A rare case of a Heterotopic pregnancy

1. CASE REPORT
HETEROTOPIC PREGNANCY
Spanish Town Hospital
Research Day
November 26, 2021
Prepared by Dr. M. Marius and
Dr. D. Townsend-Wi
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2. 2
ABSTRACT
Heterotopic pregnancy (HP) is a rare complication usually seen in
the populations at risk for ectopic pregnancy
Risk factors include assisted reproduction techniques and pelvic
inflammatory disease
It is a potentially dangerous condition occurring in 1:3900
pregnancies
Surgical intervention plays a key role in the management of HP,

3. 3
INTRODUCTION
Refers to the presence of simultaneous pregnancies at
two different implantation sites.
Most often: a combination of an intrauterine pregnancy
(IUP) and ectopic pregnancy.
The diagnosis of heterotopic pregnancy is still one of the
biggest challenges in modern gynaecology.
Most life threatening of all ectopic pregnancies.

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INCIDENCE
Considered rare, 1:30,000 spontaneous pregnancies
However, with the advent of Assisted Reproductive
Techniques (ART) - overall incidence of 1:3900 pregnancies
ART - include superovulation/ovulation induction, IUI, IVF
An analysis of ART Pregnancies in USA between 1999 –
2002 suggested 2:1000 ART pregnancies (Clayton et al,
2007)

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CASE REPORT
S.R.
27-year-old
G1P0
LMP – 30 December 2020
EDD – 6 October 2021
GA 8+2 weeks
6

7. 7
HISTORY OF PRESENTING COMPLAINT
Abdominal Pain
•Onset - 7AM
•Location - lower abdomen
•Severity - 9/10
•Character - cramping,
intermittent
•Aggravation - standing
position
•Relief - supine position
•Radiation - none
Bleeding
•Seen on wiping after
urination
•Small clots
•No fleshy material
Other
•Dysuria
•Increased urinary frequency

8. 8
PAST MEDICAL HISTORY
Dx - COVID–19 on20
February 2021
Asymptomatic:
Fever 
Cough 
Cold 
PGH - Polycystic Ovarian
Syndrome - regular menses,
Clomiphene Citrate use
PSH - none
DH - none; no known
allergies
F&SH - none; non-smoker,
non-alcoholic

9. 9
CVS
no abnormalities detected
Adbomen
soft, suprapubic
tenderness, no masses
Respiratory
Chest clinically clear
V/E
cervical os open, right
adnexal wall tenderness
EXAMINATION FINDINGS
On Examination
Nil distress.
Mucosa pink and
moist.
Anicteric,
Acyanotic
VITALS
BP 124/75
P 91
R 21
T 36.5
SpO2 98% (room air)
Urinalysis
blood (++)
WBC (+)
Bedside Ultrasound (Done in A&E)
− Live Twin intrauterine gestation
− Nil free fluid noted
− Cervical os open
− Ovaries normal
ASSESSMENT - Inevitable Miscarriage - Referred to

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GYNAECOLOGY ASSESSMENT
History noted
 V/E:
- Scant brown
discharge on
speculum
- Digital Exam:
Internal os closed
Assessment (Gyn)
- Threatened
Miscarriage -
?UTI
PLAN:
 Outpatient management
 Urine culture
 Empirical Antibiotics -
Augmentin
 Paracetamol, prenatal
vitamins
 Formal Ultrasound
 ANC review in 2 weeks
(following quarantine period)

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ANC -RV
MSU - Culture (26 Feb 2021) - mixed GPC <10,000CFU/ml – insignificant growth
Obstetric Ultrasound (04 March 2021)
 Live twin intrauterine gestation with separate amniotic sacs
 GA 9+3weeks; EDD 04 October 2021
 Cervical Length 4.0 cm, Internal os is closed
 Right ovary enlarged (25cc) with thick-walled hypo echoic cyst —> corpus
luteum cyst
 Left ovary is normal
 No free fluid or adnexal mass

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PATIENT REPRESENTED
GA - 11+2 weeks
Presenting Complaint - severe lower abdominal
pain

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PRESENTING COMPLAINTS
Abdominal Pain
•Onset - this AM
•Location - lower abdomen
•Severity – 10/10
•Character - cramping,
intermittent
•Aggravation - standing
position
•Relief - supine position
•Radiation - suprapubic area,
nil loin to groin
Absent
•No bleeding/PV losses
•No fever chills or rigors
•No urinary symptoms
•No syncope
•No reduced appetite
Other
•Vomit x 1 (previously eaten
content)

