Bilateral tubal and intrauterine pregnancies diagnosed at laparoscopy

Bilateral tubal ectopic pregnancy following induction ovulation can be missed in emergent ultrasonography: Case report

INTRODUCTION

Bilateral tubal ectopic pregnancy (BTP) is a rare and potentially life-threatening condition that is, often challenging to diagnose preoperatively.

PRESENTATION OF CASE

We present a case of BTP in a 25-year-old primigravid woman with a history of infertility due to polycystic ovarian syndrome. She was receiving letrozole when she presented with severe abdominal pain and vaginal bleeding. Initial evaluation revealed a ruptured ectopic pregnancy in the right fallopian tube, prompting an emergency laparotomy. During surgery, a second intact ectopic mass was discovered in the left fallopian tube, highlighting the diagnostic complexity of BTP. Management involved a salpingectomy on the right side and salpingostomy on the left to preserve fertility.

DISCUSSION

This case underscores the importance of considering BTP in the differential diagnosis of ectopic pregnancies and the necessity for thorough preoperative imaging studies, namely ultrasonography and surgical exploration, to prevent missed diagnoses.

CONCLUSION

BTP is a rare and challenging clinical entity that requires a comprehensive approach to diagnosis and management. Early recognition, prompt intervention, and close surveillance are essential to mitigate the risk of maternal morbidity and mortality associated with this condition.

Heterotopic pregnancy - how easily you can go wrong in diagnosing? A case study

Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms.

Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms.

Bilateral tubal pregnancies after a single-embryo transfer

Case

To present an extremely rare case of bilateral tubal pregnancies following a single‐embryo transfer in a woman with a 4 year history of infertility prior to seeking assisted reproductive technology.

Outcome

A pregnancy resulted from the transfer of an embryo that had been thawed from a frozen blastocyst during a hormone replacement cycle. An ultrasound that was performed at 5 weeks and 5 days of gestation revealed a gestational sac, embryo, and heartbeat in the right fallopian tube and similar signs of a gestational sac in the left fallopian tube. A laparoscopy revealed clear signs of an ectopic pregnancy in the ampulla of the right fallopian tube. Signs of swelling also were seen in the ampulla of the left fallopian tube. As the possibility of bilateral tubal pregnancies could not be ruled out, both fallopian tubes were removed. Pathological tests revealed chorionic villi and trophoblasts in both the left and right fallopian tubes.

Conclusion

All previously reported cases of bilateral tubal pregnancies have been a result of multiple ovulations or multiple‐embryo transfer and no case of bilateral tubal pregnancies after a single‐embryo transfer has ever been reported. No genetic testing was performed; thus, it cannot be definitively stated that the divided chorionic villi and trophoblasts came from only one embryo.

Spontaneous Bilateral Tubal Ectopic Pregnancy: Incidental Finding During Laparoscopy - Brief Report and Review of Literature

Objective: Bilateral tubal ectopic pregnancies are rare; the reported incidence is only 1 in 200 000 pregnancies. Detecting bilateral tubal ectopic pregnancy is urgent because of the associated morbidity and mortality. The appropriate fertility-preserving surgery must also be considered, as preservation of both tubes is presumed to offer better fertility prospects. Case Report: A 39-year-old gravida 2, para 1 presented with vaginal bleeding at 8 + 4 weeks of gestation. An approximately 18 mm adnexal mass in the right fallopian tube was detected on ultrasound. Laparoscopy was performed because ectopic pregnancy was suspected. This suspicion was confirmed during laparoscopy; the right fallopian tube was found to contain a mass measuring 20 mm in the isthmic part. Ultrasound of the left fallopian tube also showed a mass in the ampullary region (diameter: 10 mm), also suspicious for ectopic pregnancy. Bilateral salpingotomy was performed laparoscopically. Pathological examination confirmed the diagnosis. Conclusions for Practice: Although ectopic tubal pregnancy is seen more often after assisted reproductive techniques, bilateral spontaneous ectopic pregnancies must also be considered in other cases. Laparoscopic surgery is effective to confirm the diagnosis and treat heterotopic pregnancies. Further studies will be needed to confirm whether unilateral or bilateral conservative fertility-preserving surgery is more appropriate.

Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies

BACKGROUND

Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment.

METHODS

The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected.

RESULTS

A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence.

CONCLUSIONS

EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.