Double trouble: A case of bilateral tubal pregnancy*

By Christine Joy P. Chang, MD and Ma. Regale Noemi O. Sotto, MD, FPOGS, FPSRM, FPSGE
Department of Obstetrics and Gynecology, Quezon City General Hospital

ABSTRACT

Bilateral tubal pregnancy is the rarest form of ectopic pregnancy, and in most cases results from assisted reproductive
techniques. The incidence of simultaneous bilateral tubal pregnancies has been reported to range from 1 per 725 to 1 per 1580
ectopic pregnancies or approximately corresponds to 1 per 200,000 pregnancies. To date, this is the only case reported in our
institution. Bilateral tubal pregnancies are usually diagnosed intraoperatively, but with the advent of diagnostic tools and more
readily available diagnostic modalities, an earlier diagnosis can be made to decrease maternal morbidity and mortality.
This is a case of a 24-year old female, who came in at the emergency room complaining of severe hypogastric pain. She was
admitted as a case of ectopic pregnancy, probably ruptured. Subsequently, emergency exploratory laparotomy was done which
revealed bilateral tubal masses, which on histopathological examination confirmed bilateral tubal pregnancy.

INTRODUCTION CASE REPORT

E
ctopic pregnancy is defined as a pregnancy that This is a case of K.P., a 24-year-old, Gravida 2 Para
develops after implantation of the blastocyst 1 (1001), who came in with a chief complaint of severe
anywhere else other than the endometrial lining hypogastric pain and was admitted for the first time in our
of the uterine cavity. The incidence of ectopic pregnancy institution on May 4, 2016.
ranges between 1-2% of all pregnancies. Nearly 95% of She has unremarkable past medical history. She has a
them occur in the fallopian tubes. Synchronous bilateral family history of diabetes mellitus on her paternal side but
ectopic pregnancy is very rare, and in most cases results denies other heredofamilial diseases such as hypertension,
from assisted reproduction techniques. Bilateral ectopic malignancies, cardiac and thyroid disorders.
pregnancy is the rarest form of ectopic pregnancy and one She is the second among three siblings, a high school
has been reported in our hospital. graduate and is currently unemployed. She has been in a
relationship with a 28-year-old fast food crew for a year.
GENERAL OBJECTIVE She is a previous smoker of 0.25 pack years smoker and an
occasional alcoholic beverage drinker.
To present a rare case of bilateral tubal pregnancy Her last menstrual period was on February 10, 2016
in a 24-year-old female with no history of assisted with a computed age of gestation of 12 weeks, and an
reproductive technology and to recognize its importance expected date of confinement on November 17, 2016. She
as a life threatening condition. had her menarche at 10 years of age, with regular intervals,
lasting for 5 days, and consumes 2-3 moderately soaked
Specific Objectives pads per day. Patient claims to experience dysmenorrhea
To define ectopic pregnancy. every menstrual cycle. She had her coitarche at 14 years
To state the incidence of bilateral tubal pregnancy. of age and had 4 previous sexual partners. She has no
To identify the risk factors in developing ectopic history of contraceptive use and denies history of sexually
pregnancy especially those seen in the patient. transmitted infections.
To discuss the pathophysiology of bilateral tubal She is a gravida 2 para 1 (1001). Her first pregnancy
pregnancy. was delivered alive, term, via spontaneous vaginal
To discuss the diagnosis and management of bilateral delivery at home, assisted by a midwife. No fetomaternal
tubal pregnancy. complications were noted.
The history of present illness started a few hours
prior to admission, when the patient experienced severe,
sharp, stabbing, hypogastric pain radiating to the lower
back associated with vaginal spotting. No other signs and
symptoms were noted such as passage of meaty materials,
*Finalist, Philippine Obstetrical and Gynecological Society (Foundation), fever or dysuria. Persistence of the above symptoms