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CVS
no abnormalities detected
Abdomen
soft, marked suprapubic
tenderness, no masses,
no rebound
Respiratory
Chest clinically clear
V/E
cervical os open, no
POC seen, dark brown
discharge noted
EXAMINATION FINDINGS
On Examination
Obvious Painful
distress
Nil CPD
Mucosa pink and
moist
Anicteric
Acyanotic
VITALS
BP 106/78
P 82
R 20
T 97.8
SpO2 98% (room air)
Urinalysis
blood (+)
protein (trace)
ASSESSMENT
− Inevitable Miscarriage (twin
gestation)
− Referred to gynaecology service

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GYNAE REVIEW
Abdomen
• Soft, depressible tender +++
• Voluntary guarding no rebound
• No renal angle tenderness
• 14/4 pelvic mass
VE
• Altered blood noted
• Tender Bimanual Examination
• Internal os closed
• Clinically shortened cervix 1.5cm
Assessment (Gyn)
• Threatened Miscarriage – Twin
Gestation
PLAN:
Admit to ward
Formal ultrasound scan
Analgesia
(pethidine/gravol)
IV hydration
Normal diet
Bed rest
Follow up labs

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LABS RESULTS
CBC U&E Serology Blood
Group
WBC 12.28
Hb 10.8
Hct 32.8
Plt 267
Urea 3.6
Creat. 46
Na 136
K 4.4
Cl 103
CO2 16.4
HIV –
negative
VDRL – non
reactive
O positive

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DAY 1 ADMISSION
18
• Abdominal pain 5/10 - constant, no PV losses
S
• Nil obvious distress; vitals stable; suprapubic tenderness (+)
O
• r/o UTI
A
• rpt MSU then commence cefuroxime Rx, analgesia, bed rest
• Ultrasound
P

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DAY 2-3 ADMISSION
19
•Abdominal pain with variable intensity 4- 8/10
S
•Nil obvious distress; suprapubic tenderness (mild),
no guarding
O
•Unchanged
A
•Add Endometrin pv; Ultrasound pending; MSU
pending; continue other care
P

20. 20
DAY 4 ADMISSION
20
•Abdominal pain with variable intensity 4- 8/10
S
•Obstetric Ultrasound
Live twin intrauterine gestation
Thick-walled cystic mildly echogenic mass at the right aspect of the uterine funds
O
•May be a degenerating fibroid
•Other differentials to include - Heterotopic pregnancy
•A small amount of free fluid is seen in the posterior cul-de-sac containing blood
A
•Follow-up imaging advised
P

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REPEAT LABS
DATE 19 March 23 March
WBC 12.88 10.33
Hb 10.8 9.0
Hct 32.9 27.8
Plt 267 279
23 March 2021
CBC
WBC 10.33
HB 9.0
Hct 27.8
Plt 279
U&E
Urea 1.9
Creat. 42
Na 131
K 3.5
Cl 103
CO2 17.3

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DAY 4 ADMISSION
Called to review patient who is having worsening pain!!!
FINDINGS:
Abdomen - tender in right lower quadrant (+++) with rebound and
guarding
Assessment - Acute Abdomen

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PLAN
Informed consent for Exploratory Laparotomy+/-
Salpingoophrectomy/- Oophorectomy,+/-
Appendectomy
Patient extensively counselled re: possible risks at
surgery including
risk of miscarriage resulting in loss of pregnancy

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INTRA – OP FINDINGS
Findings: Ruptured Right Tubal (ampullary) Ectopic
Pregnancy
Anaesthesia - SPINAL
Surgery Time - 39 minutes; Blood Loss - 400mls24

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POST OP COURSE
DATE 19 March 23 March 24 March
WBC 12.88 10.33 10.37
Hb 10.8 9.0 9.1
Hct 32.9 27.8 27.3
Plt 267 279 286
Post Salpingectomy Day 1-2
Uneventful post-operative
period
Remained clinically stable
Discharged post op day 2
Home to complete one week
course Rx
Advised re: pelvic rest and
endometrin Rx

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DISCUSSION - HETEROTOPIC
PREGNANCY
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RISK FACTORS
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Age >35 years
Pelvic Surgery
Tubal disease
Endometriosis
PID
Smoking
Infertility
ART

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CLINICAL MANIFESTATIONS
Peritoneal Irritation
Abdominal pain
Enlarged Uterus
Altered Mental Status
Adnexal Mass + Tenderness
Vaginal Bleeding
.

