==== Front Cureus Cureus 2168-8184 Cureus 2168-8184 Cureus Palo Alto (CA) 10.7759/cureus.39697 Medical Education Obstetrics/Gynecology Sonographically Positive Fetal Heartbeat in Unilateral Tubal Twin Pregnancy as a Rare Case With Literature Review Muacevic Alexander Adler John R Öztürk Emine 1 Aktürk Hilal 2 1 Obstetrics and Gynaecology, Bakırköy Sadikonuk Education and Research Hospital, Istanbul, TUR 2 Obstetrics and Gynaecology, Bakırköy Sadi Konuk Education and Research Hospital, Istanbul, TUR Hilal Aktürk akturkhil91@gmail.com 30 5 2023 5 2023 15 5 e3969730 5 2023 Copyright © 2023, Öztürk et al. 2023 Öztürk et al. https://creativecommons.org/licenses/by/3.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. This article is available from https://www.cureus.com/articles/157354-sonographically-positive-fetal-heartbeat-in-unilateral-tubal-twin-pregnancy-as-a-rare-case-with-literature-review Ectopic pregnancies occur when a fertilized egg implants outside the uterus, usually in the fallopian tube. Twin ectopic pregnancies are rare and pose significant diagnostic and management challenges. This case report presents the clinical details and management of a unilateral twin ectopic pregnancy in a 31-year-old female patient. The purpose of this report is to highlight the complexities associated with the diagnosis and management of this uncommon condition. In this case, we performed the left salpingectomy. We confirmed pathologically and histologically in pregnancy in the same tube. spontane unilateral twin tubal pregnancy ectopic pregnancy ==== Body pmcIntroduction Ectopic pregnancies account for approximately 1-2% of all pregnancies and can present with various clinical manifestations. We present a case of a unilateral twin ectopic pregnancy, where both embryos are implanted in the same fallopian tube. Same time, ectopic pregnancy is one of the gynecological emergencies. It is still considered one of the most important causes of maternal death among emergency pathologies [1-3]. This case report describes a sonographically positive fetal heartbeat in a unilateral tubal twin pregnancy, emphasizing the importance of early detection and appropriate management. Case presentation A 31-year-old patient (gravida 4, para 3 c/s) was admitted to the clinic with acute abdominal pain and vaginal bleeding lasting four hours. The patient applied to the emergency service for the suspicion of left ectopic pregnancy in routine ultrasonography, whose gestational age was seven weeks and five days according to her last menstrual period. The patient was in good condition, conscious and well-oriented. Physical examination revealed abdominal tenderness and mild tenderness in the left adnexal region. Vaginal bleeding was mild. Ultrasonography revealed a thin endometrium and a complex mass of 32 x 42 mm adjacent to the left ovary, which is two thick-walled, fluid-filled cystic masses of 13 and 15 mm in size with further investigations. Additionally, both gestational sac containing a fetal pole with a sonographically positive heartbeat was identified within the left fallopian tube (Figure 1). Endometrial thickness was 12 mm, and minimal fluid was detected in the Douglas pouch. Her laboratory findings were the following: hemoglobin, 11,2 g/dl; White blood cell 21,120 /ul; serum βhCG level 25,696 mIU/ml. In light of all the findings, the patient was diagnosed with left unilateral twin tubal pregnancy. Figure 1 Transvaginal ultrasound showing twin live pregnancy was measured 11.2 mm and 11.4mm, which corresponds to the gestational age of 7 weeks 5 days and 7 weeks 4 days We immediately terminated the pregnancy by laparoscopic unilateral left salpingectomy under general anesthesia. Our surgical findings detected a 5 cm ectopic mass in the ampulla region. The postoperative period passed without complications. The patient was discharged uneventfully after a postoperative follow-up. Pathologically and histologically demonstrated a twin pregnancy in the same tube and Aries-Stella phenomenon detected in an endometrial cavity (Figure 2). Figure 2 Tubal Pathology Sampling with Hematoxylin Eosin Discussion Although twin ectopic pregnancy is quite rare, its incidence is increasing. The literature has reported 299 cases between 1911 and 2023, and this number has been determined in the last 15 years [4]. Assisted reproductive endocrinology is the biggest reason for the increase in twin tubal pregnancies. Spontaneous twin ectopic pregnancy is extremely rare and is detected in one in every 125,000 pregnancies [5]. In 1994, transvaginal ultrasonography detected a tubal pregnancy accompanied by twin heartbeats [6]. As far as is known, there are only 13 sonographically positive fetal heartbeats in unilateral tubal twin pregnancy. Cases of cardiac activity have been reported in the literature [3,5-14]. Chang et al. recently reported the 12th twin unilateral tubal pregnancy, followed by Chen et al., who reported the 13th twin unilateral tubal pregnancy. Therefore, our case represents the fourteenth instance reported in the existing literature. In four cases, there were no risk factors such as tubal pathology or surgery, and in only one case surgery was not performed (Table 1). Table 1 Recent Cases for Unilateral Twin Tubal Pregnancy Presenting Fetal Cardiac Activity Authors Year Risk Factors Clinic Feature Treatment Gualandi et al. [6] 1994 None Cardiac activity(+) Laparotomy Eddib et al. [11] 2006 None Cardiac activity(+) Ruptured Laparoscopy Karadeniz et al. [12] 2008 İnf treatment, smoke Cardiac activity(+) Unruptured Metothrexat Karanjgoober et al. [8] 2009 Retained product of conception Cardiac activity(+) Ruptured Laparoscopy