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ISSN: Print -2349-0977, Online - 2349-4387


 
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CASE IN POINT - CLINICS IN OBSTETRICS
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 48-51

Successful management of diverse types of heterotopic pregnancies


Department of Obstetrics and Gynecology, Tirath Ram Shah Hospital, Delhi, India

Date of Web Publication20-Oct-2016

Correspondence Address:
Poonam Khera
94, Sukhdev Vihar, New Delhi - 110 025
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-0977.192702

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  Abstract 

Heterotopic pregnancy is a rare complication of pregnancy. It can be a life threatening condition and can be easily missed if the diagnosis is overlooked. There is an increase in cases of heterotopic pregnancy in the last decade due to an increase in the incidence of pelvic inflammatory disease, tubal surgeries, pharmacologic ovulation stimulation, and assisted reproductive techniques. A timely diagnosis and intervention can save the life of the patient as well as the intrauterine pregnancy, which can be continued for a successful outcome. Here, we present three cases of heterotopic pregnancy that presented to our hospital over a period of 6 years with different clinical presentations who were treated with successful outcome.

Keywords: Adnexal mass, assisted conception, heterotopic


How to cite this article:
Khera P, Garg K. Successful management of diverse types of heterotopic pregnancies. Astrocyte 2016;3:48-51

How to cite this URL:
Khera P, Garg K. Successful management of diverse types of heterotopic pregnancies. Astrocyte [serial online] 2016 [cited 2021 Dec 1];3:48-51. Available from: http://www.astrocyte.in/text.asp?2016/3/1/48/192702


  Introduction Top


Heterotopic pregnancy is defined as the coexistence of intrauterine and extrauterine gestation. The incidence is estimated to be 1 in 30000 in the general population, and is much higher with assisted reproductive techniques.[1],[2]

Detection of an intrauterine pregnancy does not exclude the possibility of the simultaneous coexistence of ectopic pregnancy, and an obstetrician should always keep in mind the occurrence of a heterotopic pregnancy while dealing with pregnant females.


  Case History Top


We are reporting three cases of heterotopic pregnancy

that presented to the hospital over a period of 6 years.

Case report 1 (2006)

A 25-year-old woman married for 1½ years who was treated for primary infertility with 5.4 weeks of amenorrhea presented with right-sided pelvic pain with clinical features of shock. Urine pregnancy test was positive. Transvaginal ultrasound revealed single intrauterine live pregnancy of 5 weeks and 5 days with a large complex heterogeneous irregular mass measuring approximately 5.8 × 4.7 cm in the right adnexal region, with moderate amounts of free fluid in the pelvis was suggestive of ruptured ectopic pregnancy with 5 weeks 5 days intrauterine pregnancy [Figure 1] and [Figure 2]. The patient underwent emergency laparotomy. There was ruptured right-sided tubal pregnancy with approximately 1000 cm 3 of hemoperitoneum, and a right salpingectomy was performed. Patient received 2 units of blood. The intrauterine live gestation was allowed to continue. The patient delivered a healthy live baby at term by caesarean section.
Figure 1: Transvaginal ultrasound showing intrauterine gestational sac in the patient with heterotopic pregnancy.

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Figure 2: Transvaginal ultrasound showing complex right tubal mass with free fluid in the pouch of Douglas suggestive of ruptured ectopic pregnancy.

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Case report 2 (2008)

A 23-year-old patient was admitted with 8 weeks of amenorrhea with pain in the abdomen and bleeding per vaginum since 1 day. Transabdominal ultrasound revealed single live fetus 6 weeks and 2 days old, with small subchorionic bleed and a small solid mass adjacent to the left ovary. Patient was followed with serial ultrasound on the 7th and 15th day; size of the solid mass increased from 3.4 × 2.4 cm to 6.7 × 4.3 cm along with intrauterine 8 weeks 4 days live pregnancy. Hence, in view of the increasing size of the left tubo-ovarian mass and the patient being symptomatic but hemodynamically stable, a decision for laparotomy was taken which was performed on the same day.

Excision of the tubo-ovarian mass with left side salpingectomy and removal of blood clots was done. The tissue sent for histopathology confirmed products of conception, thus, corroborating our diagnosis of heterotopic pregnancy. The patient subsequently delivered a full-term baby by vaginal route.

