Ectopic pregnancy is a life-threatening condition and is still considered as one of the most important causes of maternal mortality. Ectopic twins is a very rare type of ectopic pregnancy.  Incidence of twin tubal pregnancy is 1 out of 725-1580 tubal pregnancy and 1in 200000 pregnancies. Very limited number of viable twin ectopic pregnancies have been reported in the literature Spontaneous twin tubal ectopic pregnancy is even rarer with reported incidence of1 in every 125,000 spontaneous pregnancies. In literature review there are more than 100 cases of twin tubal pregnancy have been reported, there are only a few cases with documented fetal heart motions in both embryos or fetuses.

Ectopic pregnancy is a life-threatening condition and is still considered as one of the most important causes of maternal mortality [1]. Ectopic twins is a very rare type of ectopic pregnancy.  Incidence of twin tubal pregnancy is 1 out of 725-1580 tubal pregnancy and 1in 200000 pregnancies. Very limited number of viable twin ectopic pregnancies have been reported in the literature Spontaneous twin tubal ectopic pregnancy is even rarer with reported incidence of1 in every 125,000 spontaneous pregnancies [2, 4, 5]. In literature review there are more than 100 cases of twin tubal pregnancy have been reported, there are only a few cases with documented fetal heart motions in both embryos or fetuses.6 

A 41 year-old Gravida 6 Para 5, presented to the emergency department of King abdulaziz Medical City- Riyadh, Saudi Arabia  at 6weeks of gestations  with Symptoms of  lower abdominal pain and vaginal spotting. Current Pregnancy resulted from induction of ovulation.  There were no histories of any major medical or surgical illness in the past.Her vital signs were stable. Abdominal examination revealed no tenderness or rebound tenderness on palpation and deep pression, Vaginal examination did not find ervical motion tenderness. Her blook work showed BHCG of 13231, other investigations were within normal. Altraound of trans-abdominal (Fig:1) and trans-vaginal scan showed  right-adnexal viable twin pregnancy with two yolk sacs and two pulsations, measuring 5.4x 4.1cm.  The patient was diagnosed as ectopic tubal twin pregnancies. The patient was taken for Emergency for laparoscopic salpingectomy.  Intraoperatively, there was moderate hemoperitoneum, right sided salpingectomy was done. The patient did well postoperatively and was discharged on the 3rd day. The histopathological examinations confirmed the Diagnosis (fallopian tube with intraluminal trophoblastic villi and fetal tissue).

                                                                                                                                 Figure: 1 

(This part needs to be rewritten again.   Sensitive methods for pregnancy diagnosis together with high-resolution transvaginal sonography mean that ectopic pregnancy can often be diagnosed at an early stable stage.7  Several factors are increased the risk of ectopic pregnancy. Pelvic inflammatory disease is associated with the greatest increase in risk, but other associated factors include operative trauma, congenital anomalies, tumors, adhesions, and advancing maternal age 9 this case has several differences from other cases of unilateral live twin tubal pregnancies. First, the patient conceived after ovulation induction only whereas most cases were associated with ART and other risk factors. Second, each fetus in the twin pregnancy had a yolk sac and fetal heart activity.

Patient presented with high level of bhcg, that may raise the concern of heterotopic pregnancy or twins pregnancy which might be overlooked as singleton viable pregnancy, for that by reporting such cases it will raise the knowledge of possible twins ectopic pregnancy in high level BHCG then it may help considering appropriate intervention and follow up accordingly.

Viable ectopic pregnancy is a life threatening with changing diagnosis surgical treatment is usual approach for management.