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

 

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.