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Jeffers K, Koyfman A, Long B. Updates in emergency medicine: Ectopic pregnancy. Am J Emerg Med 2024; 85:90-97. [PMID: 39244808 DOI: 10.1016/j.ajem.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 08/24/2024] [Accepted: 09/01/2024] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION Ectopic pregnancy is a serious condition that can have significant morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy. CONCLUSIONS Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.
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Affiliation(s)
- Kristine Jeffers
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Tavares BVG, Delfino LS, Ignarro IS, Baccaro LF. Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:192-200. [PMID: 37224841 PMCID: PMC10208733 DOI: 10.1055/s-0043-1768999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital. METHODS Observational study with women with ectopic pregnancy admitted at UNICAMP Womeńs Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran-Armitage test, chi-square test, Mann-Whitney test and multiple Cox regression. RESULTS In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61-5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41-4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62-27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98-10.74), and do not smoke (PR = 2.41; 95%CI: 1.08-5.36). CONCLUSION there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.
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Affiliation(s)
| | - Letícia Sathler Delfino
- Department of Obstetrics and Gynecology, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Luiz Francisco Baccaro
- Department of Obstetrics and Gynecology, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Nkwabong E, Atangana Mvodo D, Fouedjio J. Risk factors for ectopic pregnancy in a sub-Saharan African country. Trop Doct 2023:494755231164791. [PMID: 36942405 DOI: 10.1177/00494755231164791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Our case-control study aimed at identifying the risk factors (RFs) for ectopic pregnancy (EP), and was carried out between 1st February and 31st May, 2019. Women who had EP were compared to those without EP. Out of 3421 pregnancies, 93 (2.7%) had EP. Independent RFs were previous EP, past history of infertility, first sexual encounter <15 years, past history of chlamydia infection, ≥ 3 sexual partners, use of levonorgestrel based emergency contraceptive pill, and unemployment. Girls should be counselled concerning these RFs and specifically against early sexual intercourse and multiple sexual partnership.
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Affiliation(s)
- Elie Nkwabong
- Professor, Department of Obstetrics and Gynecology, 260103Faculty of Medicine and Biomedical Sciences & University Teaching Hospital, Yaoundé, Cameroon
| | | | - Jeanne Fouedjio
- Associate Professor, Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences, Yaoundé, Cameroon
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Bridwell R, Long B, Montrief T, Gottlieb M. Post-abortion Complications: A Narrative Review for Emergency Clinicians. West J Emerg Med 2022; 23:919-925. [DOI: 10.5811/westjem.2022.8.57929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.
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Affiliation(s)
- Rachel Bridwell
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Tim Montrief
- Jackson Memorial Health System, Department of Emergency Medicine, Miami, Florida
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Birch EM, Torres Molina M, Oliver JJ. Not Like the Textbook: An Atypical Case of Ectopic Pregnancy. Cureus 2022; 14:e29881. [PMID: 36348920 PMCID: PMC9629873 DOI: 10.7759/cureus.29881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2022] [Indexed: 11/07/2022] Open
Abstract
Ectopic pregnancy is a potentially life-threatening outcome of pregnancy that occurs with the implantation of an embryo outside of the endometrial cavity. Classically considered a “must not miss” diagnosis, ectopic pregnancy is a common emergency department presentation, associated with a symptom triad of amenorrhea, vaginal bleeding, and abdominal pain. However, varied presentations of ectopic pregnancy or lack of typical risk factors can complicate the evaluation and diagnosis of this condition. This case report describes an atypical presentation of ectopic pregnancy after a reported spontaneous abortion, in which the patient was initially discharged with a diagnosis of pelvic inflammatory disease. This case provides an illustration of ectopic pregnancy that presented without classically associated symptoms, and also highlights how anchoring bias and pre-emptive closure, among other cognitive biases, contributed to a missed diagnosis.