Inc. (POGS) Interesting Case Paper Contest, September 21, 2017, 3rd
Floor POGS Building, Quezon City prompted patient to seek consult.
36 Volume 41, Number 6, November-December 2017
 On physical examination, the patient was awake, blood count was done which revealed a hemoglobin of
coherent, and not in cardiorespiratory distress. Her 106 g/L, hematocrit of 0.314, and white blood cell count
blood pressure was 90/60 mmHg, cardiac rate of 102 of 24.15 x 109/L with predominance of neutrophils (Table
beats per minute, respiratory rate of 20 cycles per 1). Urinalysis revealed red blood cell count of 8-10/hpf and
minute and temperature of 36.5o Celsius. She had pink white blood cell count of 10-15/hpf (Table 2). The patient
palpebral conjunctivae, anicteric sclera, no nasoaural underwent emergency exploratory laparotomy under
discharge, no tonsillopharyngeal congestion, or cervical spinal anesthesia. Upon exploration, there was 1.3 liters
lymphadenopathies noted. of hemoperitoneum. The left fallopian tube was converted
Her chest expansion was symmetrical and no to a 4x4 centimeter cystic, hemorrhagic mass with a 1.5
retractions were noted on the intercostal space. centimeter point of rupture at the ampullary area. The
Auscultation of the lung area revealed clear breath sounds. right fallopian tube on the other hand was converted into
She had a dynamic precordium, her heartbeat had a a 6x6 centimeter cystic, hemorrhagic mass with no point
normal rate and regular rhythym and no murmurs were of rupture. Both ovaries and uterus were grossly normal.
appreciated. No adhesions were noted (Fig. 1). The surgical team then
Abdominal examination revealed a rigid, tender proceeded with bilateral salpingectomy. Estimated blood
abdomen with muscle guarding. loss was 2 liters. The patient tolerated the procedure well.
Her external genitalia was grossly normal. At the post anesthesia care unit, the patient had
Speculum exam revealed a pinkish and smooth vaginal stable vital signs and was noted to have adequate and
mucosa with no polyps, warts or ulcerations. On internal clear urine output.
examination, her cervix was firm, closed, with cervical On her first post-operative day, the patient had no
motion tenderness. Uterus was small with bilateral subjective complaints. She had stable vital signs and had
adnexal tenderness. already passed flatus. On physical examination, she was
Patient had full and equal pulses on all extremities. noted to have facial pallor, and abdomen was noted to be
No gross deformities noted. soft and non-tender. Post-operative complete blood count
At the emergency room, pregnancy test was positive. revealed hemoglobin of 73 g/L, hematocrit of 0.213 and
Laboratories such as complete blood count and urinalysis white blood cell count of 19.46 x 109/L with predominance
were done. of neutrophils. She was started on soft diet. Two units of
She was subsequently admitted as a case of Gravida packed RBC were transfused. Wound dressing was done
2 Para 1 (1001), Ectopic Pregnancy, Probably Ruptured and and revealed a well coaptated wound with no discharges.
the plan was for emergency exploratory laparotomy with The rest of the hospital stay was unremarkable. Vital
possible salpingectomy. sign were stable.
Histopathologic report revealed findings of a right
COURSE IN THE WARDS fallopian tube that measures 5.0 x 4.0 x 2.0 cm with a
dilated portion 2.0 cm from the fimbrae measuring 4.0 x
Upon admission, patient was venoclysed. Complete 3.0 x 1.0cm and a left fallopian tube which measures 5.0

Table 1: Complete Blood Count

5/4/16 5/4/16(post-op) 5/5/16 5/7/16

RBC x1012/L 3.23 x 10 /L
12 2.56 x 10 /L 12
2.26 x 10 /L
12
3.20 x 1012/L
Hemoglobin 106 g/L 79 g/L 73 g/L 96 g/L
Hematocrit 0.314 0.247 0.213 0.292
MCV 97.1 fl 96.4 fl 94.1 fl 91.1 fl
MCH 32.8 pg 30.9 pg 32.3 pg 30.0 pg
MCHC 338 g/L 320 g/L 343 g/L 329 g/L
Platelet count 363 x 10 L9 198 x 10 L 9
157 x 10 L 9
246 x 109 L
WBC 24.15 x 109 L 19.46 x 109 L 6.77 x 109 L 5.75 x 109 L
Diff ct: Neutrophils 97.3% 93.1% 80.3% 60.9%
Lymphocyte 1.6% 3.2% 11.9% 1.0%
Monocyte 1.0% 3.6% 6.2% 11.1%
Eosinophil 0 0.1% 1.4% 6.2%

