugs, and assisted reproduction. , Bilateral tubal ectopic pregnancy may follow spontaneous conception ,, as in the case presented, or may be induced. ,, The case presented involved four previous history of spontaneous miscarriages that were all managed at home; which may have been complicated by poorly managed infection, thus predisposing her to ectopic pregnancy. She however denied any form of instrumentation following the miscarriages. All deliveries were also managed at home. The patient reported amenorrhea of 12 weeks which was unlikely, as she was not educated and did not keep a menstrual calendar. Hence, may not be sure of her last menstrual period, though her period is said to have been regular. Two other cases had been reported in this centre; one was following a spontaneous conception, while the second occurred in a woman with secondary infertility that was on ovulation-stimulating drugs.  A case of bilateral tubal pregnancies had been reported in a human immunodeficiency virus (HIV)-seropositive woman after tubal sterilization.  Bilateral tubal ectopic pregnancy may remain undiagnosed till laparotomy,  as in the index case when one of the tubes had ruptured.  Twin ectopic gestation may involve one  or both tubes.
The management of bilateral tubal ectopic pregnancy may be medical or surgical, and depends on tubal state at presentation, and future desire for fertility. Surgery can be radical or conservative, and can be carried out through a minimally invasive procedure.  Medical treatment was contraindicated in this case because of rupture of the right Fallopian tube More Details. Conservative surgery was not done on the left unruptured tube because the pregnancy was already advanced and had caused tubal damage; and the patient had earlier expressed the desire for permanent contraception.
Ectopic pregnancy is on the increase especially with increased access to fertility drugs and assisted reproduction. This constitutes a great challenge in our environment where women have poor health seeking behavior. Proper counseling of our women, high index of suspicion, early diagnosis and proper management will go a long way to reduce the high potential for morbidity and mortality associated with it.
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[Figure 1], [Figure 2]