Bilateral haemorrhagic cysts on ultrasound with an intraoperative diagnosis of spontaneous bilateral unruptured ectopic pregnancies: A case report with management challenges in a rural setting

Abstract

Spontaneous bilateral ectopic pregnancy is extremely rare, with an estimated incidence of 1 in 200,000 spontaneous pregnancies. Diagnosis is challenging, particularly in rural and remote settings where clinicians may have limited experience with rare presentations and reduced access to advanced imaging and specialist support. This report presents the case of a 36-year-old woman (gravida4, para 3) who presented to a rural hospital with vaginal bleeding and pelvic pain at 4 + 5 weeks of gestation. Serial quantitative beta-human chorionic gonadotropin levels increased from 962 IU/L to 6545 IU/L over 15 days. Transvaginal ultrasound demonstrated no intrauterine pregnancy, a right adnexal mass, and bilateral haemorrhagic ovarian cysts. She was admitted with suspected right tubal ectopic pregnancy. After discussion regarding the ultrasound findings and management options, the patient was consented for a right salpingectomy. However, at laparoscopy, bilateral unruptured tubal ectopic pregnancies were identified. Following an intraoperative discussion with next of kin, a right salpingectomy and additional left salpingostomy were performed to preserve natural fertility. Her postoperative recovery was uncomplicated and she was discharged home with serial quantitative testing of beta-human chorionic gonadotropin levels until negative. Histopathology confirmed bilateral tubal ectopic pregnancies. Bilateral ectopic pregnancy is difficult to diagnose preoperatively. This case highlights the potential diagnostic significance of bilateral corpus lutea and the importance of maintaining a high index of suspicion. In rural settings, limited access to sonographic expertise and fertility services may complicate both diagnosis and management. Bilateral ectopic pregnancy should be considered in suspected ectopic pregnancies with bilateral adnexal findings. Careful imaging review and fertility-conscious surgical planning are essential, particularly in rural and remote healthcare settings.