Spontaneous bilateral chronic and acute tubal ectopic pregnancies following methotrexate treatment

A 29-year-old gravida 8, para 1, presented with right lower quadrant pain following 8 weeks of amenorrhea. There was no vaginal bleeding and she was haemodynamically stable. Abdominal examination evoked guarding and localised tenderness. Pelvic examination demonstrated a bulky mobile uterus with fullness in the posterior cul-de-sac, but no discrete adnexal mass. The beta-human chorionic gonadotropin (βhCG) level was 44 253 IU/L, haemoglobin level was 130 g/L, and there was no leukocytosis. Ultrasound revealed an ectopic pregnancy (crown-rump length = 15.8 mm) with cardiac activity in the left adnexa and minimal free fluid. This patient had previously undergone methotrexate treatment for two previous right ectopic pregnancies. The first resulted in documented follow-up and resolution. The second occurred 3 months prior to the current presentation with an initial serum β-hCG level of 13 675 IU/L and ultrasonographic findings of a 16-mm mass in the right adnexa. Although this level of β-hCG is higher than our recommendation for methotrexate treatment, she refused any surgical intervention even after appropriate counselling. She reported four subsequent weeks of vaginal spotting but declined any further follow up. At this admission, she consented to diagnostic laparoscopy and subsequent salpingostomy or salpingectomy. Laparoscopy revealed 50 mL dark blood in the posterior cul-de-sac and a 6-cm mass in the left tube consistent with the diagnosed ectopic pregnancy. Inspection of the contralateral adnexa revealed an unexpected 3.5 cm chronic ectopic pregnancy in the right tube. Although salpingotomy and conservation of the left tube was attempted, she ultimately underwent bilateral salpingectomy. She was discharged the subsequent day and attended for follow-up. Histopathology demonstrated an acute left tubal pregnancy and a chronic infarcted pregnancy with necrotic chorionic villi in the right tube. Discussion