Case report 3 (2012)

A 23-year-old patient was admitted with acute pain in the abdomen with 7–8 weeks of amenorrhea with slight bleeding per vaginum. Emergency transvaginal ultrasound showed intrauterine single live fetus of 7 weeks and 3 days, another sac with fetal pole, and cardiac activity in right adnexa with significant free fluid in the pelvis, which was suggestive of live heterotopic pregnancy. Patient was shifted to the operation theatre for surgical intervention. Peroperatively, right-sided rupture of  Fallopian tube More Details, showing fetus in the amniotic sac surrounded by blood clots was seen. Right salpingectomy was done. The patient received 2 units of blood during the procedure. The intrauterine live gestation was allowed to continue. The patient delivered a healthy baby at 38 weeks by vaginal route [Figure 3] and [Figure 4].
Figure 3: Specimen of salpingectomy of right tube in case of heterotopic pregnancy.

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Figure 4: Ectopic pregnancy in sac in the same case of heterotopic pregnancy.

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  Discussion Top


Heterotopic pregnancy is defined as the presence of multiple gestations, with one being in the uterine cavity and the other outside the uterus, commonly in the fallopian tube and uncommonly in the cervix or ovary.[1],[2]

The recent data show that the incidence of heterotopic pregnancy is approximately 1 in 7000 overall and 1 in 900 with ovulation induction.[3] The incidence of heterotopic pregnancy can be as high as 1% with assisted reproductive techniques.[4]

Early diagnosis of heterotopic pregnancy is often challenging due to the lack of clinical signs and symptoms as well as diagnostic confusion with other early pregnancy issues. A good history is important to identify risk factors for heterotopic pregnancy such as infertility treatment and tubal pathologies such as pelvic inflammatory disease, endometriosis, previous tubal surgeries, or previous ectopic pregnancy. In the illustrated cases, the patient in case report 1 was treated for primary infertility.

Ghandi et al.[5] reported a case of heterotopic pregnancy conceived after ovulation induction with clomiphene. The patient presented with ruptured tubal pregnancy along with intrauterine 9 weeks live gestation. Patient underwent laparotomy with salpingectomy for ruptured tubal pregnancy. The intrauterine pregnancy continued successfully to term.[5]

Umranikar et al.[6] presented a case of heterotopic pregnancy in the patient with high risk factor of previous ectopic pregnancy and salpingectomy. Because of the high risk history, patient underwent ultrasound examination on the first visit, which showed an 8-week irregular gestational sac with no fetal pole and a corpus luteal cyst in the left ovary. However, 6 days later, the patient presented to the emergency room with acute abdominal pain. A transvaginal scan showed the intrauterine gestational sac similar to the previous scan, and in addition, left adnexal mass with gestational sac and a fetal pole, which was suggestive of heterotopic pregnancy.[6]

Individuals often present with four common symptoms—abdominal mass, abdominal pain, peritoneal irritation, and enlarged uterus; although in some cases their may be either hypovolemic shock or a complete lack of symptoms. In our case reports, case 1 presented in shock, whereas in the other two cases, patients had only abdominal pain as the symptom.

In the case report by Tandon R et al., a primigravida presented to the emergency in shock and was diagnosed to have heterotopic pregnancy with ruptured tubal pregnancy on ultrasound examination. Immediate surgical intervention with supportive measures resulted in successful outcome.[7]

Basile et al.[8] reported a case of heterotopic pregnancy in a woman who came with complaints of abdominopelvic pain and generally feeling unwell. Transvaginal ultrasound showed 7 weeks intrauterine gestational sac with left ovarian pregnancy. The patient was taken up for operative laparoscopy and enucleation of ovaric gestational sac was done. The intrauterine pregnancy continued till term.[8]

Early symptoms can also be similar to those in acute appendicitis, ovarian cyst rupture, or ovarian torsion, further adding to the difficulty in diagnosis.[9]

Ahmed et al.[10] found in their study that the presence of pseudosac is associated with high false positive diagnosis of ectopic pregnancy. A hemorrhagic corpus luteum can also mimic heterotopic pregnancy both clinically and on ultrasound.

Spontaneous heterotopic pregnancy has high chances to be missed, unless the sonologist is aware and carefully screens the tubes and pelvis. If overlooked, it may present with life threatening complications.

The advances in transvaginal ultrasound has helped in the early diagnosis of heterotopic pregnancy. The heterotopic pregnancy can be detected in 41–84% of the cases with transvaginal ultrasound. Tal et al.[4] reported that approximately 70% of heterotopic pregnancies are diagnosed at 5–8 weeks, 20% are diagnosed between 9 and 10 weeks. and the remaining 10% are diagnosed at or beyond the 11th week.