Volume 41, Number 6, PJOG November-December 2017 37

Table 2: Urinalysis

Color Dark Yellow

Transparency Hazy
Protein Trace
Glucose Negative
pH Acidic
Specific Gravity 1.025
Red Blood Cells 8-10
White Blood Cells 10-15

Figure 2. Microsection of the Right Fallopian Tube (showing

chorionic villi and decidual tissues). Arrow A shows the lining
epithelium (ciliated columnar epithelial cells.) Arrow B shows
decidual tissues. Arrow C shows luminal projections lined by
ciliated cuboidal cells with immature chorionic villi.

Figure 1. Arrow A shows the 4x4 centimeter cystic, hemorrhagic

mass on the left fallopian tube; Arrow B shows the 1.5 centimeter
point of rupture at the ampullary area; Arrow C shows the 6x6
cystic hemorrhagic mass on the right fallopian tube. Arrow D
shows the uterus.
Figure 3.1. Microsection of the Left Fallopian Tube. Arrow
shows the luminal projections lined by ciliated cuboidal cells
x 3.0 x 2.0 with a dilated portion 2.0 cm from the fimbrae with immature chorionic villi.
measuring 4.0 x 3.0 x 1.0 with a 1.5 cm gross rupture at
the ampullary area. Both have a dark brown to maroon
discoloration, tubular and rubbery. Microscopic sections
of both fallopian tubes show luminal projections lined
by ciliated cuboidal cells with immature chorionic villi
and decidual tissues (Figures 3.1 and 3.2). The final
histopathologic diagnosis was Tubal Pregnancy, Right
Fallopian Tube and Tubal Pregnancy, Ruptured, Left
Fallopian Tube (Fig. 4).