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Affiliation(s)
- Neeraja Murali
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Sahar Morkos El Hayek
- Washington University in Saint Louis, 660 S Euclid Avenue CB 8072, St Louis, MO 63110, USA
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Kleinschmidt S, Dugas JN, Nelson KP, Feldman JA. False negative point-of-care urine pregnancy tests in an urban academic emergency department: a retrospective cohort study. J Am Coll Emerg Physicians Open 2021; 2:e12427. [PMID: 33969349 PMCID: PMC8087939 DOI: 10.1002/emp2.12427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 01/12/2023] Open
Abstract
STUDY OBJECTIVE To determine the prevalence of false negative point-of-care (POC) urine pregnancy tests among emergency department (ED) patients and among those with abdominal pain or vaginal bleeding. METHODS We identified all female patients, ages 14-50 years without prior hysterectomy who had a negative POC urine pregnancy test (beta subunit of human chorionic gonadotropin [β-hCG]) performed by trained clinical staff in the ED between September 1, 2017 and December 31, 2018, as well as a subgroup we defined a priori as "high risk" for early pregnancy complications based on a triage chief complaint (text) of abdominal pain or vaginal bleeding. We identified those with a positive urine β-hCG, serum β-hCG >5 mIU/mL, or a diagnosis of pregnancy within 3 months of the initial ED visit (index visit). We used structured chart review with American College of Obstetrics and Gynecology guidelines to determine pregnancy diagnosis and outcomes (ectopic, intrauterine, abnormal including spontaneous abortion, and unknown), the date of conception, and whether the pregnancy was present at the index visit. RESULTS Of 10,924 visits with a negative urine pregnancy test result that were screened for a pregnancy outcome, 171 (1.6%, 95% confidence interval [CI] = 1.4, 1.8) had a pregnancy present at the index visit. Diagnoses were ectopic (n = 12, 7.0%), intrauterine (n = 71, 41.5%), abnormal (n = 77, 45.0%), and unknown (n = 11, 6.4%). Of the 2732 patients with high-risk complaints, 97 (3.6%, 95% CI = 2.9, 4.3) had a pregnancy present at the index visit (relative risk of a pregnancy diagnosis 3.9, 95% CI = 2.9,5.3), including 10/12 ectopic (83%), 58/77 abnormal (75%), and 25/71 intrauterine pregnancies (35%). Serum β-hCG ranged from 2 mIU/mL to above assay (median = 119.5, interquartile range = 957.5). CONCLUSION Although false negative urine pregnancy tests were uncommon, multiple pregnancy diagnoses were missed, including ectopic pregnancies. False negatives were more common among patients with abdominal pain or vaginal bleeding. Concurrent serum β-hCG levels demonstrated a broad distribution.
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Affiliation(s)
- Sarah Kleinschmidt
- Department of Emergency MedicineBoston Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Julianne N. Dugas
- Department of Emergency MedicineBoston Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Kerrie P Nelson
- Department of Emergency MedicineBoston Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | - James A Feldman
- Department of Emergency MedicineBoston Medical CenterBoston University School of MedicineBostonMassachusettsUSA
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Lijuan SMD, Hui LMS, Juhong LMS, Cuixia GMS, Qingqing WMD. Preoperative Diagnosis of Ovarian Pregnancy by Transvaginal Ultrasound: A Case Report. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2021. [DOI: 10.37015/audt.2021.200015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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The Largest Tubal Pregnancy: 14th Week. Case Rep Obstet Gynecol 2020; 2020:4728730. [PMID: 32518701 PMCID: PMC7260646 DOI: 10.1155/2020/4728730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/02/2020] [Accepted: 05/12/2020] [Indexed: 01/07/2023] Open
Abstract
