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Transabdominal ultrasonography diagnosis of ectopic twin gestation
European Journal of Radiology Extra 52 (2004) 127–128
Transabdominal ultrasonography diagnosis of ectopic twin gestation Gamanagatti Shivanand∗ , Deep Narayana Srivastava, Hiralal, S. Subramanian Department of Radio diagnosis, All India Institute of Medical Sciences, New Delhi 110029, India Received 28 June 2004; received in revised form 15 October 2004; accepted 18 October 2004
Abstract The coexistence of ectopic and intrauterine pregnancy is rare; presence of ectopic twin is even less frequent. We report a rare case of live ectopic tubal twin gestation, which detected preoperatively at 11 weeks of gestation by transabdominal sonography, when patient experienced severe lower abdominal pain. © 2004 Published by Elsevier Ireland Ltd. Keywords: Twin gestation; Ectopic; Transabdominal; Sonography
1. Introduction Prior to the development of ultrasonography, the unilateral twin pregnancy diagnosed after tubal rupture either at the time of surgery or by histopathology. With advantages of combinations of transvaginal ultrasonography, serum quantitative human chorionic gonadotrophin (hCG) and laparoscopy has resulted in significant reduction in mortality and morbidity associated with condition [1]. Thus, early detection of such condition might save the patient from serious complication. We describe a case of live ectopic tubal twin gestation detected at 11 weeks of pregnancy by transabdominal sonography.
vealed closed cervical os and no evidence of vaginal bleeding. Based on clinical findings, ectopic pregnancy was suspected. Transabdominal sonography revealed normal uterus and two gestational sacs separated by a septum were seen outside the uterine cavity (Figs. 1 and 2). Both the gestational sacs with fetal poles showed cardiac activity. There was no evidence of free fluid around the gestational sacs or in pelvis. The diagnosis of ectopic twin gestation made. In view of severe abdominal pain and twin gestation outside the uterine cavity, emergency surgery was done. At operation, the gestational sacs were found inside the right ampulla and right side salphingectomy was performed. Patient did well postoperatively.
2. Case report
3. Discussion
A 25-year-old woman, Primi gravida, was presented with 11 weeks of amenorrhea and severe lower abdominal pain for one day. There was no history of vaginal bleeding. A pregnancy test was positive. Gynaecologic examination re-
The incidence of ectopic pregnancy is 1–2% of all pregnancies and only 5–10% of ectopic pregnancies are live [2,3]. The incidence of live ectopic twin pregnancy is nearly 1 in 125,000 all pregnancies and 1:200 ectopic pregnancies [1]. The combined intrauterine and ectopic pregnancies (heterotopic pregnancy) are more frequent than purely multiple ectopic pregnancies. The incidence of heterotopic pregnancy has increased recently with increasing use of ovulation induction and in vitro fertilization embryo transfer techniques.
∗ Corresponding author. Present address: C/o Vijay Kumar Uppal, 198/58, East of Kailash, Uppal’s house, Ramesh market, New Delhi 110065. Tel.: +91 11 2641 2131; fax: +91 11 2686 2663. E-mail address: [email protected] (G. Shivanand).
1571-4675/$ – see front matter © 2004 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrex.2004.10.003
128
G. Shivanand et al. / European Journal of Radiology Extra 52 (2004) 127–128
Fig. 1. Transabdominal sonography in transverse section shows two gestational sacs with fetal poles on right side of uterus (arrow head).
which diagnosis was made preoperatively by ultrasound either transvaginal or transabdominal approach [7–10]. In our case, we saw two clear gestational sacs with their respective yolk sacs and fetal poles with cardiac activity. Although it is easier to demonstrate ectopic twins on transvaginal ultrasonography but it is unusual to demonstrate on transabdominal ultrasonography as in our case Figs. 1–2. The complications of ectopic twin pregnancies are similar to those of single ectopic pregnancy such as tubal rupture and maternal death. With the advent of transvaginal sonography, serum hCG titre and high index clinical suspicion helps in early diagnosis and treatment. In summary, live ectopic twin pregnancies is a rare event and transabdominal/transvaginal ultrasonography is used in early diagnosis prior to rupture. References
Fig. 2. Magnified image shows two gestational sacs with fetal poles separated by a septum (arrow).
