Heterotopic Pregnancy after In Vitro Fertilisation and Embryo Transfer Post-unilateral Salpingectomy: A Case Report and Literature Review

Heterotopic pregnancy (HP) is the simultaneous occurrence of intrauterine and ectopic pregnancies (EP). The incidence of HPs occurring spontaneously ranges from 1 in 10,000 to 1 in 30,000. However, this incidence is reported to be 1 in 100 pregnancies following artificial reproductive techniques. HP is a potentially life-threatening condition that is frequently misdiagnosed, as most diagnoses for HPs are delayed, and are only made after rupture of the EP. A high index of suspicion is, therefore, required for an accurate and timely diagnosis in order to reduce maternal morbidity and mortality, which currently stands at 1 in 200,000 live births. The most common risk factors include pelvic inflammatory disease, previous EP, assisted reproduction techniques, and ovarian hyperstimulation syndrome. Transvaginal ultrasound is the gold standard for diagnosis. As detection of an intrauterine pregnancy often leads to the mistaken exclusion of a concomitant EP, a careful transvaginal scanning of the uterus and appendages should be performed in all females of reproductive age with a positive pregnancy test and red flags in anamnesis, and/or with clinical symptoms. Routine transvaginal ultrasound at Day 27 after embryo transfer could facilitate the diagnosis of HP; however, symptoms onset before or after Day 27 are clues to early diagnosis. MRI can be very helpful in diagnosing atypical cases.

A case report of heterotopic pregnancy

Heterotopic pregnancy is the presence of both intrauterine and extrauterine (ectopic) implantation as described by Reece in 1983 and is extremely rare. It accounts for 1 per 30000, in natural cycles and 9 per 10000, in assisted reproduction cycles. The aim of this report is to introduce this case as it poses a challenge to diagnosis due to its complex clinical and laboratory findings. A primigravida aged 30 at 6 weeks period of gestation, reported with minimal bleeding per vaginum. On performing a physical examination her vitals were stable and no significant findings were noted except for an enlarged uterus corresponding to 6 weeks with posterior forniceal fullness. Her beta-hCG was 23765 IU/ml and ultrasound showed a live intrauterine gestation with left adnexal mass- likely ectopic gestational sac. Laparoscopy showed a left tubal pregnancy and salpingectomy was done. The postoperative period was uneventful and she was discharged with a single live intrauterine gestation of 6-7 weeks. She carried on with her pregnancy and delivered a healthy baby at term. The diagnosis is possible only in cases when there is a high index of suspicion by the treating clinician. The adnexa must be inspected carefully in the confirmatory ultrasound. The early timely diagnosis gives a good maternal outcome and hence crucial in the management.

Spontaneous heterotopic pregnancy: a case report

Heterotopic pregnancy is defined as multiple gestation in which intrauterine and extrauterine gestational sacs co-exist. The extra uterine gestational sac is most commonly tubal ectopic pregnancy. We presented case of a 26 years old multigravida who presented to emergency with complaints of pain abdomen and giddiness for 2-3 days. She was at period of gestation (POG) 7 weeks and on clinical examination patient was anxious with mild pallor, mildly tachycardiac and blood pressure (BP) was 90/60 mm of Hg. After thorough clinical examination and sonography diagnosis of heterotopic pregnancy with ruptured tubal ectopic was made. She was taken up for Emergency laparotomy after investigations and consent. Left salpingectomy was done and she was discharged with a single intrauterine live pregnancy on 6th post op day. For early detection of cases of heterotopic pregnancy careful evaluation of adnexa is mandatory in early gestation scan.

Study On Diagnosis And Management Strategies On Heterotopic Pregnancy

Objective The aims of this study were to analysis the clinical characteristics of women with heterotopic pregnancy (HP) following embryo transfer (ET) and explore the early predictors for pregnancy outcomes.Methods This retrospective study reviewed patients with HP following assisted reproductive technology (ART) in our institution between January 2013 and December 2020. The relationships between pregnancy outcomes and general features, ultrasonic characteristics and different treatment modality were analyzed by logistic regression analysis.Results Fourty patients were identified, including 27 with tubal HP, 7 interstitial HP and 6 cornual HP. The most frequent manifestations before diagnosis was vaginal bleeding (30.0%), while 7 patients (17.5%) had no symptoms before diagnosis. The mean gestational age at symptom onset was 44.8 ± 8.6 days (range 27–68). Gestational age at diagnosis was 49.4 ± 7.6 days (range 29–68). Among these cases, twenty-nine patients of HP were accurately diagnosed by transvaginal ultrasonography (TVS). Hence, the sensitivity of TVS for detecting HP was 72.5% (29/40). Eleven patients received expectant management, while 29 patients underwent laparotomy (13/29) or laparoscopy (16/29) surgery. Gestational age at surgery day was 51.0±8.6 days (range 33–67). Live births occurred for 18 patients in the surgery group, 3 of whom delivered preterm. Additionally, the miscarriage rate was lower for patients with IUP cardiac activity (16.7% vs. 90.0%) than patients without IUP cardiac activity at HP diagnosis (P < 0.001). Further by logistic regression analysis, an IUP with cardiac activity at HP diagnosis was identified as an independent factors of pregnancy outcome (P<0.001).Conclusions Symptoms combined with routine TVS scans could reduce misdiagnosis and facilitate the diagnosis of HP. An IUP with cardiac activity at HP diagnosis as predictors for a favorable prognosis of HP. Prompt surgical intervention after diagnosis may minimize the incidence of abortion of IUP.

