Coexisting tubal pregnancy and intrauterine pregnancy during a natural pregnancy, first diagnosed via ultrasonography: A case report

Abstract

Rationale: The coexistence of intrauterine and extrauterine pregnancies is termed heterotopic pregnancy (HP). Most reported cases of HP occur after assisted reproductive technology, and HP in a natural pregnancy (NP) is very rare, often discovered intraoperatively. HP is a significant challenge for obstetricians, gynecologists, and sonographers.

Patient concerns: A 30-year-old nulliparous woman presented to the emergency department of a local tertiary hospital on day 66 of amenorrhea with abdominal pain, nausea, and vomiting without an obvious cause.

Diagnoses: Transabdominal gynecological ultrasonography revealed coexisting left ectopic pregnancy (EP) and intrauterine pregnancy (IP) in the NP, both with measurable fetal heart activity. In addition, abdominal fluid and extensive pelvic hematoma were observed.

Interventions: Given a ruptured EP with hemorrhage, the obstetrician-gynecologist performed an emergency surgery, finding approximately 500 mL of blood and blood clots in the abdominal and pelvic cavities. The left tubal ampullary segment was dilated and thickened, with a visible rupture and active bleeding. Therefore, the left fallopian tube was resected, and IP was managed with therapy.

Outcomes: The patient recovered well postoperatively and delivered a male infant by cesarean section at full term.

Lessons: The presence of IP does not exclude the coexistence of EP, even in NP. Although HP is rare and the symptoms of EP may not be obvious, sometimes masked by IP, obstetricians, gynecologists, and sonographers must remain vigilant in this regard to reduce the rate of missed diagnoses, provide early intervention, and safeguard the health of the pregnant woman and fetus.

Keywords: heterotopic pregnancy; intrauterine pregnancy; natural pregnancy; tubal pregnancy; ultrasonography.

Figure 1.

TAS results on day 66 of amenorrhea. (A) Showing IP with a gestational sac size of 55 × 24 × 42 mm. (B) Embryonic pole size of 28 mm in length. (C) CDFI revealing primitive cardiac activity within the embryonic pole. CDFI = color doppler flow imaging, TAS = transabdominal sonography.

Figure 2.

TAS results on day 66 of amenorrhea. (A) Showing EP in the left region, with a gestational sac size of 38 × 24 × 26 mm. (B) CDFI showing primitive cardiac activity in the embryonic pole of the left EP. (C) Embryonic pole size of 25 mm in length. CDFI = color doppler flow imaging, EP = ectopic pregnancy, TAS = transabdominal sonography.

Figure 3.

TAS results on day 66 of amenorrhea. (A) Showing HP. (B) Simultaneous showing HP on the same tangent plane. HP = heterotopic pregnancy, TAS = transabdominal sonography.

Figure 4.

TAS results on postoperative day 8 (day 74 of amenorrhea). (A) Showing IP with a gestational sac size of 52 × 16 × 44 mm. (B) Embryonic pole size of 41 mm in length. IP = intrauterine pregnancy, TAS = transabdominal sonography.