The current incidence of heterotopic pregnancy is 1 in 7000 [4]. Several etiological factors contribute to the occurrence of ectopic pregnancy such as: (i) mechanical obstruction within tube either due to previous infection or due to large cell mass of the fertilized twin zygote (ii) congenital abnormalities of tube and (iii) previous surgery [3]. The first unilateral ectopic twin pregnancy was reported by De Ott in 1891, since then more than 100 case reports have been reported [5]. Prior to the development of ultrasonography, the unilateral twin pregnancy diagnosed after tubal rupture either at the time of surgery or by histopathology. The first unruptured ectopic twin was diagnosed by ultrasound by Santos [6]. Since then only few cases have been reported in
[1] Parker J, Hewson AD, Calder-Mason T, Lai J. Transvaginal ultrasound diagnosis of live twin tubal ectopic pregnancy. Australas Radiol 1999;43:95–7. [2] Ash K, Lyons EA, Levi CS, Lindsay DJ. Endovaginal sonographic diagnosis of ectopic twin gestation. J Ultrasound Med 1991;10:497–500. [3] Coleman BG, Arger PH. Ultrasound in early pregnancy complication. Clin Obstet Gynecol 1988;31:3–18. [4] Gerscovich EO, McGahan JP. High-resolution ultrasonography in the diagnosis of twin tubal ectopic pregnancies. J Clin Ultrasound 1991;19:501–4. [5] De Ott. A case of unilateral tubal twin gestation. Ann Gynecol Obstet 1891;36:304. [6] Santos CA, Sicuranza BJ, Chatterejee MS. Twin tubal gestation diagnosed before rupture. Perinatol Neonatol 1986;10:52. [7] Basama FM. Preoperative diagnosis of unilateral tubal twin ectopic pregnancy with one live twin. J Obstet Gynaecol 2003;23(3):313– 4. [8] Halvorsen AC, Colov NS. Unilateral ectopic twin pregnancy. Ugeskr Laeger 1994;156(39):5709–10. [9] Gulandi M, Steemers N, de Keyser JL. First reported case of preoperative ultrasonic diagnosis and laparoscopic treatment of unilateral twin tubal pregnancy. Rev Gyecol Obstet Fr 1994;89(3):134– 6. [10] Hanchate V, Garg A, Sheth R, Rao J, Jadhav PJ, Karayil D. Transvaginal sonographic diagnosis of live monochorionic twin ectopic pregnancy. J Clin Ultrasound 2002;30(1):52– 6.
Transabdominal ultrasonography diagnosis of ectopic twin gestation Gamanagatti Shivanand∗ , Deep Narayana Srivastava, Hiralal, S. Subramanian Department of Radio diagnosis, All India Institute of Medical Sciences, New Delhi 110029, India Received 28 June 2004; received in revised form 15 October 2004; accepted 18 October 2004
Abstract The coexistence of ectopic and intrauterine pregnancy is rare; presence of ectopic twin is even less frequent. We report a rare case of live ectopic tubal twin gestation, which detected preoperatively at 11 weeks of gestation by transabdominal sonography, when patient experienced severe lower abdominal pain. © 2004 Published by Elsevier Ireland Ltd. Keywords: Twin gestation; Ectopic; Transabdominal; Sonography
1. Introduction Prior to the development of ultrasonography, the unilateral twin pregnancy diagnosed after tubal rupture either at the time of surgery or by histopathology. With advantages of combinations of transvaginal ultrasonography, serum quantitative human chorionic gonadotrophin (hCG) and laparoscopy has resulted in significant reduction in mortality and morbidity associated with condition [1]. Thus, early detection of such condition might save the patient from serious complication. We describe a case of live ectopic tubal twin gestation detected at 11 weeks of pregnancy by transabdominal sonography.
vealed closed cervical os and no evidence of vaginal bleeding. Based on clinical findings, ectopic pregnancy was suspected. Transabdominal sonography revealed normal uterus and two gestational sacs separated by a septum were seen outside the uterine cavity (Figs. 1 and 2). Both the gestational sacs with fetal poles showed cardiac activity. There was no evidence of free fluid around the gestational sacs or in pelvis. The diagnosis of ectopic twin gestation made. In view of severe abdominal pain and twin gestation outside the uterine cavity, emergency surgery was done. At operation, the gestational sacs were found inside the right ampulla and right side salphingectomy was performed. Patient did well postoperatively.
