Heterotopic Pregnancy - A Diagnostic Challenge. Six Case Reports and Literature Review

Abstract

Heterotopic pregnancy is defined as the simultaneous presence of intrauterine and ectopic pregnancies. It is a rare condition, but due to the increasing use of artificial reproductive techniques, the incidence of heterotopic pregnancy is increasing. Most of the patients with heterotopic pregnancy have a previous history of infertility or tubal diseases. In this case series, we are presenting six cases of heterotopic pregnancy. Three of them had a history of assisted reproductive technique: one patient had in vitro fertilization with three embryos transferred, and two patients received follicular stimulating hormone therapy. In one of the cases, heterotopic pregnancy was missed on an initial transabdominal scan, and in the following weeks, it was diagnosed on transvaginal ultrasound. Five patients underwent laparoscopic salpingectomy, and one patient had laparotomy and then a salpingectomy was done. Follow-up ultrasound scans for intrauterine pregnancy (IUP) showed abortion of the IUP, except in one patient who delivered a healthy full-term baby via spontaneous vaginal delivery. Therefore, there is a need to develop diagnostic criteria to rule out heterotopic pregnancy if the patient underwent any type of assisted reproductive techniques. We are emphasizing the need for more careful scanning of the adnexa via transvaginal ultrasound, especially in high-risk patients, even if the intrauterine gestation is confirmed.

Vaginal Delivery at Term in a Woman with a Spontaneous Heterotopic Pregnancy Treated with Laparoscopic Salpingectomy

“…Until today, only a small number of naturally conceived heterotopic pregnancies have been reported, and even a smaller number of them have resulted in the delivery of a live-born infant [ 7 ]. The most common site of a heterotopic pregnancy is the fallopian tube, followed by the uterine cornua [ 5 , 6 ].…”

“…The main risk factors of heterotopic pregnancy, reported in 70% of the patients, are fertility treatment techniques (such as ovulation induction or multiple embryo transfer), previous tubal surgical procedures (such as salpingotomy, salpingectomy, or tubal ligation), and tubal damage (such as hydrosalpinx and tubal adhesions as a result of pelvic inflammatory disease or endometriosis) [ 1 – 3 , 6 – 9 ]. Nonetheless, as illustrated in our case, no predisposing factor was present, suggesting that other yet unknown types of tubal pathology may play a role in the genesis of an ectopic pregnancy.…”

“…Since the rupture of a tubal gestation has been reported to be as high as 20%, leading in an emergency operation, the management of a heterotopic pregnancy highly depends on several factors, which, among others, are the week of gestation, the site of the ectopic pregnancy, the experience of the physicians, and the desire of the patient to preserve the intrauterine pregnancy [ 6 , 9 , 13 , 14 ]. In order to maintain the intrauterine pregnancy, surgical excision of the ectopic gestation through either laparoscopy or laparotomy should be performed right after diagnosis [ 2 , 3 ].…”

“…Assisted Reproduction Technologies have increased the occurrence of coexisting intra- and extrauterine pregnancies, currently reported to be varied between 1 in 100 and 1 in 500 cycles [ 2 – 4 ]. Given that heterotopic pregnancy is considered a major complication of a pregnancy, the early diagnosis is of high importance for the therapeutic management of this condition and is directly associated with increased maternal and fetal morbidity and mortality [ 5 , 6 ].…”

Spontaneous Heterotopic Pregnancy: Case Report and Literature Review

“…It is defined as a rare condition when intrauterine and extrauterine gestations coexist. The theoretically calculated incidence of a spontaneous HP is approximately 1 in 30,000 [ 1 ], while some risk factors increase the frequency up to 1 in 100 [ 2 , 3 , 4 ]. HP is a life-threatening condition that may lead to complications such as the rupture of an ectopic pregnancy (EP) and the loss of the intrauterine (IU) embryo after treatment [ 5 ].…”