Subsequent development and implantation of embryo outside the uterine lining are defined as an ectopic pregnancy. Ectopic pregnancies have a wide range of presentations, for example, acute hemoperitoneum to chronic ectopic pregnancy. The case presented is an unusual case of ectopic pregnancy with large hematosalpinx with classic symptoms. To the best of the authors' knowledge, this case is the largest intact tubal ectopic pregnancy reported ever in the 14th week of gestation. A 40-year-old patient presented to the emergency department with lower abdominal pain, mild dysuria, and loose motion. The patient's previous menstrual cycles were regular till four months ago, then started to be irregular, and she had no history of chronic diseases except repeated pelvic inflammatory diseases (PID). Clinically, the patient was hemodynamically stable. On palpation, the abdomen was tender, and cervical movements were not tender. BHCG in the blood came very high. The bedside point-of-care ultrasound (POCUS) showed free fluid in the abdomen and a sac in the left adnexa with a living fetus (visible heartbeats). The conventional ultrasound showed 14 weeks of an extrauterine gestational sac with visible early pregnancy. Differential diagnosis was either an abdominal pregnancy versus a complicated tubal pregnancy. The surgical pathology report confirmed the diagnosis of ectopic tubal pregnancy as the tube was dilated in the middle portion containing chorionic villi, decidual reaction, and the whole gestational sac consistent with the ectopic tubal pregnancy. The patient had a successful laparotomy with salpingectomy and hemostasis and did well after the operation. So, an intact ectopic tubal pregnancy may last until the 14th week of gestation.
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Ge L, Sun W, Wang L, Cheng L, Geng C, Song Q, Zhan X. Ultrasound classification and clinical analysis of ovarian pregnancy: A study of 12 cases. J Gynecol Obstet Hum Reprod 2019; 48:731-737. [PMID: 30980997 DOI: 10.1016/j.jogoh.2019.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 03/31/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the clinical significance of preoperative ultrasound diagnosis and classification of ovarian pregnancy (OP). METHODS The ultrasonographic reports, medical records, and operative summaries were reviewed for twelve women with a confirmed diagnosis of OP. According to the ultrasonographic appearance, OP was classified into two types. For every type, we analyzed the possibility and clinical significance of preoperative ultrasound diagnosis, combining with its clinical manifestations and treatments. RESULTS According to sonographic features, twelve cases of OP can be classified into ruptured type (n = 6) and unruptured type (n = 6), the latter was subclassified into embryo sac type (n = 2) and non-homogeneous mass type (n = 4). All the unruptured OP have the characteristic solid hyperechoic rings or masses, and 66.7% (4/6) were correctvly diagnosed by preoperative ultrasound. No characteristic ultrasonogram was detected in ruptured OP which were all diagnosed as ruptured ectopic pregnancy (EP) or corpus luteum by preoperative ultrasound. The diagnostic and surgical procedures of four cases diagnosed by preoperative ultrasound were all laparoscopy and removal of the gestational products, and their average hemoperitoneum, operation time, hospital days was 313 ± 278 ml, 57 ± 9 min, and 4.25 ± 0.5days, respectively. While ruptured OP cases (6 cases diagnosed at first visit and 1 underdiagnosed but ruptured after 6 days), the diagnostic procedures was laparoscopy(3/7) or laparotomy(4/7), the surgical procedure was removal of the gestational products(2/7), wedge resection(3/7), or adenexectomy(2/7), and their average hemoperitoneum, operation time, and hospital days was 1914 ± 1059 ml, 93 ± 17 min, and 5.9 ± 1.3days, respectively. CONCLUSIONS Ultrasound plays a significant role in diagnosis of OP, and part of the unruptured OP based on the typical sonographic characteristics could be correctly diagnosed by an experienced sonographer, this is beneficial and effective in terms of the risk of patient's operation and life. Whereas ruptured OP were generally diagnosed as ruptured EP or corpus luteum because there were no characteristic ultrasound manifestations.
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Affiliation(s)
- Ling Ge
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Wenrong Sun
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Lihua Wang
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Lei Cheng
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Chenchen Geng
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Qian Song
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Xinfeng Zhan
- Department of Ultrasound, Qilu Hospital of Shandong University (Qingdao), Qingdao, China.
