Diagnosis of Heterotopic Pregnancy Using Ultrasound and Magnetic Resonance Imaging in the First Trimester of Pregnancy: A Case Report

Abstract

Heterotopic pregnancy is a condition characterized by implantation of one or more viable embryos into the uterine cavity while another one is implanted ectopically, particularly into the uterine tube. Its occurrence has increased drastically over the last few years due to assisted reproduction procedures. In general, the diagnosis is made during the first trimester by using endovaginal two-dimensional ultrasound (2DUS), through observing a complex para- or retrouterine mass in association with a viable uterine pregnancy. However, under some conditions such as atypical ultrasonographic presentations, 2DUS does not clarify the situation whereas magnetic resonance imaging (MRI) of the pelvis is able to do so. We present the case of a pregnant woman in her fifth pregnancy, with a clinical condition of lower abdominal pain and pallor. Endovaginal 2DUS showed a complex voluminous mass in the left pelvic region in association with a viable intrauterine pregnancy. 2DUS in power Doppler mode showed “ring” vascularization, compatible with an ectopic gestational sac. MRI was of great importance in that it suggested that the mass had hematic content, which together with the clinical features, indicated that laparotomy should be performed. This surgical choice was essential for the woman to achieve a clinical improvement and for good continuation of the intrauterine pregnancy.

Therapeutic Approaches in Cases with Heterotopic Pregnancy: A Retrospective Analysis of Six Patients

“…It has been suggested that a delay in diagnosis can cause maternal mortality of 1% and foetal mortality of 45-65% [2]. It is important to perform a meticulous pelvic sonography evaluation to detect HP even in cases with a positive pregnancy test and an intrauterine gestational sac on sonography after infertility treatment [1]. Diagnosis of a HP can be challenging and a high index of suspicion is mandatory for early diagnosis and appropriate treatment.…”

“…Gestational age, findings of transvaginal sonography, treatment modalities used and outcomes of pregnancy in cases. In cases of HP with tubal localisation, patients can present with acute abdomen and hypovolemic shock secondary to tubal rupture [1]. In such cases, the differential diagnosis includes a haemorrhagic corpus luteum cyst, adnexal torsion, a neoplasm and abortion [1,2].…”

“…In cases of HP with tubal localisation, patients can present with acute abdomen and hypovolemic shock secondary to tubal rupture [1]. In such cases, the differential diagnosis includes a haemorrhagic corpus luteum cyst, adnexal torsion, a neoplasm and abortion [1,2]. The use of TVUS and ß-hCG should be beneficial in the differential diagnosis of such clinical entities.…”

“…Heterotopic pregnancy (HP) is defined as the simultaneous occurrence of intrauterine and extrauterine pregnancy [1]. Ectopic pregnancy is generally observed at tubes, but it may also occur at a caesarean scar or have a cervical, ovarian or abdominal localisation in rare instances [2].…”

“…Other potential reasons include tubal surgery, pelvic inflammatory disease, a history of ectopic pregnancy, endometriosis and in vitro fertilisation [2][3][4]. The most frequent symptoms of HP are abdominal pain and vaginal bleeding, but patients can occasionally present with acute abdomen resulting from a haemoperitoneum [1]. High-resolution transvaginal sonography (TVUS) is the primary diagnostic method, and management may vary depending on the patient's haemodynamic status, localisation of the ectopic pregnancy and desire of the family for a child [2].…”