INTRODUCTION
Ectopic
pregnancies are the leading cause of maternal mortality in the first trimester,
with an incidence of 5%–10% of all pregnancy-related deaths. Diagnosis of
ectopic pregnancies is difficult due to clinical mimics and non-specific
symptoms of abdominal pain and vaginal bleeding [1]. Ectopic pregnancy occurs
when a fertilized ovum implants outside of the uterine cavity. Risk factors
include a history of pelvic inflammatory disease, cigarette smoking, fallopian
tube surgery, previous ectopic pregnancy, and infertility. Serial beta human
chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine
aspiration can be used to arrive at a definitive diagnosis. Treatment of a
diagnosed ectopic pregnancy includes medical management with intramuscular
methotrexate, surgical management via salpingostomy or salpingectomy, and, in
rare cases, expectant management. A woman who has been diagnosed with an
ectopic pregnancy should have surgery right away if she has peritoneal signs or
hemodynamic instability, if her initial beta human chorionic gonadotropin level
is high, if ultrasonography shows fetal cardiac activity outside of the uterus,
or if medical management is not an option [2, 3]. Given the rarity of twin
ectopic pregnancies, it is important to address the question of where they
originate and whether they are similar or not. In this report, we dealt with a
case of twin ectopic pregnancy, which was detected by chance before the
development of complications.
CASE REPORT
A
37-year-old woman from Alfola city, West Kordofan
state, approximately 289 kilometers from El-Obeid city, presented to our clinic
with a five-day history of left-sided abdominal pain and a 7-week history of
amenorrhea. She was born via cesarean section prior to the age of 20, is G3 P
1+1, and has a prior history of miscarriage during the third trimester of a
twin pregnancy. She presented herself at our obstetrics and gynecology facility
subsequent to receiving a diagnosis of an ectopic pregnancy from a sonographer
in her place of residence. There was no pain, vaginal bleeding, or
gastrointestinal distress that she reported. Her vital signs were within normal
range, and the examination revealed a soft abdomen and a small tender lesion in
the right iliac fossa. All other tests came back normal, except for the serum
HCG level, which was positive. Images 1 and 2 show a healthy ectopic twin
pregnancy in the right adnexa, whereas image 3 shows an empty uterine cavity.
Following the patient's counseling, an appointment for surgery was set up.
During the patient's preoperative preparations, she complained of severe
abdominal pain and sweating. Upon examination, the doctor found hemoperitoneum
and a ruptured right ectopic pregnancy; the patient underwent a right salpingectomy
(see Image 4). The patient's left tube was attached to the posterior uterine
wall and had an abnormal fimbrial end, suggesting
pelvic inflammatory disease. The patient's postoperative recovery was smooth,
and she was counseled regarding her fertility.
DISCUSSION
Ectopic twin pregnancy is a rare
and hazardous first-trimester pregnancy condition. To avoid maternal morbidity
and mortality, a high index of suspicion and rapid intervention are required.
Unilateral tubal twins are a rare diagnosis, occurring in approximately one in
every 200,000–2,500,000 spontaneous births [4,5].
Obstetric abdominal pain poses a
challenging diagnostic challenge in the emergency department (ED) due to the
extensive list of differential diagnoses that must be considered and the
potential for atypical signs and symptoms associated with each disease, which
may be exacerbated by the patient's pregnancy. However, emergency physicians
(EPs) encounter constraints on investigative imaging modalities as a result of
the mandate to minimize embryonic radiation exposure. In a timely manner, EPs
must address this diagnostic challenge while balancing maternal and fetal
outcomes, as any delays in decision-making at the ED could endanger the life
and well-being of both the mother and the fetus. Ectopic pregnancy and acute
appendicitis are two common causes of abdominal distress in pregnant women who
present to the emergency department. By the tenth week of gestation,
identification of the latter is almost certain [6].
The fallopian tube is the most
prevalent location for ectopic pregnancy. The management of such instances is
not well defined. The surgical technique consisting of a salpingectomy or
salpingostomy is the most common in the case of a desire to sustain an intrauterine
pregnancy. Such a treatment is beneficial, but it has the potential dangers
associated with surgery; therefore, in certain circumstances, expectant
management appears fair [7].
The risk of rupture is higher in
twin ectopic pregnancies, and rupture is anticipated to occur in 30–50% of
cases, despite the fact that the morbidity and mortality associated with
singleton ectopic pregnancies have greatly decreased. For these pregnancies,
surgical intervention remains the cornerstone of care [8].
In
conclusion, for ectopic pregnancies, healthcare
personnel should have a high level of clinical suspicion. While unilateral
tubal twin ectopic pregnancies are uncommon, transvaginal ultrasonography can
detect them. Laparoscopic salpingostomy is a safe and effective procedure for
unilateral tubal twin pregnancy with a quick recovery time.
ACKNOWLEDGMENTS
We would like to thank Professor Ahmed Ajab eldour for his valuable
assistance and guidance, as well as the theater personnel at obstetric
department in El-Obeid Teaching Hospital for their care and support.
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Image 1: Image of
gestational sac contains two fetal poles in the Rt Fallopian tube.
Image2: Two fetal poles and yolk sac within the RT fallopian tube
besides the empty uterine cavity.
Image 3: empty uterin cavity with thick endometrium.
Image 4: Two embryonic fetuses and their placental tissue.
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