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Abstract
Early in pregnancy women frequently experience nausea, vomiting, and vaginal bleeding. Nausea and vomiting can be mild, managed by dietary modifications and medications, or severe, requiring intravenous fluids and medications. Care should be used when selecting medications for nausea to avoid additional side effects or potential harm to the developing fetus. When evaluating vaginal bleeding in early pregnancy, ectopic pregnancy must be ruled out. If an intrauterine pregnancy is seen, threatened miscarriage should be considered and the patient appropriately counseled. If neither intrauterine pregnancy nor ectopic pregnancy can be established, a management algorithm for pregnancy of unknown location is presented.
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Affiliation(s)
- Elizabeth Pontius
- Department of Emergency Medicine, Georgetown University School of Medicine, MedStar Georgetown University Hospital, MedStar Washington Hospital Center, 110 Irving Street, Northwest, NA 1177, Washington, DC 20010, USA
| | - Julie T Vieth
- Department of Emergency Medicine, Canton-Potsdam Hospital, 50 Leroy Street, Potsdam, NY 13676, USA.
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Gauvin C, Amberger M, Louie K, Argeros O. Previously asymptomatic ruptured tubal ectopic pregnancy at over 10 weeks' gestation: Two case reports. Case Rep Womens Health 2018; 21:e00089. [PMID: 30591911 PMCID: PMC6305792 DOI: 10.1016/j.crwh.2018.e00089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/09/2018] [Accepted: 11/13/2018] [Indexed: 12/16/2022] Open
Abstract
Ectopic pregnancy is a life-threatening condition affecting up to 2% of gestations. Implantation in the fallopian tube is most common, with symptoms typically presenting earlier for gestations in the ampulla and isthmus compared with the cornua and non-tubal sites. In this paper, the cases are described of two patients with advanced ectopic pregnancies that ruptured. One woman aged 36 years presented at 17 1/7 weeks' gestation with a ruptured cornual ectopic pregnancy. The other woman, aged 35 years, presented at 11 1/7′ weeks gestation with a ruptured ectopic pregnancy in the left tubal ampulla. To our knowledge, there are no other reported cases of a tubal ampulla pregnancy presenting at such an advanced gestation with no prior symptoms. Ectopic pregnancy is a common condition and a contributor to maternal mortality. The cases are reported of two women who displayed symptoms well beyond the usual presenting gestational age. This case report encourages the consideration of routine, first-trimester ultrasound scanning. It also highlights the opportunity for patient education regarding ectopic pregnancy.
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Affiliation(s)
- Caitlin Gauvin
- NYIT College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY, USA
| | | | - Kevin Louie
- Department of Surgery, St. Barnabas Hospital, Bronx, NY, USA
| | - Olga Argeros
- Department of Obstetrics and Gynecology, St. Barnabas Hospital, Bronx, NY, USA
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Abstract
RATIONALE Ectopic pregnancy (EP) is a condition in which a fertilized oocyte implants outside the uterine. Spontaneous bilateral tubal pregnancies are the rarest form of ectopic and are considered spontaneous when no fertility treatments are involved. There are few prior cases. Here I report a case of spontaneous bilateral tubal pregnancy. PATIENT CONCERNS A 24-year-old female with long lasting vaginal bleeding of 29 days duration. DIAGNOSES Transvaginal ultrasound observed small complex masses on both adnexal sides without intrauterine gestational sac, and the hCG level was 21438 IU/L. But diagnosing based only on imaging findings and blood test result was difficult. INTERVENTIONS Operative laparoscopy with salpingectomy bilaterally. OUTCOMES Villi were clearly shown in both resected tubes. A spontaneous bilateral tubal pregnancy was confirmed finally and the patient recovered uneventfully. LESSONS Women of reproductive age with irregular menstruation should get access to diagnosis and appropriate treatment without delay. Salpingotomy should also be considered if the patient had a strong wish for future pregnancy. Developments of diagnosis and management of such condition are strongly called for.
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