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DIFFERENTIAL DIAGNOSIS
GYNAECOLOGICAL VS NON -GYNAECOLOGICAL
Ovarian Torsion
Ruptured corpus luteal /
Hemorrhagic Cyst
Degenerating Fibroid
UTI in Pregnancy
Renal Stone
Ruptured
Appendix

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DIAGNOSTIC DILEMMA
Patient tends to present at a later Gestational age –
late T1 – T2 cp to isolated ectopic pregnancies.
The Diagnosis is often not considered in the presence
of an observed intrauterine pregnancy.
Due to high incidence of ‘misdiagnosis’ - there is a
high incidence that by the time the patient presents
they might have already ruptured – potentially life
threatening.
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Locate
Pregnancy
Evaluate adnexa
Presence of
Free fluid?
BHCG
Establish
Pregnancy
BHCG –not useful as it
primarily reflects the
intrauterine pregnancy.
IUP with a complex
adnexal mass. Often
mistaken as consider
corpus luteal cyst .
TVUS – sonographic
modality of choice
Reproductive age
women with abdominal
pain uterine bleeding or
menstrual abnormalities
-must do a PT
Could represent Tubal
rupture. Ascites 2˚ OHSS
if ART)
DIAGNOSTIC EVALUATION

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TREATMENT
Treatment of the Ectopic is tailored based on site of
implantation
Ideally the least invasive method – to preserve maternal
health and the co-existing viable IUG
Salpingectomy is the standard surgical approach –
Laparoscopic approach
Limited use of Systemic medical therapies - Methotrexate
(MTX) – contraindicated
Unruptured – 10% KCL or Hyperosmolar Glucose - high
therapeutic efficacy and low toxicity to the IUP – 55%
success rate

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OUTCOME
Successful preservation of the intrauterine pregnancy
is estimated to be about 66%
If not treated significant morbidity and mortality to
mother with loss of IUP

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PREGNANCY COURSE – S.R.
GA – 35 weeks
Pregnancy progressed to late
preterm to 35 weeks - uneventful
except for worsening anaemia for
which she was being optimized
with haematinics
E-LSCS
Delivered via Emergency
Caesarean Section - EBL
800cc
Discharged
Mother and Babies doing well
and were discharged day 6
post delivery.
SROM 35+2
Patient presented @ 35+2
with passage of pv fluid – AM.
Preterm Labour with SROM,
Twin A Breech , Anaemia (7.2)
POSTPARTUM
Mother transfused in post
partum period with 2 units
PRBC + Venofer due to
symptomatic anemia.

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TAKE AWAYS
The presence of an
intrauterine pregnancy
does not rule out the
presence of a coexisting
ectopic pregnancy.
A careful ultrasound scan
of the uterus and
appendages is a must in
all women of reproductive
age with clinical
symptoms.
Clinicians should always
keep in mind that a
heterotopic pregnancy
may occur in a woman of
reproductive age.
Delay in diagnosis can be
catastrophic and therefore
require a high level of
suspicion.

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TWIN BABIES @ 7 WEEKS OLD
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Images Courtesy of S.R. – shared with permission

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REFERENCES
Harzif AK, Hyaswicaksono P, Kurniawan RH, Wiweko B. Heterotopic Pregnancy: Diagnosis and
Pitfall in Ultrasonography. Gynecol Minim Invasive Ther. 2021;10(1):53-56. Published 2021 Jan
30. doi:10.4103/GMIT.GMIT_92_19
Reece EA, Petrie RH, Sirmans, et al combined intrauterineand extrauterine gestations: a review.
Am J Obstet Gynecol 1983;146:323
Pisarska MD, Carson SA. Incidence and risk factors for ectopic pregnancy. Clin Obstet Gynecol
1999;42:2.
Goldstein JS, Ratt VS, Philpott T, Dahan MH. Risk of Surgery after use of potassium chloride for
treatment of tubal heterotopic pregnancy. Obstet Gynecol 2006;107:506
Noor N, Bano I, Parveen S. Heterotopic pregnancy with successful pregnancy outcome. J Hum
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Ntounis, T., Fasoulakis, Z., Koutras, A., Diakosavvas, M., Bourazan, A., Pagkalos, A., Samara, A. A.,
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intrauterine pregnancy in a patient with systemic lupus erythematosus: A case report. Case
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Chadee, A., Rezai, S., Kirby, C., Chadwick, E., Gottimukkala, S., Hamaoui, A., Stankovich, V., Hale,
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Clayton HB, Schieve LA, Peterson HB, et al. A comparison of heterotopic and intrauterine-only 37

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