Heterotopic Pregnancy after Natural Conception: A Case Report

Abstract

Introduction !The simultaneous occurrence of an intrauterine and an extrauterine pregnancy is referred to as heterotopic pregnancy (HP). To date, only a few cases of HP after spontaneous natural conception have been reported in the literature. The reported incidence of HP in a spontaneous cycle is between 1 : 2600 and 1 : 30 000. The morbidity and mortality associated with HP are directly correlated to the time between the first occurrence of symptoms and the final diagnosis [4]. Early diagnosis of heterotopic pregnancy is difficult. Most cases of HP are diagnosed between the 5th and 34th gestational week (GW); 70% of cases are diagnosed between the 5th and the 8th GW, 20 % between the 9th and the 10th GW and the remaining 10 % after the 10th GW [10,11]. We report here on a very rare case of HP with sonographic visualisation of cardiac activity in the intrauterine Abstract ! Heterotopic pregnancy (HP), i.e. the simultaneous development of an intrauterine and an ectopic pregnancy, is rare with a reported incidence of between 1 : 2600 and 1 : 30 000. Only a few cases have been described in the literature. We report here on an extremely rare case of HP after natural conception with cardiac activity noted on sonography in both the intrauterine and the ectopic foetus. Examination excluded appendicitis. Vaginal sonography (VS) was performed and revealed a second, extrauterine foetus with cardiac activity. The differential diagnosis included twin pregnancy in a bicornuate uterus, but HP could not be excluded. Diagnostic laparoscopy was scheduled due to progressive abdominal pain. Shortly before surgery the patient became acutely hypotensive. Laparoscopy confirmed a heterotopic pregnancy in the right tube. Due to acute rupture of the extrauterine pregnancy with intraabdominal bleeding, the procedure was converted to a laparotomy with right-sided salpingectomy. Subsequently, the intrauterine pregnancy continued without complications. The intrauterine pregnancy was uneventful with spontaneous delivery at term. Zusammenfassung

Heterotopic pregnancy with natural conception; a rare event that is still being misdiagnosed: a case report

“…Moreover, serum B-HCG was around the normal range and transvaginal ultrasound could not help for diagnosis. Missed HP also has reported by Kratschla-Apochal et al and Gibson Kyle et al [9,10]. Nevertheless, it was earlier detected in other series [11,12].…”

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 ].…”

“…Approximately 70% to 75% of the heterotopic pregnancies are discovered between the 5 th and 8 th weeks of gestation, and in only 10% of the cases, they are diagnosed past 10 th week of gestation [ 4 – 7 , 10 ]. In 60% to 75%, the ectopic pregnancy is discovered during an emergency situation right before the surgery which is required due to rupture and subsequent intra-abdominal bleeding hemoperitoneum or even hypovolemic shock and is found via ultrasound or computerized tomography [ 4 , 5 , 7 , 11 ]. However, obstetricians should always perform examination for ectopic pregnancy, abortion, and ovarian torsion [ 12 ].…”

“…However, obstetricians should always perform examination for ectopic pregnancy, abortion, and ovarian torsion [ 12 ]. B-human chorionic gonadotropin (beta-hCG) is of no value in order to differentiate cases of heterotopic pregnancies, since the pathologic hormone levels of the extrauterine pregnancy are masked by the beta-hCG produced by the intrauterine pregnancy [ 2 , 5 ].…”

“…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 ].…”