Spontaneous Heterotopic Pregnancy: Diagnosis and Management

Abstract

Background: Heterotopic pregnancies albeit rare are conceivably life-threatening if missed. With the development of assisted reproductive techniques, the incidence has increased. Confirmation of an intrauterine pregnancy (IUP) should not preclude the existence of a heterotopic pregnancy.

Case: A healthy 27-year-old patient (gravida 4, term 1, preterm 0, abortion 2, living 1) at approximately 5 weeks gestation through natural conception presented to the emergency room with acute abdominal pain and vaginal bleeding. Pelvic ultrasound showed evidence of an IUP and a right adnexal mass, raising suspicion for a heterotopic pregnancy. The patient underwent an uncomplicated laparoscopic right salpingectomy. An IUP was confirmed on ultrasound postoperatively. The patient had an early pregnancy loss at 8 weeks of gestation.

Conclusion: With a high index of suspicion from clinical presentation and pelvic imaging, heterotopic pregnancy, while rare, should not be ruled out.

Figure 1

Longitudinal transvaginal ultrasound demonstrates an intrauterine gestational sac (red arrow) with a fetal pole (yellow arrow). Crown rump length measures 0.37 cm which correlates to the gestational age of 5 weeks and 5 days. Fetal heart rate was 128 beats per minute.

Figure 2

Longitudinal transvaginal ultrasound of the right adnexa demonstrates a thick walled hypoechoic cystic structure (red arrow) with weak peripheral vascularity (“ring of fire”). There is no fetal pole present.

Figure 3

Longitudinal (a) and transverse (b) transvaginal ultrasound images of the right adnexa structure demonstrate possible internal echogenicity or septations (red arrow) which may represent a yolk sac or reverberation artifact.

Figure 4

Sagittal transvaginal ultrasound image of the cervix with the posterior cul-de-sac with free fluid concerning for hemorrhage (red arrow).

Figure 5

Intraoperative view of an enlarged uterus (U) and enlarged right fallopian tube with a purple-red hue (yellow arrow).

Figure 6

Intraoperative view of an enlarged uterus (U) and enlarged right fallopian tube with hemoperitoneum from the ruptured ectopic gestation (green arrow).

Figure 7

Intraoperative view of an enlarged uterus (U), right ovary (RO), and right salpingectomy (green arrow).