- Research Article
15- 10.1034/j.1600-0412.2002.810417.x
Laparoscopic management of an unrecognized spontaneous bilateral tubal pregnancy.
- Apr 01, 2002
- Acta Obstetricia et Gynecologica Scandinavica
- Eva Maria Sommer + 3 more +3
In industrialized countries, the incidence of ectopic pregnancy has increased sixfold over the past 30 years, and is now estimated to be approximately 2% of all reported pregnancies (1). The rise in incidence has been attributed to improved methods in diagnosis and reporting, an increased frequency of pelvic inflammatory disease (2) and the growing importance of assisted reproductive techniques (ART). Bilateral ectopic pregnancy, however, is a rare condition, occurring at a ratio of 1/725–1/1580 ectopic pregnancies (3). Published some 60 years ago, Fishback's series of 76 cases of bilateral simultaneous tubal pregnancies probably represents the first comprehensive report on this topic (4). Compared with natural conception, the incidence of ectopic pregnancy in in vitro fertilization (IVF) programs is considerably higher with frequencies reported between 2% and 12.4% 5-7). The underlying mechanisms of this phenomenon are still discussed controversially. Of note, the first recorded pregnancy following IVF, reported by Steptoe and Edwards in 1976, was a tubal pregnancy in a woman with a known history of tubal damage (8). Tubal damage, however, is a major reason for women to seek treatment in IVF programs, and thus it is difficult to rule out the inherent risk of the IVF procedure per se. Clearly, the key to successful management of an ectopic pregnancy is early diagnosis. Given the current accuracy of different tests, algorithms using a combination of ultrasound and hCG testing provide the most favorable outcomes (9). We present a case of a bilateral tubal pregnancy; despite thorough preoperative work up including repeat ultrasound and serial hCG testing, correct diagnosis was not made until surgery. A 30-year-old nulliparous woman presented to the gynecologic outpatient department with the only clinical symptom of painless vaginal bleeding for 2 days. β-hCG in the urine was positive, indicating a pregnancy of 5.6 gestational weeks, calculated from the first day of her last menstrual period. Her previous history revealed two miscarriages and a hysteroscopic metroplasty performed 9 months ago. Pelvic examination at the time of admission was unremarkable, and transvaginal ultrasound showed an endometrium of 10.3 mm without an amniotic sac, normal adnexa on both sides and no fluid within the peritoneal cavity. The woman was hospitalized for clinical observation and β-hCG testing, and 4 days later developed left-sided lower abdominal pain, remaining in a stable hemodynamic condition. Transvaginal ultrasound performed by a senior clinician revealed a complex structure with a predominantly fluid center in the left adnex region, suggesting a yolk sac. The additional abnormal rise in quantitative serum β-hCG levels (966 U/L at admission, 1130 U/L after 48 h and 1800 U/L after 72 h) indicated a left-sided tubal pregnancy. The patient was carefully counselled and opted straight away for laparascopy instead of intramuscular methotrexate (MTX) administration. Immediately after insertion of the laparoscope, diagnosis of a bilateral tubal ectopic pregnancy was made. The left and right tube were approximately 3–4 cm and 2–3 cm in diameter, indicating an ampullary-fimbrial and isthmic ectopic pregnancy, respectively (Fig. 1). Two 5-mm secondary ports were inserted on either side of the mid-line within the safety triangle delineated inferiorally by the bladder fundus and laterally by the obliterated umbilical arteries. Bilateral salpingotomy was performed with a monopolar needle (50 watts), the incisions placed on the proximal part of the anti-mesenteric border of each tube; no vasoconstrictive agent was injected into the mesosalpinx. Brownish fluid extruded, and the products of conception were extracted on both sides with the use of atraumatic grasping forceps, toothed biopsy forceps, and irrigation from an aquadissector. Thorough lavage was performed and a small bipolar forceps (30 watts) applied for meticulous hemostasis. The tubal incisions were left open, and at the end of the procedure, an abdominal drainage was placed in the cul-de-sac. Estimated blood loss was 300 mL. . Intraoperative sites: uterus and adnexa, ampullary-fimbrial and isthmic ectopic pregnancy of the left and right tubes, respectively. Histologic examination identified chorionic villi in each tube, thus confirming the presence of a bilateral tubal pregnancy. Postoperative serial β-hCG measurements indicated complete removal of the trophoblast. The patient made an uneventful recovery and was discharged from hospital on day 4 after the operation. Twelve months later, the patient was admitted with a recurrent left-sided tubal pregnancy. As IVF treatment had already been planned, a laparoscopic bilateral salpingectomy was performed. The postoperative course was unremarkable and the patient was discharged on day 3 after the operation. Ectopic pregnancy represents an increasingly common condition associated with a great variety of clinical symptoms. Thorough pelvic examination, knowledge of possible risk factors, and serial β-hCG testing combined with ultrasonography allow for early and correct diagnosis thereby preventing tubal rupture in most cases. Established therapeutic options for the management of an early unruptured tubal pregnancy include laparoscopic surgery and systemic or local MTX, the primary aim of both being tubal preservation. With minimal access surgery, however, controversy exists regarding the best technique to preserve the tube. In our case we performed a bilateral tubal salpingotomy without suturing the tubal incisions, a technique recommended by many authors, the idea being to provide better long-term results in terms of tubal patency and adhesion prevention. This approach, however, is in contrast to a similar case described in the literature 2 years ago, where the tubal incisions were closed (10). In our case, the occurrence of a bilateral tubal pregancy had not been recognized until surgery, even though a senior staff member had performed preoperative work up. A major draw back for every clinician, this phenomenon has been described in the literature several times (11). For instance, Mahoney et al. reported that in 20% of women with surgically confirmed ectopic pregnancy normal adnexa had been seen sonographically (12). Although correct diagnosis would not have altered outcome in our patient because she had opted for surgical management, we emphasize the rare possibility of a dual pregnancy, be it tubal or at other sites. In the near future, an increasing number of patients diagnosed with tubal pregnancy might choose medical treatment instead of surgery. For instance, MTX, either administered systemically or injected locally under sonographic guidance, has emerged as an alternative to surgical procedures (13, 14). The presence of a bilateral ectopic pregnancy, however, requires either adjustment of the systemic methotrexate dosage (15) or local injection on both sides. Even though the diagnostic performance of ultrasound has improved through the availability of high-resolution equipment and vaginal probes, it still bears the flaws inherent to any imaging method, not to speak about the sonographer's experience. In contrast, laparoscopy allows for direct visualization of the condition and thus prompt, correct and impeccable diagnosis. Avoiding surgical trauma to the tube, some authors suggest that MTX treatment might offer better fertility prospects than conservative laparoscopic surgery (16, 17). According to these findings, primary MTX therapy in our patient would have reduced the risk of a recurrent ectopic pregnancy. Apart from the fact that the conservative diagnostic approach would have missed the bilaterallity, the superiority of MTX in terms of future reproductive outcome is not uncontradicted (17). A third way of administering MTX treatment is local injection under laparoscopic control (18). This approach would not bear the risk of missing an eventual bilaterallity, but in terms of long-term reproductive outcome compares with laparoscopic salpingostomy (19). In conclusion, laparoscopy remains the cornerstone of diagnosis and treatment in the majority of women with a tubal pregnancy (20); this is especially true in complex cases such as a bilateral tubal pregnancy.
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