Ectopic pregnancy is a gyneco-obstetric emergency with a high morbidity and mortality rate, and is the leading cause of maternal mortality in the first trimester. Its prevalence is 7.2% in Thiès [1], but in its bilateral form it remains very rare (1/200,000) [2],[3]. The diagnosis is sometimes very difficult depending on the context due to the lack of clinical specificity, and the management can compromise obstetrical prognosis. Medically assisted reproduction techniques are therefore an integral part of this management. We report here a case of ruptured bilateral spontaneous ectopic pregnancy managed at the El Hadji Amadou Sakhir Ndieguene Hospital in Thiès.

The patient was 36 years old, 9th gestational age, 8th pare, with 8 healthy live children and no known pathological history. She was admitted for gravid amenorrhea of 8 SA with a positive urine pregnancy test. Physical examination on admission revealed stable hemodynamics, signs of peritoneal irritation, and minimal metrorrhagia. On digital vaginal examination, the uterus was enlarged and painful on mobilization, with the perception of two tender laterouterine masses. Culdocentesis yielded incoagulable lysed blood. Ultrasound examination revealed an evolving right ectopic pregnancy of 8 weeks +2 days (Figure 1), with an intrauterine pseudo-gestational sac visible (Figure 2), and an effusion of moderate size. Blood tests showed microcytic hypochromic anemia at 9 g/dL. An emergency laparotomy was performed. Surgical exploration revealed a bilateral ectopic pregnancy: a ruptured right ampullary of 9 × 6 cm, a ruptured left ampullary of 6 × 4 cm (Figure 3).

The preoperative assessment found anemia at 9 g/dL. The ovaries were macroscopically normal. Bilateral retrograde total salpingectomy was performed. She also benefited from intrauterine manual aspiration immediately postoperatively for uterine evacuation. The operating parts (Figure 4) were sent for anatomo-pathological study. The postoperative course was complicated by microcytic hypochromic anemia at 7.8 g/dL. The patient was discharged at post-op day 5.

Histological examination of the surgical specimens confirmed a bilateral tubal ectopic pregnancy.

In our patient’s case, the ectopic pregnancy was spontaneous, as there was no evidence of medication or assisted reproduction techniques. Ovarian stimulation is generally suspected in such cases, but the high prevalence of herbal medicine in our social context means that we cannot formally rule out drug-induced stimulation.

In its bilateral form, the possible etiologies are either bilateral multiple ovulations, or transperitoneal migration of trophoblastic cells from an ectopic pregnancy with implantation in the other tube [4]. However, the mechanism is difficult to pinpoint, as diagnosis is often delayed.

Although the clinical signs are not very different from the classic form, preoperative diagnosis of the bilateral form is more difficult, as this clinical picture is so exceptional that it is not routinely considered. In addition, the emergency context does not leave enough time for further investigations. In our case, the diagnosis was made intraoperatively despite a preoperative ultrasound scan showing an ectopic pregnancy and a gestational pseudo-sac.

Laparoscopy is the gold standard for the management of ectopic pregnancy [5]. In our context, laparotomy is justified because the endoscopy column is not available in the obstetric emergency department. Open surgery has also been described, but remains the preserve of developing countries.

Conservative treatment can be envisaged in unruptured forms, but the risk of recurrence is high. We opted for radical treatment in our patient because of the local condition of the fallopian tubes and the patient’s desire for permanent sterilization prior to surgery. Cases reported in the literature have also benefited from bilateral salpingectomy [6],[7],[8].

In an emergency situation, preoperative diagnosis of bilateral ectopic pregnancy is difficult, and laparotomy is justified in the absence of an endoscopy column. Intraoperative inspection of the contralateral adnexa must be systematic and meticulous, even in the case of a classic ectopic pregnancy. Treatment is surgical, with bilateral salpingectomy indicated in the event of rupture. Assisted reproduction remains an option in cases where pregnancy is desired.