Heterotopic pregnancy: case report

Abdom Imaging 27:677– 679 (2002) DOI: 10.1007/s00261-001-0125-5

Abdominal Imaging © Springer-Verlag New York Inc. 2002

Heterotopic pregnancy: case report ¨ zer, H. Eg៮ ilmez, F. D. Apaydın, A. Yıldız, E. Kara M. Nass Duce, C. O Department of Radiology, Mersin University Faculty of Medicine, Zeytinlibahc¸e Cad, Eski Otogar Yanı TR-33070, Mersin, Turkey Received: 22 April 2001/Accepted: 28 June 2001

Abstract Heterotopic pregnancy in a spontaneous cycle is a rare entity with an estimated frequency below one per 30,000 pregnancies. Its incidence evidently has increased in accordance with the widespread use of in vitro fertilization and ovulation induction. We report a case of heterotopic pregnancy in a 40-year-old woman who presented with acute abdominal pain. We also present findings from transvaginal ultrasound imaging. Key words: Heterotopic pregnancy—Transvaginal ultrasound—Acute abdomen.

Heterotopic pregnancy is the simultaneous occurrence of intrauterine and extrauterine pregnancies. This condition is very rare in a natural cycle, with an estimated occurrence of one per 30,000 spontaneous pregnancies [1–3]. Its incidence has increased with the widespread use of assisted reproductive technologies such as in vitro fertilization and embryo transfer and the increased use of ovulatory drugs [1– 6]. We present transvaginal ultrasonographic (TVUS) findings in a case of heterotopic pregnancy during a spontaneous cycle.

Case report A 40-year-old woman was admitted to our hospital with the chief complaint of crampy abdominal pain. She had a history of vague pelvic pain for the past 15 days, but the pain had worsened over the previous 24 h and progressed to severe diffuse abdominal pain. She also complained of intermittent nausea and vomiting. Her last menstrual period occurred 3 weeks before as vaginal spotting. She also noted that she was not using contraceptives. Correspondence to: M. Nass Duce

Physical examination showed tenderness to palpation, especially in the left lower quadrant, with rebound and guarding. The examination was otherwise normal. Vital signs were stable. Laboratory studies showed a hemoglobin value of 12.2 g/dL and a hematocrit of 34%. The other laboratory tests were within normal limits. The patient had a positive pregnancy test. TVUS showed a 29-mm gestational sac with a yolk sac within the uterine cavity, and positive fetal cardiac activity was detected (Fig. 1A). Around the gestational sac, there was a 1-mm-thick, crescent-shaped, hypoecoic area that was presumed to be subchorionic bleeding (Fig. 1B). Next to the left ovary, another gestational sac with a hyperechoic wall and a diameter of 25 mm, was found (Fig. 1C). Inside that gestational sac, positive fetal cardiac activity was noted (Fig. 1D). In addition, within the pelvis, a large amount of echogenic, free fluid, thought to represent hemorrhage, was seen. The right ovary and the fallopian tube were normal. The patient was taken to the operating room. During the operation, a ruptured ectopic pregnancy was found in the ampullary region of the left fallopian tube. There was approximately 500 mL of intraperitoneal hemorrhage. The patient had a left salpingectomy and the intrauterine pregnancy was terminated at her request.

Discussion Simultaneous intra- and extrauterine pregnancies are a rare obstetric phenomenon. However, the increases in pelvic inflammatory diseases and assisted reproductive technologies have increased the overall incidence of heterotopic pregnancies. The incidence of heterotopic pregnancy after in vitro fertilization has been reported to range from 1% to 2.9% [1– 8]. Previous pelvic inflammatory disease, pelvic surgery, associated uterine malformations, use of ovarian hyperstimulation drugs, multiple embryo transfers, and a his-

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M. Nass Duce et al.: Heterotopic pregnancy

Fig. 1. A Within the uterus, a 29-mm gestational sac is seen with a yolk sac and a fetal pole (not shown). B Around the gestational sac, a hypoechoic, crescent-shaped collection, which was assumed to be a

subchorionic hematoma, is visible. C Next to the left ovary, another gestational sac with a yolk sac and fetal pole is seen. D Doppler ultrasound shows fetal cardiac activity in the ectopic gestational sac.

tory of ectopic pregnancy are some of the risk factors for heterotopic pregnancy [1, 2, 5, 8]. For the diagnosis of heterotopic pregnancy, clinical symptoms are not always helpful. Reece et al. reported that four symptoms and signs were seen frequently in heterotopic pregnancies in their series of 66 patients. These were abdominal pain, adnexal mass, peritoneal irritation signs, and an enlarged uterus [7]. Even though these findings may indicate the presence of a heterotopic pregnancy, the most useful diagnostic tool is ultrasound, especially TVUS. Sonographic detection of an extrauterine gestational sac with or without a fetal pole (with or without existence of cardiac activity) and an intrauterine pregnancy leads to the definitive diagnosis. Treatment of heterotopic pregnancy has included surgical management and potassium chloride injection into the ectopic gestational sac [6, 9]. Detailed discussion of the treatment is not within the scope of this paper. This case is interesting because it occurred during a natural cycle. The easy detection of the intrauterine pregnancy at first seemed to explain the positive pregnancy

test, but not the clinical findings. The careful examination of the adnexa with the demonstration of the ectopic pregnancy and the presence of free fluid within the pelvis soon guided us to the right diagnosis. To conclude, although rare, heterotopic pregnancy should be thought in the differential diagnosis of an acute abdomen. One also should remember that detection of an intrauterine pregnancy does not exclude the existence of an accompanying ectopic pregnancy.

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