CASE DISCUSSION

Ectopic is derived from the greek word ektopos

meaning out of place. After successful fertilization, the
blastocyst normally implants in the endometrial lining
of the uterine cavity. Implantation anywhere else is Figure 3.2 Microsection of the Left Fallopian Tube. Arrow shows
considered an ectopic pregnancy1. About 1-2 percent of decidual tissues.
38 Volume 41, Number 6, November-December 2017
 secondary anemia due to either preoperative hemorrhage
or both preoperative and postoperative hemorrhage and
infection18.
Bilateral tubal pregnancy, in the absence of preceding
induction of ovulation or assisted reproductive technology,
is an extremely unusual occurrence and the rarest form of
ectopic pregnancy. Worldwide, the estimated incidence
of bilateral tubal pregnancy is 1 in 725 to 1 in 1580 of all
ectopic pregnancies12 which corresponds to an occurrence
of 1 in 200,000 pregnancies3. This is in contrast with the
incidence of the other variants of ectopic pregnancy, with 1
in 9,000 pregnancies for cervical pregnancy, 1 in 2,000 to 1
in 60,000 pregnancies for ovarian pregnancy, 1 in 183,000
pregnancies for abdominal pregnancy and 1 in 16,000 to 1
in 30,000 pregnancies for heterotopic pregnancy2.
Fishback, in 1953, reported a series of 76 cases of
bilateral tubal pregnancy in the Canadian medical associated
journal 8,11. In 1989, Edelstein found 22 more cases7,11.
Andrews, in 2008, reviewed literature and revealed 45
further case reports, 17 of which are associated with
assisted reproductive techniques, and 28 patients are listed
as spontaneous 4,11. De Los Ríos, reviewed and analyzed 42
cases of bilateral tubal pregnancies reported in the last 10
years 9,11. In total, there are about 200 cases of bilateral
tubal pregnancy reported in the literature to date14. Most of
Figure 4: Copy of the final histopathologic report.
these cases are usually diagnosed intraoperatively.
In 2007, Llovit reported a case of bilateral tubal
all conceptions are ectopic and these account for 6 percent pregnancy in a woman with no significant risk factors in the
of all pregnancy related deaths1. Nearly 95 percent of Philippine Council for Health Research and Development
ectopic pregnancies are implanted in the segments of Library11. At present, there is no reported case of bilateral
the fallopian tubes and the remaining 5 percent are tubal pregnancy that has been published in the archives
implanted in the ovary, peritoneal cavity or cervix1. About of the Philippine Obstetric and Gynecologic Society. There
81 percent are ampullary implantations and these are the were no cases reported in the hospital census as well. The
most common, 12 percent are in the isthmus, 5 percent in incidence of bilateral tubal pregnancy in the Philippines is
the fimbrial end and 2 percent in the interstitial region2. not known.
Multifetal pregnancies may implant simultaneously with The major risk factor of ectopic pregnancy is
either both ectopic or one intrauterine and the other salpingitis2. Its morphologic sequelae account for about
extrauterine1. Such usually occurs following assisted half of the initial episodes of ectopic pregnancy. The
reproductive technologies (ART)12. The rate of ectopic agglutination of the plicae (folds) of the endosalpinx
pregnancies continue to increase in the United States and produced by salpingitis can allow passage of sperm,
many European countries due to a number of factors which but prevent the normal transport of the larger morula.
include increased rates of sexually transmitted infections, The morula can be trapped in blind pockets formed by
failed contraception, use of ARTs and tubal surgery2. adhesions of the endosalpinx2. Though not documented,
According to World Health Organization (2007), prior tubal infection, which can distort normal tubal
5 percent of maternal deaths in developed countries anatomy, is likely present in our patient. Her sexual history
are from ectopic pregnancy. These deaths declined revealed that the patient had 4 previous sexual partners
markedly from 1980-1992 due to improved diagnosis which is a risk factor for having tubal infection.
and management. In a review of deaths from ectopic It is also reported that cigarette smoking is associated
pregnancy in Michigan, 44 percent of the women who with increased risk of ectopic pregnancy2. The number of
died were either found dead at home or were dead on cigarettes smoked per day was found to be directly related
arrival at the emergency department17. In a review of to the development of ectopic pregnancy, with a fourfold
206 cases of ectopic pregnancy in the Philippines, the increased risk noted among women who smoked 30 or
mortality was 7.28 percent. The main causes of death were more cigarettes per day6. In the case of our patient, she