The use of Doppler signal improves the sensitivity and specificity of ultrasound for diagnosing heterotopic pregnancies especially in suspected adnexal masses. In the case report 2, the patient had a suspicious adnexal mass, which was increasing in size on serial ultrasound. The patient was taken for laparotomy with differential diagnosis of heterotopic pregnancy, which was confirmed on histopathology report.

The diagnostic role of serum beta-human chorionic gonadotropin levels in heterotopic pregnancy is debatable. The normal algorithm for the rapid increase in the serum beta-human chorionic gonadotropin in early pregnancy cannot be used due to the presence of the intrauterine gestation, which could lead to false assurances.

Heterotopic pregnancies usually occur with singleton intrauterine pregnancy. However, triplet and quadruplet heterotopic pregnancy have also been reported.

The treatment of heterotopic pregnancy can be expectant, medical, or surgical. Expectant management is considered if ectopic pregnancy is not evolving. However, there are no clear guidelines or test showing which patients can be followed.[11] The second option is medical treatment. Potassium chloride or hyperosmolar glucose can be injected locally into the intact heterotopic gestational sac or fetus via laparoscopy or transvaginal sonography. Other drugs such as methotrexate and prostaglandins cannot be used because of the possibility of harmful effects on intrauterine pregnancy.[12] These two options are useful in very few cases.

The third option is the surgical removal of the ectopic gestation by salpingectomy or salpingostomy. This is the most commonly used modality. Removal of ectopic gestation with minimal trauma and avoidance of intraperitoneal hemorrhage is associated with favourable outcome of intrauterine pregnancy in 50–66% cases.[4]


  Conclusion Top


To conclude, heterotopic pregnancy should be kept in mind even if an intrauterine pregnancy is diagnosed and one should take extra efforts to look for the same. A high index of suspicion is required for timely diagnosis and management so as to prevent the life-threatening complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hirose M, Nomura T, Wakuda K, Ishiguro T, Yoshida Y. Combined intrauterine and ovary pregnancy: A case report. Asia Oceania J Obstet Gynaecol 1994;20:25-9.  Back to cited text no. 1
    
2.
Peleg D, Bar-Hava I, Neuman-Levin M, Ashkenazi J, Ben-Rafael Z. Early diagnosis and successful nonsurgical treatment of viable combined intrauterine and cervical pregnancy. Fertil Steril 1994;62:405-8.  Back to cited text no. 2
    
3.
Govindarajan MJ, Rajan R. Heterotopic pregnancy in natural conception. J Hum Reprod Sci 2008;1:37-8.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Tal J, Haddad S, Gordon N, Timor-Tritsch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: A literature review from 1971 to 1993. Fertil Steril 1996;66:1-12.  Back to cited text no. 4
    
5.
Ghandi S, Ahmadi R, Fazel M. Heterotopic pregnancy following induction of ovulation with clomiphene citrate. Iran J Reprod Med 2011;9:319-21.  Back to cited text no. 5
    
6.
Umranikar S, Umranikar A, Rafi J, Bawden P, Umranikar S, O'Sullivan B, et al. Acute presentation of a heterotopic pregnancy following spontaneous conception: A case report. Cases J 2009;2:9369.  Back to cited text no. 6
    
7.
Tandon R, Goel P, Saha PK, Devi L. Spontaneous heterotopic pregnancy with tubal rupture: A case report and review of the literature. J Med Case Rep 2009;3:8153.  Back to cited text no. 7
    
8.
Basile F, Di Cesare C, Quagliozzi L, Donati L, Bracaglia M, Caruso A, et al. Spontaneous heterotopic pregnancy, simultaneous ovarian, and intrauterine: A case report. Case Rep Obstet Gynecol 2012;2012:509694.  Back to cited text no. 8
    
9.
Chen KH, Chen LR. Rupturing heterotopic pregnancy mimicking acute appendicitis. Taiwan J Obstet Gynecol 2014;53:401-3.  Back to cited text no. 9
    
10.
Ahmed AA, Tom BD, Calabrese P. Ectopic pregnancy diagnosis and pseudo-sac. Fertil Steril 2004;81:1225-8.  Back to cited text no. 10
    
11.
Wang YL, Yang TS, Chang SP, Ng HT. Heterotopic pregnancy after GIFT managed with expectancy: A case report. Zhonghua Yi Xue Za Zhi (Taipei) 1996;58:218-22.  Back to cited text no. 11
    
12.
Scheiber MD, Cedars MI. Successful non-surgical management of a heterotopic abdominal pregnancy following embryo transfer with cryopreserve-thawed embryos. Hum Reprod 1999;14:1375-7.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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