Author
Information
Jamdade
Kshitij*, Gupta AS**
(* Assistant Professor, ** Professor. Department
of Obstetrics and Gynecology, Seth G.S. Medical
College and K.E.M
Hospital, Mumbai, India.)
Abstract
A woman presented
with simultaneous tubal pregnancy and scar ectopic after previous two caesarean
deliveries and prior history of genital tuberculosis. Ultrasonography (USG) diagnosis
was heterotopic pregnancy with ruptured tubal ectopic pregnancy. At laparotomy,
an accurate diagnosis of multiple ectopic gestations with ruptured scar ectopic
and un-ruptured tubal pregnancy was made.
Introduction
Twin or
multiple ectopic gestations may appear in a variety of locations and
combinations. About 250 twin ectopic gestations have been reported till now.[1]
Although most reports are confined to twin tubal gestations, ovarian,
interstitial, and abdominal twin pregnancies have been reported. Twin and
triplet gestations have been reported following partial salpingectomy[2]
and IVF.[3] Twin or multiple ectopic gestations occur less
frequently than heterotopic gestations whose estimated incidence is between
1/7000 and 1/30,000 pregnancies. Multiple ectopic pregnancies are diagnostic
and therapeutic challenges for obstetricians. A missed diagnosis even during
surgery can lead to a life threatening situation.
Case Report
A 30 years
old woman G5P3L2IUFD1MTP1 with 9 weeks of pregnancy presented with complaints
of abdominal pain and giddiness. She had had 2 cesarean sections in the past. She
had taken anti-tubercular treatment for genital tuberculosis 4 years ago. She
had already undergone USG elsewhere, which showed features of ruptured ectopic
pregnancy. On presentation she was pale, afebrile, with a pulse of 92/min and
blood pressure of 110/60 mm of Hg. Her abdomen was distended, tender and showed
a scar of previous LSCS. On vaginal examination the uterus was found to be of 6
weeks size. Tenderness was present on cervical motion and in the right fornix. The
left fornix was free. Culdocentesis yielded 2-3 ml of blood which did not clot.
USG at our center showed a heterotopic pregnancy with a single, live
intrauterine gestation of 10 weeks with sub-chorionic bleed and a right side
ruptured tubal ectopic pregnancy. Her Hb was 7.2 gm%, platelet count, renal and liver function tests were normal. During
an exploratory laparotomy a hemoperitonium
of about 500 ml, and a right tubal ampullary unruptured but oozing ectopic
gestation were found. Both ovaries and the left salpinx were normal. Right
terminal partial salpingectomy was done. We looked for the source of persistent
bleeding and found a 5 mm actively bleeding rent in the previous LSCS scar near
its right lateral angle. Products of conception were in the process of extrusion
from there. A fetus measuring 3.5X1X0.5 cm with identifiable head, eyes, limbs
and umbilical cord was removed. Placenta measuring 6.5X5.0X0.5 cm was also
removed. The gestational bed was communicating with the uterine cavity. The scar
was excised and the lower uterine rent was repaired with polyglactin 910 No. 0
suture. The patient was transfused with 2 units of packed cells. Her
postoperative course was uneventful. Pathological examination of the tube
showed the fallopian tube measuring 4X3X1.5cm to be externally congested and with
a cystic structure within it measuring 0.6X0.6 cm in it. There were foci of hemorrhages
and fibrin. Partially mixed inflammatory cells in the tubal wall and multiple
chorionic villi, decidual and trophoblastic tissue were seen on microscopy.
Figure 1A: Fetus with placenta
and decidua. (E: Embryo, D: Decidua, P: Placenta);
1B: Scar ectopic pregnancy. (Hollow
arrows: site of the ectopic pregnancy, U: Uterus)
Discussion
There are
many case reports in literature about multiple ectopic pregnancies, but our case
is unique as it is first of its kind with simultaneous scar and tubal ectopic.[4,5,6]
Various treatment options ranging from conservative management to radical
surgery like hysterectomy are available.[6,7] Hemoperitoneum warranted the surgical
intervention in our patient. The scar ectopic was in the process of rupturing
as the USG had shown a live intrauterine fetus. Timely detection allowed an
optimal conservative surgical treatment. Previous cesarean section and old
genital tuberculosis predisposed the patient for simultaneous scar and tubal
ectopic pregnancy.
Conclusion
Multiple
ectopic pregnancies must be considered in patients presenting with clinical and
USG features suggestive of heterotopic pregnancy, particularly after previous
cesarean deliveries and history of tuberculosis.
References
1. Olsen ME.
Bilateral twin ectopic gestations with intraligamentous and interstitial
components: a case report. J Reprod Med 1994;39:
118-120.
2. Adair CD, Benrubi GI, Sanchez-Ramos L, et al. Bilateral tubal ectopic
pregnancies after bilateral partial salpingectomy: a case report. J Reprod Med 1994;39:131-33.
3.
Goffner L, Bluth MJ,
Fruauff A, et al. Ectopic
gestation associated with intrauterine triplet pregnancy after in vitro
fertilization. J Ultrasound Med 1993;12:63-64.
4.
Abbas Honarbakhsh et al. Heterotopic pregnancy
following ovulation induction by Clomiphene and a healthy live birth: a case report.
Journal of Medical Case Reports 2008, 2:390
5.
James Andrews, Scott Farrell et al. Spontaneous
Bilateral Tubal Pregnancies: A Case Report. J Obstet Gynaecol Can
2008;30(1):51–54
6.
R Oliver et al. Management of extra-tubal and
rare ectopic pregnancies: case series and review of current literature
http://link.springer.com/journal/404: August 2007, Volume 276, Issue 2, pp
125-131
7.
Rock JA, Damario MA. Ectopic Pregnancy. In:
TeLinde’s Operative Gynecology, 10th Edition. Philadelphia: Lippincott, Williams and
Wilkins; 2008: 798–824.
Citation
Jamdade K, Gupta AS. Simultaneous Scar and Tubal Twin Ectopic
Gestation. JPGO 2014
Volume 1 Number 2 Available from: http://www.jpgo.org/2014/02/simultaneous-scar-and-tubal-twin.html