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Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 37-39

Unusual presentation of heterotopic pregnancy

Department of Obstetrics and Gynaecology, JSS Medical College Hospital, Mysuru, Karnataka, India

Date of Submission28-Nov-2019
Date of Acceptance06-Jan-2020
Date of Web Publication17-Mar-2020

Correspondence Address:
Deepika Bohra
No. 304, JSS PG Resident Hostel, M. G. Road, Agrahara, Mysuru - 570 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_75_19

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Heterotopic pregnancy is a rare occurrence in naturally conceived pregnancy and is difficult to assess as pain and bleeding may be due to abortion. We report a case of spontaneous heterotopic pregnancy which was missed in initial transabdominal scan and was reported to be intrauterine pregnancy and was later identified as heterotopic pregnancy with serial beta-human chorionic gonadotropin levels and clinical features. If assisted reproductive treatment procedures are not involved, it is likely to be missed and may lead to serious and delayed consequences.

Keywords: Assisted reproductive treatment-assisted reproductive technology, heterotopic pregnancy, human chorionic gonadotropin, incomplete abortion, transabdominal ultrasound

How to cite this article:
Poornima M, Mamatha S, Madhuri N, Sapna H P, Bohra D. Unusual presentation of heterotopic pregnancy. Apollo Med 2020;17:37-9

How to cite this URL:
Poornima M, Mamatha S, Madhuri N, Sapna H P, Bohra D. Unusual presentation of heterotopic pregnancy. Apollo Med [serial online] 2020 [cited 2020 Sep 22];17:37-9. Available from: http://www.apollomedicine.org/text.asp?2020/17/1/37/280917

  Introduction Top

Heterotopic pregnancy is defined as the simultaneous presence of intrauterine and extrauterine pregnancy. The most common site of extrauterine pregnancy is  Fallopian tube More Detailss. The incidence of spontaneous heterotopic pregnancy is 1 in 30,000–1 in 50,000.[1],[2]

The first case was reported in 1708 as an autopsy finding.[3] A case of ectopic pregnancy in each tube with a single intrauterine gestation was reported.[4] The incidence among patients with assisted reproduction is higher and is around 1–3:10,000.[5],[6]

  Case Report Top

A 28-year-old woman came with 2 months of amenorrhea, complaints of pain abdomen on and off for 1 week, and bleeding per vagina for 1 week. She is gravida 3 abortion 2 with first spontaneous abortion and second induced abortion in the first trimester. On examination, her B.P and pulse rate were normal, on abdomen examination- soft, non tender, on speculum examination, cervical os open and products of conception were seen and on per vaginal examination; cervix was 2 cm dilated, products of conception felt at os and on bimanual examination-uterus was around 8–10 weeks size.

The patient presented with a complaint of pain over the left iliac fossa after 2 days. Serial beta-human chorionic gonadotropin (HCG) monitoring was done, and it was noted that there was a rise of beta-HCG, but not of the doubling range, 3 days later, transabdominal scan of the pelvis was done which showed the left tubo-ovarian mass of around 3.0 cm × 2.1 cm with no internal vascularity on Doppler [Figure 1].
Figure 1: (a) Intra-operative finding of left tubal pregnancy, (b) Findings after left salpingectomy was done

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Hence, diagnostic laparoscopy was done, and intraoperatively, hemoperitoneum of approximately 100 ml with left tubal pregnancy in process of tubal abortion was noted and left salpingectomy was done [Figure 2].
Figure 2: This is the histopathological report showing chorionic villi with product of conception for instrumental evacuation done for a patient with incomplete abortion

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Instrumental evacuation was done on the same day and products of conception obtained. Oral antibiotics were started and check scan was done, which showed an empty uterine cavity [Figure 3].
Figure 3: Transabdominal scan done 2 days later showed a left tubo-ovarian mass of 3 cm × 2 cm with no internal vascularity on Doppler suggestive of ectopic pregnancy with tubal abortion

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Postoperatively, the patient was symptom less and repeat beta-HCG was done after 3 days and was falling. Hence, the patient was discharged on the 4th postoperative day.

  Discussion Top

Heterotopic pregnancy can be a life-threatening condition and can be easily missed. A high index of suspicion is needed with risk factors for an ectopic pregnancy and in low-risk women with an intrauterine gestation who have free fluid with or without an adnexal mass or in those presenting acute abdominal pain and shock. The ectopic component is usually treated surgically and the intrauterine one is expected to continue normally. The common presenting signs and symptoms are pain abdomen, adnexal mass, peritoneal irritation, and an enlarged uterus; abdominal pain was reported in 83% of cases and hypovolemic shock with abdominal tenderness was reported in 13% of cases of heterotopic pregnancies.[3] Furthermore, 50% of the patients did not complain of vaginal bleeding, and it may also occur from ectopic pregnancy due to the intact endometrium of intrauterine pregnancy.[7] The sensitivity of TVS in diagnosing ectopic pregnancy is only 56% at 5–6 weeks.[8]

