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In a stable patient with tubal pregnancy, treatment with methotrexate often allows preservation of the tube. In spontaneous tubal twin pregnancy, of which only five cases have been reported, experiences with this method are lacking.
A nulliparous woman of 24 attended the emergency department after a day of abdominal pain and brown vaginal discharge. Her last menstrual period had been six weeks previously and a pregnancy test was positive. 4 years earlier she had been treated for chlamydia infection. On examination she was tender in the left iliac fossa without peritonism. Vaginal examination revealed cervical excitation and left adnexal tenderness. A left-sided ectopic pregnancy was suspected. Human chorionic gonadotropin (HCG) was 10 500 IU/L. Transvaginal sonography showed the uterus to be empty, with endometrium thickened at 15 mm. The right ovary was normal with no adnexal masses. The left adnexa had two separate gestation sacs, each containing a fetal pole and yolk sac. Both fetal poles showed heart pulsation. The left ovary was normal. There was little fluid in the pouch of Douglas. Live left tubal twin pregnancy was diagnosed. At laparoscopy two separate bulges were seen on the left tube, and a salpingectomy was performed.
Sensitive methods for pregnancy diagnosis together with high-resolution transvaginal sonography mean that ectopic pregnancy can often be diagnosed at an early stable stage, allowing medical management in selected cases. The Royal College of Obstetricians and Gynaecologists ('Green Top Guidelines') recommends discussion of methotrexate with the patient if serum HCG is < 3000 IU/L, the tubal mass is moderate in size, there is no heartbeat and the pouch of Douglas contains no free fluid.1 A single dose of methotrexate 50 mg/m2 then offers 85% success in resolution of the pregnancy with a 7% risk of tubal rupture. Our patient did not satisfy these criteria in various ways, including the high HCG.
In a retrospective study Lipscombe et al.2 reported mean HCG of 4019 IU/L in 350 women successfully treated with methotrexate compared with 13 420 in 30 women unsuccessfully treated. Stika et al.3 reported that single-dose methotrexate was universally unsuccessful when serum HCG exceeded 5000. A high serum HCG level is also associated with increased risk of tubal rupture.4