Spontaneous Heterotopic Pregnancy: Dual Case Report and Review of Literature

Abstract

Introduction. Heterotopic pregnancy is a rare complication usually seen in populations at risk for ectopic pregnancy or those undergoing fertility treatments. It is a potentially dangerous condition occurring in only 1 in 30,000 spontaneous pregnancies. With the advent of Assisted Reproduction Techniques (ART) and ovulation induction, the overall incidence of heterotopic pregnancy has risen to approximately 1 in 3,900 pregnancies. Other risk factors include a history of pelvic inflammatory disease (PID), tubal damage, pelvic surgery, uterine Mullerian abnormalities, and prior tubal surgery. Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. Most commonly, heterotopic pregnancy is diagnosed at the time of rupture when surgical management is required. Case. This paper represents two cases of heterotopic pregnancies as well as a literature review. Conclusion. Heterotopic pregnancy should be suspected in patients with an adnexal mass, even in the absence of risk factors. Clinicians must be alert to the fact that confirming an intrauterine pregnancy clinically or by ultrasound does not exclude the coexistence of an ectopic pregnancy. A high index of suspicion in women is needed for early and timely diagnosis, and management with laparotomy or laparoscopy can result in a favorable and successful obstetrical outcome.

Figure 1

Patient number 1. Pelvic ultrasound showing the intrauterine and extrauterine/tubal ectopic pregnancies, both with fetal pole (FP), fetal heart rates (+FHM) present, and free fluid (FF) in the peritoneal cavity.

Figure 2

Patient number 1. Operative finding showing a ruptured right ectopic pregnancy (black arrow) with an ovarian corpus luteal cyst (blue arrow).

Figure 3

Patient number 2. Obstetric ultrasound on 3/2/2014: intrauterine gestational sac seen. There is adjacent heterogeneity suggesting subchorionic hemorrhage. No fetal cardiac activity detected. Fetal pole measures approximately 2.9 mm.

Figure 4

Pathology for patient 2. Specimen 1: endometrium and product of conception (POC) from D&E for VTOP. Green circles: decidua and chorionic villi with viable syncytiotrophoblast; blue circles (purple color): degenerating villi; red circles (pink color): fibrin or degenerated villi.

Figure 5

Pathology for patient 2. Specimen 2: left tubal ectopic pregnancy from laparoscopy. Tubal pregnancy: slide from fallopian tube, showing the wall of fallopian tube and a tubal pregnancy with decidua, chorionic villi, and syncytiotrophoblast inside the fallopian tube, confirming the ectopic pregnancy in the fallopian tube and therefore heterotopic pregnancy.