Volume 41, Number 6, PJOG November-December 2017 39

is a 0.25 pack-years smoker consuming 2-3 sticks per day indicating limitations in ultrasonography. Martinez, in
for 2 years which probably increased her risk of having an 2009, made an unusual case report of early diagnosis
ectopic pregnancy. by ultrasonography of a bilateral tubal pregnancy10. The
There are three possible theories for development most common method of diagnosing the second ectopic
of bilateral tubal pregnancy: 1) simultaneous multiple is through direct inspection of contralateral tube in the
ovulation, 2) sequential impregnation or 3) transperitoneal operating room or laparoscopic examination. In this case,
migration of trophoblastic cells from one extrauterine it was diagnosed intraoperatively.
pregnancy to the other tube with implantation there16. Laparoscopic surgical treatment is preferable to
Foster stated that bilateral tubal pregnancy open procedures, because of faster patient recovery2.
requires multiple ovulations to occur with simultaneous However, because of the acute symptoms of the patient,
fertilization and implantation of both oocytes5. Another conservative management, with either laparoscopic
possible etiology is sequential impregnation, which implies surgery or medical management with methotrexate was
fertilization and development of a second oocyte when a not considered. Tubal surgery is considered conservative
woman is already pregnant16. This is considered to be an when there is tubal salvage, such as with salpingostomy
extremely rare event in humans and is inherently difficult or salpingotomy. Salpingostomy was attempted on the
to prove. Tabachnikoff et al stated that transperitoneal unruptured side of the fallopian tube. However, it was
migration of trophoblastic cells from one tube to another unsuccessful due to the uncontrolled bleeding from the
is a plausible explanation for the finding of fetal tissue in implantation site. Some have shown conservative surgery
one tube and only villi in the other tube 4,16. may increase the rate of subsequent uterine pregnancy but
The most possible explanation applicable in our is associated with higher rates of persistently functioning
case is the theory of simultaneous multiple ovulation. trophoblast. Radical surgery is defined by salpingectomy.
Both ectopic gestations are of approximately the same Unfortunately, bilateral salpingectomy was done to our
age ruling out the theory of sequential impregnation. patient due to the size of the mass in both tubes.
Transperitoneal migration of trophoblastic cells is also Intraoperatively, the left fallopian tube was
not a likely explanation because histopathology revealed converted to a 4x4 centimeters hemorrhagic mass with
the presence of decidual tissues and chorionic villi in the a 1.5 centimeter point of rupture at the ampullary area.
lumen of both fallopian tubes. The right fallopian tube is converted to a 6x6 centimeters
The most common symptoms of ectopic pregnancy cystic hemorrhagic mass with no point of rupture. Our
which are abdominal pain, absence of menses, and findings in this case are similar to that of Himangini et
irregular vaginal bleeding often characterized as spotting1 al and G.A.AL Quraan et. al who both noted a ruptured
were all present in our patient. In addition, physical right ectopic with unruptured left ectopic pregnancy in
examination of the abdomen revealed a rigid, tender which decision to undertake bilateral salpingectomy was
abdomen with muscle guarding. There was exquisite also done13. With bilateral salpingectomy, the chances of
cervical motion tenderness, with bilateral adnexal having another natural pregnancy is impossible. The only
tenderness on internal examination which gives a high way for her to have another pregnancy is through assisted
index of suspicion for a ruptured ectopic pregnancy. reproductive technology such as in vitro fertilization
Rupture of an ectopic pregnancy causes intense pain and which is cannot be afforded by the patient. Thus, a
exquisite tenderness especially on bimanual examination thorough patient education and counseling regarding the
and cervical motion which are present in nearly all women consequences of bilateral salpingectomy was provided for
with an advanced or ruptured ectopic pregnancy. Other this patient. Advise on methods of assisted reproductive
symptoms that develop following tubal rupture include technology that maybe utilized in the event that she
syncope, dizziness and an urge to defecate2. desires to have another child, as well as the expenses it
Diagnostic modalities used to identify ectopic would incur, was also explained.
pregnancies include beta HCG level measurements,
progesterone, transvaginal ultrasound and diagnostic CONCLUSION
surgery such as laparoscopy. Identification of an
extrauterine yolk sac, embryo, or fetus in the fallopian This is a rare case of spontaneous bilateral tubal
tubes or ovaries through sonography clearly confirms pregnancy. Cases such as this are usually diagnosed
ectopic pregnancy2. This, however, was not done in our case intraoperatively, but with the advent of diagnostic tools
since the patient presented with an acute abdomen thus and more readily available diagnostic modalities, an earlier
warranting a direct operation for emergency exploratory diagnosis can be made to decrease maternal morbidity
laparotomy. Spontaneous bilateral tubal pregnancy is and mortality. Although the incidence of a bilateral tubal
rare, therefore preoperative diagnosis is uncommon pregnancy is rare, both adnexae and ovaries as well as

40 Volume 41, Number 6, November-December 2017

the entire pelvis should be thoroughly examined at the cases with attempts to save the tubes. Keeping in mind
time of exploratory laparotomy when diagnosis of an hopes of having future natural pregnancies, especially
ectopic pregnancy is made. Even if patients are at a high in our setting, where not everybody can afford assisted
risk of having another ectopic pregnancy, conservative reproductive technologies.
management is also an important consideration in such

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