1 Department of Obstetrics and Gynecology, Al Jahra Hospital, Kuwait

Corresspondence to:
Dr.Ramadevi V Wani MRCOG
PO Box 17672
Khaldiya, 72457
KUWAIT
Email: ramawani@msn.com
Mobilel: 00965-6779120
Residence: 00965-4880924
Fax: 00965-4577045

A 28 year old nullipara who had suffered 4 first trimester abortions attended our hospital emergency department with history of 8 weeks amenorrhoea and complaints of sudden onset of lower abdominal pain and dyschesia of one day duration. She said that she had had an ultrasound three days ago and was told she had a normal intrauterine pregnancy corresponding to LMP gestational age. There was no vaginal bleeding. She had no known risk factors for ectopic pregnancy. She had felt faint prior to the time of presentation. On examination she was in pain with pallor, tachycardia with low volume pulse and hypotension with blood pressure of 90/60. The abdomen was distended and there was marked generalized tenderness. A provisional diagnosis of 8 weeks pregnancy with ruptured hemorrhagic corpus luteal cyst was made. Resuscitative measures were commenced for the treatment of shock. Simultaneously an urgent ultrasound was done. It showed a single intrauterine gestational sac with a viable embryo corresponding to 7+ weeks pregnancy. Another gestational sac with a live embryo of approximately seven weeks gestational age was seen in the right adnexa (Fig 1 and 2). There was fluid with low level echoes in the pelvis and hepatorenal pouch, suggestive of hemoperitoneum. Thus, a diagnosis of heterotopic pregnancy with ruptured ectopic pregnancy and hemoperitoneum was made. An emergency laparotomy was performed.

There was hemoperitoneum of 1.5 liters. Uterus was enlarged corresponding to 8 weeks size. The right adnexa showed ruptured right tubal ectopic pregnancy. The ectopic gestational sac with embryo was still seen within the ruptured tube. The left adnexa appeared normal. The tubal ectopic pregnancy contents were removed and salpingostomy was performed taking care to avoid undue manipulation of the uterus. She received three units of packed red blood cells in the intraoperative and immediate postoperative period. Ultrasound done on the third postoperative day affirmed the viability of intrauterine embryo. She was discharged home on the fourth postoperative day on folic acid and progesterone support. The intrauterine pregnancy continued uneventfully till term. Cesarean section was done at 38 weeks pregnancy as there was non-reassuring fetal trace during labor and she delivered a live girl, weight 3.070 kg, with Apgar score of 8 at 1 minute and 9 at five minutes.

Fig 1: Transabdominal scan demonstrating intrauterine pregnancy and tubal ectopic pregnancy

Fig 2: Transabdominal scan showing viable tubal ectopic pregnancy

Heterotypic pregnancy defined as the presence of intrauterine pregnancy coexisting with an ectopic pregnancy is a relatively underestimated clinical condition. It was first described by Duverney in 1708 during an autopsy. The incidence of heterotopic pregnancy in spontaneous cycles was quoted as 1: 30,000 about 50 years ago. However in the last three decades there has been an almost four-fold increase in the incidence of ectopic pregnancy and a corresponding increase in the incidence of heterotopic pregnancy. The current quoted risk of heterotopic pregnancy is 1 in 3889-6778 in the general population^[1]. In a meta-analysis in 1996, previous ectopic pregnancy, previous tubal surgery, documented tubal pathology and in utero diethylstilbestrol (DES) exposure were found to be associated strongly with the occurrence of ectopic pregnancy^[2]. In the same study previous genital infections (pelvic inflammatory disease, Chlamydia, gonorrhoea), infertility, and a lifetime number of sexual partners > 1 were associated with a mildly increased risk. Heterotopic pregnancy occurs even more frequently after pharmacologic ovulation stimulation. After ART the risk is greatest increasing to 1.2-2.9%^[3,4].

Diagnosis of heterotopic pregnancy is often difficult. It is more likely to be thought of and diagnosed in pregnancies following assisted reproductive technology. Even then there are several diagnostic pitfalls. Clinical diagnosis of heterotopic pregnancy is unlikely as the symptoms of pain and bleeding are often attributed to be due to the complication of intrauterine pregnancy. Quantitative assessment of ß HCG and progesterone are falsely reassuring, as they are often in the normal range due to co-existing intrauterine pregnancy. Our patient had natural conception. Secondly the woman did not have any of the above-mentioned risk factors for ectopic pregnancy. Moreover the presence of a viable intrauterine pregnancy may have reassured the ultrasonographer and he may have overlooked the adnexa. These could probably be the reasons for the diagnosis not being made at the time of first ultrasound.

The improved resolution of the transvaginal ultrasound enables more accurate diagnosis of heterotopic pregnancy^[5]. It has resulted in the earlier diagnosis of ectopic pregnancy and has contributed to a decrease in the maternal mortality and morbidity associated with this condition. However Qusehal A et al reported transabdominal ultrasound to be more useful than transvaginal ultrasound as it can visualize those areas, which cannot be assessed by the latter. In effect both methods are complimentary^[6]. Sonographic detection of an extra uterine gestation sac with or without fetal pole and /or cardiac activity, together with an intrauterine pregnancy confirms the diagnosis of heterotopic pregnancy. In our patient who presented with acute abdomen and shock, in view of the history of an ultrasound showing normal intrauterine pregnancy, ruptured hemorrhagic
corpus luteal cyst was the first diagnosis considered. However an urgent ultrasound done in the department clinched the diagnosis. In our patient the ectopic embryo located in the upper zone of the right iliac fossa was only picked up by the transabdominal ultrasound. It was inaccessible to transvaginal ultrasound.

In a woman with heterotopic pregnancy who is clinically stable laparoscopic management is both feasible and safe. All tubal pregnancies irrespective of their location - even in the technically most demanding situations with interstitial or cornual location can be successfully managed by laparoscopy with an uneventful course for the remaining intrauterine pregnancy^[7]. Feasibility of laparoscopic surgery depends on the expertise of the surgical team. Non-surgical management is an efficient alternative with a good prognosis for intrauterine pregnancy. Transvaginal ultrasound guided aspiration of the gestational sac fluid and injection of potassium chloride, hyperosmolar glucose or hypertonic sodium chloride solution into it results in resorption of the ectopic trophoblastic tissue^[8,9,10]. Unlike ectopic pregnancy, heterotopic pregnancy with viable intrauterine pregnancy cannot be treated with methotrexate for obvious reasons. However, when a patient presents with acute abdomen and shock, laparotomy and salpingectomy/salpingostomy is the safest option. In our patient as she presented with shock we did laparotomy and salpingostomy. Prompt resuscitative measures for the treatment of shock and the careful introduction of cardiac sparing anesthetics are necessary for the survival of the intrauterine pregnancy.

In a literature review by Tal et al involving 139 cases of heterotopic pregnancy, where most of them were treated surgically the overall live intrauterine pregnancy rate was 66% irrespective of the presence of hemoperitoneum^[11]. In a comparison study of assisted vs. spontaneous heterotopic conceptions, the assisted conception group had a higher live birth rate than the spontaneous group (47.8 vs. 20%)^[12]. Our patient was delivered at term by cesarean section.

Heterotopic pregnancy is a potentially fatal condition. However when diagnosed early and treated appropriately it can result in survival of the precious intrauterine pregnancy. We recommend that all obstetricians and sonologists performing obstetric ultrasound should routinely evaluate the adnexa and document it. This practice in addition to diagnosing heterotopic pregnancy will also help in the diagnosis of other adnexal pathology. In pregnant women with acute abdomen clinicians should always consider heterotopic pregnancy in the differential diagnosis.

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