2009-09-cases-ar_09-09_adenijirc
TRANSCRIPT
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CASE SUMMARY
A 24-year-old gravida 3, para 2 + 1
presented to the emergency room with
2 days of severe lower abdominal pain
of increasing intensity. She was 9
weeks 3 days pregnant by date. There
was no associated vaginal bleeding.
There was no significant past medical
or surgical history.
Physical examination revealed that
her vital signs were:
-Blood presure 114/95
-Pulse rate 94/minute
-Respiratory rate 20/minute.
Systemic review was unremarkable
except for mild tenderness with guarding
in the right lower quadrant. The hemo-
globin level was 9.0 g/dL. The other
blood chemistry levels were normal.
She was then referred for transab-
dominal and endovaginal ultrasound,
which revealed an empty uterus and 2
live fetuses with cardiac activities in
the right adnexa. The left ovary and
adnexa was normal. A mild amount of
fluid was noted in the cul de sac.
The patient was then taken to the
operating room where she had abdomi-
nal laparotomy and right salpingectomy.
IMAGING FINDINGS
Endovaginal ultrasound revealed an
empty uterus (Figure1) and 2 live
fetuses with cardiac activities in the
right adnexa (Figures 2 and 3).
DIAGNOSIS
Live right-tubal twin-ectopic preg-
nancy. Differential diagnosis: abdomi-
nal pregnancy.
DISCUSSION
Live twin-ectopic gestations are
extremely rare. More than 100 twin-
tubal pregnancies have been reported,
but <10 have cardiac activities demon-
strated in both fetuses.2
Unilateral twin-ectopic pregnancies
occur in 1:200 ectopic pregnancies.
Most cases are monochorionic and
monozygotic.3
Ectopic pregnancies account for 2%
of all pregnancies and represent a major
health risk for women of childbearing
capacity, which can result in life-threat-
ening complications if not treated prop-
erly. They result from the abnormal
implantation and maturation of the con-
ceptus outside of the endometrial cavity.
The incidence of ectopic pregnancies
has been increasing since the 1970s. The
first case of live twin-ectopic pregnancy
was described in 1994.4 The classic clin-
ical triad of ectopic pregnancy is pain,
amenorrhea and vaginal bleeding.
Multiple risk factors contributing to
the incidence of ectopic pregnancy
include: pelvic inflammatory disease,
previous ectopic pregnancy, history of
tubal surgery and conception after tubal
ligation, and use of fertility drugs or
assisted reproductive technology. Other
risk factors include use of an intrauterine
40A ■ APPLIED RADIOLOGY © www.appliedradiology.com September 2009
R A D I O L O G I C A L C A S E
Adejimi O. Adeniji, MD, and Irene Lin, DO
Live right-tubal twin-ectopicpregnancy
FIGURE 1. Longitudinal (A) and transverse (B) oblique ultrasound revealing an empty
endometrial cavity.
A B
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www.appliedradiology.com APPLIED RADIOLOGY ©
■ 40BSeptember 2009
contraceptive device, increasing age,
smoking and variant anatomy of the
uterus (T-shaped uterus).
CONCLUSION
Live twin-ectopic gestations are
extremely rare but there are treatment
options. These have typically been clas-
sified as either conservative or surgical.
Patients are typically sent for surgi-
cal intervention if they are at high risk
of tubal rupture, hypotension, anemia
or if they have an ectopic pregnancy
>3 cm in diameter. Those eligible for
conservative treatment typically
receive a chemo- therapeutic agent like
methotrexate, which is less invasive
and has a significantly lower risk and
cost compared with surgery. The suc-
cess rate with methotrexate ranges
from 70% to 100%.5
REFERENCES
1. Atye, Lam SL. Viable left tubal twin ectopic preg-
nancy. Singapore Med J. 2005;46:651-655.
2. Parker J, Hewson AD, Calder-Mason T, Lai J.
Transvaginal ultrasound diagnosis of a live twin
tubal ectopic pregnancy. Australas Radiol.
1999;43:95-97.
3. Storch MP, Petrie RH. Unilateral tubal twin ges-
tation. Am J Obstet Gynecol. 1976;125:1148-
1150.
4. Gualandi M, Steemers N, de Keyser JL. First
reported case of preoperative ultrasonic diagnosis
and laparoscopic treatment of unilateral, twin tubal
pregnancy. Rev Fr Gynecol Obstet. 1994;89:134-
136. in French.
5. Luciano AA, Roy G, Solima E. Ectopic preg-
nancy from surgical emergency to medical man-
agement. Ann N Y Acad Sci. 2001;943:235-254.
R A D I O L O G I C A L C A S E
FIGURE 2. Transverse ultrasound (A and B) demonstrating two fetuses in the right adnexa.
FIGURE 3. (A and B) M-mode Doppler ultrasound tracing of cardiac activities and fetal
heart rates.
A B
A B
Prepared by Adejimi O. Adeniji ,
MD, Divisional Chairman, Pedi-
atric Radiology, John Stroger Hos-
pital of Cook County, Chicago, IL,
and Irene Lin, DO, Medical Diag-
nostic Imaging Group Ltd., Phoenix,
AZ.
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