Langoria et al. [3] 2014 Previous Tubal Surgery Cardiac activity(+) Unruptured Laparoscopy Ghanbarzadeh et al. [13] 2015 Previous Tubal Surgery Cardiac activity(+) Ruptured Laparotomy Chang Kim et al. [5] 2018 None Cardiac activity(+) Unruptured Laparoscopy Chen-June et al. [14] 2019 None Cardiac activity(+) Unruptured Laparoscopy Martin et al. [7] 2021 None Cardiac activity(+) Unruptured Laparoscopy The best treatment option involves various factors; hemodynamic stability, medical conditions, presence of a heartbeat, and fertility desire should be investigated. Systemic methotrexate is successfully administered to a hemodynamically stable patient with a beta-hCG value of less than 5000 mIU/ml and no fetal heartbeat [10]. However, this is not suitable for twin ectopic pregnancies. In the 40-case study by De Los Rios, systemic methotrexate was administered in only one case [1]. In our case, the patient was counseled about the potential risks of a twin ectopic pregnancy, including tubal rupture and hemorrhage. After obtaining informed consent, the patient underwent a laparoscopic left salpingectomy, which involved tube removal. The procedure was successful, and the patient had an uneventful recovery. In cases of acute ruptured ectopic pregnancy, hemodynamically unstable patients, failed medical management, or those who are contraindicated for medical management, surgical management is preferred. Laparoscopic management is becoming more popular due to its lower cost, faster recovery, shorter operation time, and hospital stay. However, salpingectomy is still the recommended treatment. In cases where fertility preservation is desired, salpingostomy may be considered. For unilateral tubal twin pregnancies, surgical management is typically the preferred treatment, as supported by the literature, similar to singleton ectopic pregnancies [15]. The morbidity and mortality of ectopic pregnancy have decreased with improved diagnosis and treatment protocols. It has a life-threatening potential in the first three months of life. It is known to be responsible for 9%-13% of pregnancy-related deaths [16]. Conclusions Unilateral twin ectopic pregnancies are exceptionally rare, and their diagnosis and management can be challenging. Early recognition and prompt intervention are crucial in preventing complications such as tubal rupture and hemorrhage. This case report highlights the importance of maintaining a high index of suspicion in patients with an acute abdomen and the need for close monitoring and timely surgical intervention. Further research and clinical reports are warranted to improve our understanding of this uncommon condition and optimize its management. Human Ethics Consent was obtained or waived by all participants in this study The authors have declared that no competing interests exist. ==== Refs References 1 Bilateral ectopic pregnancy J Minim Invasive Gynecol De Los Ríos JF Castañeda JD Miryam A 419 427 14 2007 17630158 2 Transvaginal ultrasound diagnosis of a live twin tubal ectopic pregnancy Australas Radiol Parker J Hewson AD Calder-Mason T Lai J 95 97 43 1999 10901879 3 Live unilateral twin ectopic pregnancy in a fallopian tube remnant after previous ipsilateral salpingectomy J Clin Ultrasound Longoria TC Stephenson ML Speir VJ 169 171 42 2014 23893568 4 Pub Med 1 2023 2023 https://pubmed.ncbi.nlm.nih.gov/ 5 A rare case of spontaneous live unilateral twin tubal pregnancy with both fetuses presenting with heart activities and a literature review Obstet Gynecol Sci Kim CI Lee TY Park ST Kim HB Park SH 274 277 61 2018 29564320 6 First reported case of preoperative ultrasonic diagnosis and laparoscopic treatment of unilateral, twin tubal pregnancy (Article in French) Rev Fr Gynecol Obstet Gualandi M Steemers N de Keyser JL 134 136 89 1994 https://pubmed.ncbi.nlm.nih.gov/7516089/ 7516089 7 Management of a spontaneously conceived live unilateral twin ectopic pregnancy in Australia: a case report Case Rep Womens Health Martin A Balachandar K Bland P 0 30 2021 8 Laparoscopic management of a ruptured unilateral live twin ectopic pregnancy in a Jehovah's Witness J Obstet Gynaecol Karanjgaokar V Shah P Nicholson Y Spence-Jones C 557 558 29 2009 19697216 9 A case of unilateral tubal twin gestation Ann Gynecol Obstet De Ott D 304 36 1891 https://scholar.google.com/scholar_lookup?journal=Ann+Gyn%C3%A9col+Obst%C3%A9t&title=A+case+of+unilateral+tubal+twin+gestation&author=D.+De+Ott&volume=36&publication_year=1891&pages=304& 10 Unilateral twin tubal pregnancy: a case report and review of the literature Acta Biomed Betti M Vergani P Damiani GR 423 427 89 2018 30333471 11 Live twin tubal ectopic pregnancy Int J Gynaecol Obstet Eddib A Olawaiye A Withiam-Leitch M Rodgers B Yeh J 154 155 93 2006 16564050 12 Unilateral twin tubal pregnancy successfully treated with methotrexate Int J Gynaecol Obstet Karadeniz RS Dilbaz S Ozkan SD 171 102 2008 18455728 13 Unilateral twin tubal ectopic pregnancy in a patient following tubal surgery J Res Med Sci Ghanbarzadeh N Nadjafi-Semnani M Nadjafi-Semnani A Nadjfai-Semnani F Shahabinejad S 196 198 20 2015 https://pubmed.ncbi.nlm.nih.gov/25983775/ 25983775 14 Unilateral live twin tubal ectopic pregnancy presenting at 12 weeks of gestation: a case report Medicine (Baltimore) Seak CJ Goh ZN Wong AC Seak JC Seak CK 0 98 2019 15 Ectopic pregnancy: a life-threatening gynecological emergency Int J Womens Health Lawani OL Anozie OB Ezeonu PO 515 521 5 2013 23983494 16 Spontaneous twin ectopic pregnancy managed successfully with methotrexate-mediated ultrasound-guided fetal reduction: a fertility-preserving approach Cureus Madaan S Jaiswal A Banode P Dhok A Dewani D 0 13 2021