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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 91-92

Heterotopic pregnancy: A rare entity


1 Department of Obstetrics and Gynecology, NEIGRIHMS, Shillong, Meghalaya, India
2 Department of Pathology, NEIGRIHMS, Shillong, Meghalaya, India
3 Department of Radiology, NEIGRIHMS, Shillong, Meghalaya, India

Date of Submission17-Sep-2019
Date of Decision22-Apr-2020
Date of Acceptance24-Apr-2020
Date of Web Publication20-Jun-2020

Correspondence Address:
Dr. Ananya Das
Department of Obstetrics and Gynecology, NEIGRIHMS, Shillong, Meghalaya
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_134_19

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  Abstract 


Heterotopic gestation is a very rare entity in natural conception, occurring in only 1 in 30,000 spontaneous pregnancies. A high index of suspicion is necessary for the timely diagnosis and appropriate intervention. We report the case of heterotopic pregnancy in a 32-year-old female presented with hemoperitoneum from ruptured tubal pregnancy with live intrauterine gestation at 6 weeks' period of gestation, diagnosed on ultrasound examination.

Keywords: Heterotopic pregnancy, transabdominal ultrasound, transvaginal ultrasound


How to cite this article:
Das A, Panda S, Baruah SR, Lynser D, Marbaniang E. Heterotopic pregnancy: A rare entity. Arch Med Health Sci 2020;8:91-2

How to cite this URL:
Das A, Panda S, Baruah SR, Lynser D, Marbaniang E. Heterotopic pregnancy: A rare entity. Arch Med Health Sci [serial online] 2020 [cited 2020 Oct 1];8:91-2. Available from: http://www.amhsjournal.org/text.asp?2020/8/1/91/287347




  Introduction Top


Heterotopic pregnancy is the simultaneous coexistence of an intrauterine and extrauterine gestation.[1] It is a rare and potentially dangerous condition, occurring in only 1 in 30,000 spontaneous pregnancies. Transvaginal ultrasound is the key to diagnosing heterotopic pregnancy. However, it continues to have a low sensitivity because the diagnosis is often missed or overlooked. Surgical intervention plays a key role in the management of heterotopic pregnancy.[2] The goal is to remove the ectopic pregnancy without jeopardizing the intrauterine pregnancy.[3] Other management options mentioned in the literature include the local injection of potassium chloride, hyperosmolar glucose, or methotrexate into the sac under ultrasound guidance followed by the aspiration of the ectopic pregnancy.[3]


  Case Report Top


A 22-year-old female with 2 months of amenorrhea presented emergency with pain abdomen. Urine pregnancy test was positive. Transvaginal ultrasound revealed hemoperitoneum with a live intrauterine gestation of about 6 weeks. A complex right adnexal ectopic mass with yolk sac was also noted [Figure 1]. Provisional diagnosis of a heterotopic pregnancy with ruptured right adnexal ectopic gestation was suggested in view of clinical history, hemoperitoneum, and an intrauterine gestation. The patient underwent emergency laparotomy [Figure 2]. There was ruptured right-sided ovarian pregnancy with hemoperitoneum and bilateral  Fallopian tube More Detailss intact. Ruptured ectopic pregnancy was removed and sent for histopathological examination which revealed the product of conception [Figure 3]. The intrauterine live gestation was allowed to continue with progesterone support.
Figure 1: Ultrasound picture of both the intrauterine and adnexal pregnancy

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Figure 2: Intraoperative picture showing heterotopic pregnancy

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Figure 3: Histopathology

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  Discussion Top


A heterotopic gestation is difficult to diagnose clinically because of its similarity in presentation with ectopic gestation and also its rarity. Conventionally, laparotomy is performed because of ruptured ectopic pregnancy. At the same time, the uterus is congested, softened, and enlarged; ultrasound examination can nearly always show gestational products in the uterus. The incidence was originally estimated on theoretical basis to be 1 in 30,000 pregnancies. The rate is higher due to assisted reproduction and is approximately 1 in 7000 overall and as high as 1 in 900 with ovulation induction.[1],[4] Intrauterine gestation with hemorrhagic corpus luteum can simulate heterotopic/ectopic gestation both clinically and on ultrasound.[5] High-resolution transvaginal ultrasound with color Doppler will be helpful as the trophoblastic tissue in the adnexa in a case of heterotopic pregnancy shows increased flow with significantly reduced resistance index.[4] The treatment of a heterotopic pregnancy is laparoscopy/laparotomy for the tubal pregnancy.[2] A heterotopic pregnancy requires a high index of suspicious for early and timely diagnosis; a timely intervention can result in a successful outcome of the intrauterine fetus.[6] It can also save the patient in case of hemorrhage due to ruptured ectopic.


  Conclusion Top


Clinicians should always keep heterotopic pregnancy in the differential diagnosis in a reproductive patient with abdominal pain and signs or symptoms of ectopic pregnancy.[7],[8] They must be alert to the fact that confirming an intrauterine pregnancy clinically or by ultrasound does not exclude the coexistence of an ectopic pregnancy.[9]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lyons EA, Levi CS, Dashefsky SM. The first Trimester. In: Rumack CM, Wilson SR, Charboneau JW (eds). Diagnostic ultrasound. 2nd ed., St Louis; Mosby. 1998:975-1011  Back to cited text no. 1
    
2.
Esterle J, Schieda J. Hemorrhagic heterotopic pregnancy in a setting of prior tubal ligation and re-anastomosis. J Radiol Case Rep 2015;9:38-46.  Back to cited text no. 2
    
3.
Yu Y, Xu W, Xie Z, Huang Q, Li S. Management and outcome of 25 heterotopic pregnancies in Zhejiang, China. Eur J Obstet Gynecol Reprod Biol 2014;180:157-61.  Back to cited text no. 3
    
4.
Glassner MJ, Aron E, Eskin BA. Ovulation induction with clomiphene and the rise in heterotopic pregnancies. A report of two cases. J Reprod Med 1990;35:175-8.  Back to cited text no. 4
    
5.
Headley AJ, Adum V. Naturally occurring heterotopic pregnancy in a multiparous patient: A case report. J Reprod Med 2013;58:541-4.  Back to cited text no. 5
    
6.
Espinosa Picazo M, Alcántar Mendoza MA. Heterotopic pregnancy: Report of a case and review of the literature. Ginecol Obstet Mex1997;65:482-6.  Back to cited text no. 6
    
7.
Sohail S. Haemorrhagic corpus luteum mimicking heterotopic pregnancy. J Coll Physicians Surg Pak 2005;15:180-1.  Back to cited text no. 7
    
8.
Mihmanli V, Kilickaya A, Cetinkaya N, Karahisar G, Uctas H. Spontaneous heterotopic pregnancy presenting with hemoperitoneum. J Emerg Med 2016;50:44-6.  Back to cited text no. 8
    
9.
Fylstra DL. Ectopic pregnancy after hysterectomy may not be so uncommon: A case report and review of the literature. Case Rep Womens Health 2015;7:8-11.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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