Clinical Communications: OB/GYNDelayed Detection of Spontaneous Bilateral Tubal Ectopic Pregnancies After Methotrexate Treatment
Introduction
Ectopic pregnancy accounts for 1.4% of all pregnancies (1). Even though rare, ectopic pregnancies are the leading cause of maternal death in the first trimester, with an incidence of death of 1 per 1000 pregnancies, necessitating prompt identification and intervention 1, 2, 3. Risk factors for ectopic pregnancy include a history of ectopic pregnancy, history of a sexually transmitted infection (particularly Chlamydia trachomatis) or pelvic inflammatory disease, tobacco use, prior tubal or pelvic surgery, use of infertility treatments, and in utero exposure to diethylstilbestrol 3, 4. In addition, although rates of pregnancy are significantly decreased when an intrauterine contraceptive device is in place, if a pregnancy does occur it is more likely to result in an ectopic pregnancy compared to women not using any form of contraception (5). However, the majority of those diagnosed with an ectopic pregnancy have no identifiable risk factors (3).
Bilateral tubal ectopic pregnancies have an estimated incidence of 1 in 750 to 1 in 1580 ectopic pregnancies and are typically the result of assisted reproductive techniques 2, 6. Spontaneous bilateral tubal ectopic pregnancies are the rarest form of ectopic (heterotopic and twin ectopic [two gestational sacs in one tube] are more common) and are considered spontaneous when no fertility treatments are involved 2, 7. Diagnosis typically happens at time of surgery with direct visualization 7, 8. The most common treatment is bilateral salpingectomy (9). There are few reported cases of preoperative diagnosis of bilateral tubal ectopic pregnancies with most literature reporting no prior cases 2, 10, 11. There have been no reports of successful treatment of bilateral tubal ectopic pregnancies with methotrexate (7). This case report describes an instance of spontaneous bilateral tubal ectopic pregnancies diagnosed via ultrasound and treated with methotrexate.
Section snippets
Case Report
A 32-year-old G5P1031 (gravida: 5 pregnancies including current pregnancy, para: 1 full-term delivery, 0 preterm deliveries, 3 abortions [2 spontaneous abortions and 1 prior ectopic pregnancy treated with methotrexate, side unknown], and 1 living child) with a right ectopic pregnancy diagnosed 7 days prior presented to the emergency department with vaginal bleeding and pelvic cramping. At time of diagnosis of right ectopic pregnancy, the patient had a serum beta–human chorionic gonadotropin
Discussion
A suspicion of ectopic pregnancy is based on the presence of abdominal or pelvic pain and vaginal bleeding in a female patient with a history of amenorrhea and a positive urine or serum pregnancy test (12). Although risk factors strengthen the likelihood of the diagnosis, the lack of risk factors should not prompt a clinician to rule out the condition because >50% of patients with an ectopic pregnancy have no risk factors (3). The diagnosis of ectopic pregnancy is based on quantitative serum
Why Should an Emergency Physician Be Aware of This?
As seen in this case report, the diagnosis of bilateral tubal ectopic pregnancies may not occur at the time of initial diagnosis. As such, it is imperative for clinicians to consider the possibility of bilateral tubal ectopic pregnancies in any female who presents with continued or worsening abdominal pain and persistent or abnormally elevated β-hCG level despite prior medical or surgical management of an ectopic pregnancy. In addition, the use of methotrexate in this patient demonstrates that
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Cited by (2)
Previously asymptomatic ruptured tubal ectopic pregnancy at over 10 weeks’ gestation: Two case reports
2019, Case Reports in Women's HealthCitation Excerpt :A paper published in Pakistan detailed ectopic rupture up to 10 weeks of gestation in an analysis of 80 patients [12]; however, the authors have not come across a publication detailing a tubal pregnancy of over 10 weeks as seen in the present report. Similarly, the lack of symptoms prior to presentation in the current case was also impressive, and literature describing initial symptom presentation at a comparable gestation is equally sparse [13–15]. The other case report, detailing a ruptured cornual ectopic pregnancy at over 17 weeks' gestation, is also remarkable.
A Rare Case of Bilateral Tubal Ectopic Pregnancy following Intracytoplasmic Sperm Injection-Embryo Transfer (ICSI-ET)
2020, Revista Brasileira de Ginecologia e Obstetricia
Reprints are not available from the authors.