Bilateral Tubal Ectopic Pregnancy (BTP): A Rare Case of Spontaneous Conception and Surgical Management

Case Presentation
• 27 year-old female, G3P2 (Gravida 3, Para 2).
• Symptoms:
• Spotting per vagina and lower abdominal pain for two
days.
• History:
• Last menstrual period six weeks before.
• Two previous Caesarean sections.
• No history of assisted reproduction treatment (ART) or
sexually transmitted infections (STI).
• Quit smoking upon pregnancy.
• Urine pregnancy test positive.
• Initial Examination:
• Normal observations.
• Tenderness present over lower abdomen.
• Investigations:
• Serum β-hCG (Beta human chorianic gonadotropin)
was 8532 IU/mL.
• Rest within normal limits.
• Referral:
• Sent to early pregnancy assessment unit (EPAU) for
ultrasound and further management.
• Follow-Up:
• Pain reduced.
• Normal observations, mild tenderness persisted.
• Transvaginal ultrasound showed left ectopic
pregnancy (24 x 22 mm) and possible failing
heterotopic pregnancy.
• Serum β-hCG of 9178 IU/L.

Management Options: Serial β-hCG levels follow-up, surgical
management (laparoscopic salpingectomy/salpingotomy) and
evacuation of retained products.
• Laparoscopy: 200 mL of blood in pelvis and both fallopian
tubes distended and bleeding. Right salpingectomy and left
salpingotomy performed.

 

Diagnostic and Management Challenges:
• High index of suspicion and thorough evaluation.
• Early and accurate diagnosis is crucial to prevent
complications and ensure optimal outcomes.
• Diagnosis facilitated by a combination of ultrasound and
laparoscopy.
• Management of BTP:
• Should be individualized based on the patient's clinical
condition, fertility desires, and healthcare team's expertise.
• Surgical intervention is a cornerstone of treatment.

 

Clinical Practice Implications:
• Heightened awareness and consideration of BTP needed to
improve diagnostic accuracy and patient care.
• BTP requires a tailored approach; in this case, right
salpingectomy and left salpingotomy were performed after
obtaining a second opinion.
• Successful surgical intervention and uneventful postoperative
recovery highlight the effectiveness of timely and appropriate
management.

Conclusion

BTP is extremely rare, especially following spontaneous

conception.
• The rarity often leads to misdiagnosis and delayed treatment,
increasing the risk of morbidity and mortality.
• Common symptoms include amenorrhea, spotting, and lower
abdominal pain.
• Despite the absence of typical risk factors like ART or STIs, the
patient's history of two previous Caesarean sections may have
contributed to BTP.
• Transvaginal ultrasound identified a left tubal ectopic pregnancy
and a heterotopic intrauterine sac, complicating the clinical
picture.
• High β-hCG levels supported the diagnosis, but bilateral nature
was confirmed only during laparoscopy.
• Consider BTP in differential diagnoses, especially in patients
with risk factors and atypical presentations.

References
Lubna Khan et al. *Bilateral Alive Tubal Ectopic Pregnancy and its
Management*. J Gynecol 2020, 5(1): 000201.
Elham Eghbali et al. *Spontaneous bilateral tubal ectopic
pregnancy preoperatively diagnosed by ultrasound: a case report*.
BMC Pregnancy and Childbirth, 23 February 2023. "2").
Maria Reichenber C. Arcilla et al. *Primary Bilateral Tubal
Pregnancy: A Case Report and Review of Literature*.

Authors
Dr. Padiyappa Chetan (Clinical fellow, QEH, King’s Lynn)
Mr Mohamed Mohamed (Consultant Obstetrician and
Gynecologist, QEH, King’s Lynn)
Ms Sindagi Parvathi (Consultant Obstetrician and Gynecologist,
QEH, King’s Lynn)