2. Case report
3. Discussion
A 25-year-old woman, Primi gravida, was presented with 11 weeks of amenorrhea and severe lower abdominal pain for one day. There was no history of vaginal bleeding. A pregnancy test was positive. Gynaecologic examination re-
The incidence of ectopic pregnancy is 1–2% of all pregnancies and only 5–10% of ectopic pregnancies are live [2,3]. The incidence of live ectopic twin pregnancy is nearly 1 in 125,000 all pregnancies and 1:200 ectopic pregnancies [1]. The combined intrauterine and ectopic pregnancies (heterotopic pregnancy) are more frequent than purely multiple ectopic pregnancies. The incidence of heterotopic pregnancy has increased recently with increasing use of ovulation induction and in vitro fertilization embryo transfer techniques.
∗ Corresponding author. Present address: C/o Vijay Kumar Uppal, 198/58, East of Kailash, Uppal’s house, Ramesh market, New Delhi 110065. Tel.: +91 11 2641 2131; fax: +91 11 2686 2663. E-mail address: [email protected] (G. Shivanand).
1571-4675/$ – see front matter © 2004 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrex.2004.10.003
128
G. Shivanand et al. / European Journal of Radiology Extra 52 (2004) 127–128
Fig. 1. Transabdominal sonography in transverse section shows two gestational sacs with fetal poles on right side of uterus (arrow head).
which diagnosis was made preoperatively by ultrasound either transvaginal or transabdominal approach [7–10]. In our case, we saw two clear gestational sacs with their respective yolk sacs and fetal poles with cardiac activity. Although it is easier to demonstrate ectopic twins on transvaginal ultrasonography but it is unusual to demonstrate on transabdominal ultrasonography as in our case Figs. 1–2. The complications of ectopic twin pregnancies are similar to those of single ectopic pregnancy such as tubal rupture and maternal death. With the advent of transvaginal sonography, serum hCG titre and high index clinical suspicion helps in early diagnosis and treatment. In summary, live ectopic twin pregnancies is a rare event and transabdominal/transvaginal ultrasonography is used in early diagnosis prior to rupture. References
Fig. 2. Magnified image shows two gestational sacs with fetal poles separated by a septum (arrow).
The current incidence of heterotopic pregnancy is 1 in 7000 [4]. Several etiological factors contribute to the occurrence of ectopic pregnancy such as: (i) mechanical obstruction within tube either due to previous infection or due to large cell mass of the fertilized twin zygote (ii) congenital abnormalities of tube and (iii) previous surgery [3]. The first unilateral ectopic twin pregnancy was reported by De Ott in 1891, since then more than 100 case reports have been reported [5]. Prior to the development of ultrasonography, the unilateral twin pregnancy diagnosed after tubal rupture either at the time of surgery or by histopathology. The first unruptured ectopic twin was diagnosed by ultrasound by Santos [6]. Since then only few cases have been reported in
[1] Parker J, Hewson AD, Calder-Mason T, Lai J. Transvaginal ultrasound diagnosis of live twin tubal ectopic pregnancy. Australas Radiol 1999;43:95–7. [2] Ash K, Lyons EA, Levi CS, Lindsay DJ. Endovaginal sonographic diagnosis of ectopic twin gestation. J Ultrasound Med 1991;10:497–500. [3] Coleman BG, Arger PH. Ultrasound in early pregnancy complication. Clin Obstet Gynecol 1988;31:3–18. [4] Gerscovich EO, McGahan JP. High-resolution ultrasonography in the diagnosis of twin tubal ectopic pregnancies. J Clin Ultrasound 1991;19:501–4. [5] De Ott. A case of unilateral tubal twin gestation. Ann Gynecol Obstet 1891;36:304. [6] Santos CA, Sicuranza BJ, Chatterejee MS. Twin tubal gestation diagnosed before rupture. Perinatol Neonatol 1986;10:52. [7] Basama FM. Preoperative diagnosis of unilateral tubal twin ectopic pregnancy with one live twin. J Obstet Gynaecol 2003;23(3):313– 4. [8] Halvorsen AC, Colov NS. Unilateral ectopic twin pregnancy. Ugeskr Laeger 1994;156(39):5709–10. [9] Gulandi M, Steemers N, de Keyser JL. First reported case of preoperative ultrasonic diagnosis and laparoscopic treatment of unilateral twin tubal pregnancy. Rev Gyecol Obstet Fr 1994;89(3):134– 6. [10] Hanchate V, Garg A, Sheth R, Rao J, Jadhav PJ, Karayil D. Transvaginal sonographic diagnosis of live monochorionic twin ectopic pregnancy. J Clin Ultrasound 2002;30(1):52– 6.