Clinical Communications: OB/GYN
Delayed Detection of Spontaneous Bilateral Tubal Ectopic Pregnancies After Methotrexate Treatment

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Abstract

Background

Bilateral tubal ectopic pregnancies are a rare subset of ectopic pregnancy that can pose a diagnostic dilemma for clinicians. There is no distinct clinical presentation for bilateral tubal ectopic pregnancies, although they are typically associated with assistive reproductive techniques. In addition, there is no single diagnostic feature to help clinicians delineate bilateral tubal ectopic pregnancies from other types of ectopic pregnancy prior to passing the discriminatory zone (such as heterotopic pregnancy or twin ectopic [two gestational sacs in one tube]). Diagnosis is typically made via direct visualization intraoperatively and therefore treatment is usually surgical.

Case Report

We present a case of spontaneous bilateral tubal ectopic pregnancies diagnosed 7 days apart via transvaginal ultrasound. The patient presented to the emergency department with pelvic pain on the contralateral side of her previously diagnosed ectopic pregnancy and vaginal spotting. Bilateral adnexal masses were visualized on ultrasound and her serum beta–human chorionic gonadotropin level had a 5.9% decline from day 4 to day 7 after methotrexate administration 7 days prior; gynecology was consulted. The patient was successfully treated with an additional dose of intramuscular methotrexate without any complications.

Why Should an Emergency Physician Be Aware of This?

The implications of this case suggest that diagnosis of bilateral tubal ectopic pregnancies requires clinicians to have a high level of suspicion in any pregnant female with a suspected or known ectopic pregnancy who presents with pelvic pain regardless of prior diagnosis or 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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