Tubal ring, an adnexal mass with concentric echogenic rim of tissue and a gestational sac surrounding a hypoechoic empty center, was noted in 68% of ectopic pregnancies in which the tube had not been ruptured.[7]

At times, an adnexal sac can be mistaken for hemorrhagic corpus luteum or an ovarian cyst, especially in hyperstimulated ovaries.[9] If beta-HCG levels are higher for period of gestation with an intrauterine pregnancy, one must look for a coexistent tubal pregnancy. Ultrasonography (USG) shows features of both intrauterine and extrauterine pregnancies. Ring of fire sign on colour doppler, gestational sac is seen in adnexa.[4] Other ultrasound features include hemoperitoneum, hematosalpinx, and free fluid in the pouch of Douglas.[10]

Knowledge of heterotopic pregnancy is becoming important as more women are undergoing assisted reproduction, more commonly being ovulation induction. Heterotopic pregnancy should be thought and kept in mind if the patient with assisted reproduction presents with pelvis pain or per vaginum (PV) bleeding.

If ectopic component of heterotopic pregnancy is ruptured, the management is always surgical and intrauterine pregnancy can be continued normally. If ectopic component is detected at an early stage where it has not been ruptured, expectant management with aspiration an instillation of potassium chloride or prostaglandin into the gestational sac.[3],[11] In case of nonviable intrauterine pregnancy or if the patient does not wish to continue the pregnancy, methotrexate can be given. Local injection of potassium chloride or hyperosmolar glucose with aspiration of sac contents under USG guidance can be done. Medical management has a limited role as intrauterine pregnancy needs to be conserved and protected.

  Conclusion Top

Heterotopic pregnancy in a natural conception is rare and can rarely be a fatal condition. A high index of suspicion is required in patients presenting with amenorrhea, pelvic pain, PV bleeding, and adnexal mass. Even if intrauterine pregnancy has been confirmed, the suspicion should be higher in women with high-risk factors for ectopic pregnancy. The ultrasound visualization of cardiac activity in both intra- and extrauterine gestations is important for diagnosis but rare. Therefore, even in the presence of intrauterine pregnancy, a complete USG review of the whole pelvis including the adnexa should be done to rule out heterotopic pregnancy.[8]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kamath MS, Aleyamma TK, Muthukumar K, Kumar RM, George K. A rare case report: Ovarian heterotopic pregnancy afterin vitro fertilization. Fertil Steril 2010;94:1910.e9-11.  Back to cited text no. 1
Basile F, Di Cesare C, Quagliozzi L, Donati L, Bracaglia M, Caruso A, et al. Spontaneous heterotopic pregnancy, simultane-ous ovarian, and intrauterine: A case report. Case Rep Obstet Gynecol. 2012;2012:50969.  Back to cited text no. 2
Sujatha MS, Suma KB, Poornima M, Shree S, Divyashree B, Gowda S. Heterotopic pregnancy in natural conception: A rare entity. Pharm Biomed Sci 2016;6:86-8.  Back to cited text no. 3
Jeong H, Park L, Yoon S, Park S. heterotopic triplet pregnancy with bilateral tube and intrauterine pregnancy after spontaneous conception. Eur J Obstet Gynecol 2009;142:161-2.  Back to cited text no. 4
Available from: https://radiopaedia.org/articles/heterotopic-pregnancy. [Last accessed on 2019 Dec 12].  Back to cited text no. 5
Tchounzou R, Simo Wambo AG, Nana Njamen T, Dadao F, Elong F, Egbe O, et al. Heterotopic pregnancy in natural uninduced cycles: A case series with two positive outcomes in a semi-urban area in Cameroon. A case series with two positive outcomes in a Semiurban Area in Cameroon. J Case Rep 2018;8:263-6.  Back to cited text no. 6
Hassani KI, Bouazzaoui AE, Khatouf M, Mazaz K. Heterotopic pregnancy: A diagnosis we should suspect more often. J Emerg Trauma Shock 2010;3:304.  Back to cited text no. 7
[PUBMED]  [Full text]  
Dundar O, Muhcu M, Yergok YZ. Heterotopic pregnancy: Tubal ectopic pregnancy and monochorionic monoamniotic twin pregnancy: A case report. Perinat J 2006;14:96-100.  Back to cited text no. 8
Callen PW. Ultrasonography in obstetrics and gynecology. In: Levine D, editor. Ectopic pregnancy. 5th ed. Philadelphia: Saunders Elsevier; p. 1020-47.  Back to cited text no. 9
Bourgon Dr Ectopic Pregnancy. eMedicine. Available from: http://www.wmwdicine.com/radio/topic231.htm. [Last accessed on 2019 Dec 12].  Back to cited text no. 10
Lialios GA, Kallitsaris A, Kabisios T, Messinis IE. Ruptured heterotopic interstitial pregnancy: Rare case of acute abdomen in a Jehovah's Witness patient. Fertil Steril 2008;90:1200.e15-7.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3]


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