Heterotropic pregnancy: a common masquerade than ever thought?

Heterotopic pregnancy, coexistence of living or dead intrauterine pregnancy, single or multiple, with extra-uterine pregnancy located in the oviduct, ovary, uterine cornua, cervix or rarely peritoneal cavity. Heterotropic pregnancy is relatively uncommon in spontaneous conception with 1 in 30,000 cases reported, the incidence of heterotopic pregnancy increases to 1 in 3900 when conception is enhanced with various assisted reproduction techniques (ART). It is an ectopic pregnancy coexisting with intrauterine pregnancy. But is the incidence of heterotropic pregnancy rising? A case was reported from our centre in 2018 by Ejikeme et al, and we have recorded another two cases in the period of one year. Ectopic pregnancy has been described as a great masquerader, which makes diagnosis and management of heterotropic pregnancy a dilemma to attending physician. We present a case of an unbooked 26 years old G4P3+0 who has no family history of multiple gestation and presented at gestational age of 8 weeks and 5 days with 2 days history of abdominal pain and vaginal bleeding and 2 hours history of loss of consciousness. She later had exploratory laparotomy with left salpingectomy and manual vacuum aspiration of Retained Products of Conception with good outcome. In conclusion, spontaneous heterotropic pregnancy is a rare occurrence, however with advent of artificial reproductive technology and increase incidence of pelvic inflammatory disease, the incidence could be higher than earlier suspected.

Pitfalls in Diagnosing Heterotopic Pregnancy in Sub-Saharan Africa: A Case Report at the Yaounde University Teaching Hospital (Cameroon)

Heterotopic pregnancy (HP) is a dizygotic twin pregnancy in which one gestational sac is intrauterine and the other is extrauterine. The prevalence of HP is unknown in Cameroon where the diagnosis is difficult and usually fortuitous like in other resource-poor settings. We herein depict pitfalls and delays in the diagnosis and management of a ruptured heterotopic pregnancy at the Yaounde University Teaching Hospital. After a wrong diagnosis and inadequate treatment, our patient presented at our emergency unit with severe pelvic pain and clinical signs of hemoperitoneum with shock. She underwent a total left salpingectomy through laparotomy. She had a complete spontaneous abortion five days after the surgery. Given that sonography is not routinely available in emergency departments in resource-poor settings, it may be relevant for practitioners to always bear HP in mind when facing ruptured ectopic pregnancies.

Angular Heterotopic Pregnancy: Successful Differential Diagnosis, Expectant Management and Postpartum Care

Heterotopic pregnancy is a rare, difficult to diagnose and life-threatening pathology, which requires timely decisions made by an experienced multidisciplinary team. In this type of multiple pregnancy there are both intrauterine and ectopic pregnancies present. Its incidence increases in pregnancies conceived by assisted reproductive technology or in pregnancies with ovulation induction. This article presents an angular heterotopic pregnancy case in a 34-year-old multigravida. The patient was admitted on the 14th week of gestation due to abdominal pain on the left side with suspicion of heterotopic pregnancy. Transabdominal ultrasound and magnetic resonance imaging (MRI) were performed to confirm the diagnosis of heterotopic angular pregnancy in the left cornu of the uterus. Multidisciplinary team made a decision to keep monitoring the growth of both pregnancies by ultrasound while maternal vitals were stable. Due to intensifying abdominal pain, diagnostic laparoscopy was performed. No signs of uterine rupture were observed, and no additional surgical procedures were performed. Maternal status and ultrasonographic findings were closely monitored. The mass in the left cornu of the uterus did not change significantly and the fetal growth of the intrauterine pregnancy matched its gestational age throughout pregnancy. At the 41st week of gestation, a healthy female neonate was born via spontaneous vaginal delivery. The incidence rate of heterotopic pregnancy tends to grow due to an increased number of pregnancies after assisted reproductive technology and ovulation induction. It is important to always assess the risk factors. The main methods for diagnosing heterotopic pregnancies are ultrasonography and MRI. The main management tactics for heterotopic pregnancy include expectant management as well as surgical or medical termination of the ectopic pregnancy. Expectant management may be chosen as an option only in a limited number of cases, if the clinical situation meets the specific criteria. When applicable, expectant management may reduce the frequency of unnecessary interventions and help to prevent patients from its complications.