Heterotopic pregnancy – how easily you can go wrong in diagnosing? A case study

Abstract

Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms.

Spontaneous Heterotopic Pregnancy with Unaffected Intrauterine Pregnancy: Systematic Review of Clinical Outcomes

“…The majority of patients presented with pelvic pain, accompanied by vaginal bleeding and amenorrhea [4,10]. This triad seems to be encountered by all patients described in the case reports we have identified.…”

“…The cause of this is an ovulatory abnormality or a difference in the migration speed of the two embryos, due to a delay in the capture of the fertilized egg by the fallopian tube [2]. It is a rare condition with an incidence of approximately 1 per 30,000 pregnancies [3] and can be potentially fatal [4,5].…”

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

“…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 ].…”

“…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 ]. The most common surgeries performed for the treatment of tubal heterotopic pregnancies are salpingectomy, salpingotomy, or even salpingo-oophorectomy [ 9 ]. In our case, after thorough consultation of the patient, due to the hemoperitoneum found in the sonographic evaluation and her hemodynamic stability, surgery through a minimally invasive route (laparoscopy) was employed.…”