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CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 276-279

Outcome of heterotophic pregnancy


Department of Obstetrics and Gynaecology, Mamata General Hospital, Khammam, Telangana, India

Date of Submission17-Jul-2015
Date of Decision29-May-2020
Date of Acceptance01-Jun-2020
Date of Web Publication6-Jan-2021

Correspondence Address:
Dr. Myneni Pujita
Flat no. 104, Samskruthi Towers, Near Oasis First Gate, Rotary Nagar, Khammam - 507001, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_100_15

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  Abstract 


Heterotophic pregnancy is defined as presence of combined intrauterine and ectopic pregnancy. We are reporting 3 cases of heterotophic pregnancy out of 54 ectopic pregnancy cases during a study period of two years (April 2013–March 2015) in Mamata General Hospital Telangana. All of the three heterotophic pregnancies are due to induction of ovulation and intrauterine insemination. Early diagnosis and management of ruptured ectopic pregnancy was done and intrauterine pregnancy was managed conservatively. Of the three, two pregnancies reached term gestation and had good perinatal outcome. The other case aborted spontaneously at 26 weeks of gestation. Interesting thing in our cases is continuation of intrauterine pregnancies with good perinatal outcome even after catastrophic rupture of ectopic pregnancies.

Keywords: Intrauterine insemination, heterotopic pregnancy, ovulation induction


How to cite this article:
Pujita M, Kavitha B, Prabhakar G C, Usha Rani T. Outcome of heterotophic pregnancy. J NTR Univ Health Sci 2020;9:276-9

How to cite this URL:
Pujita M, Kavitha B, Prabhakar G C, Usha Rani T. Outcome of heterotophic pregnancy. J NTR Univ Health Sci [serial online] 2020 [cited 2021 Apr 23];9:276-9. Available from: https://www.jdrntruhs.org/text.asp?2020/9/4/276/306117




  Introduction Top


Though heterotophic pregnancy is a rare complication in pregnancy with natural cycles, its incidence is increasing due to advances in infertility treatment like induction of ovulation with drugs and following assisted reproductive techniques. Incidence of heterotophic pregnancy is 1 in 7000 to 1 in 30,000.[1] With induction of ovulation, the incidence goes up to 1 in 900,[1] risk factor for heterotophic pregnancy being multiple ovulation.


  Case Report Top


Case 1 live pregnancy in right horn of bicornuate uterus with left ruptured tubal pregnancy

A 28-year old G2P1D1 with the history of amenorrhoea of 10 weeks came to the emergency room with severe pain abdomen and giddiness. She previously had full-term normal vaginal delivery, 12 years ago. She underwent treatment for secondary infertility with clomiphene citrate and IUI in a private hospital. On clinical examination and ultrasound, she was diagnosed to have ruptured left tubal pregnancy with live intrauterine pregnancy in the right horn of bicornuate uterus [Figure 1] and [Figure 2]. Emergency laparotomy with left salpingectomy was done and intrauterine pregnancy was managed conservatively with progesterone up to 34 weeks. She delivered normally at full term and gave birth to a male baby of 2.8 kg.
Figure 1: Aparotomy image showing bicornuate uterus

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Figure 2: Laparotomy image showing ruptured left tubal ectopic pregnancy

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Case 2 Triplet intrauterine pregnancy with left ruptured tubal pregnancy

Primi gravida with 8 weeks of amenorrhoea came with the history of pain abdomen and giddiness. She had the treatment for primary infertility with ovulation induction and IUI. She had intrauterine pregnancy and an ectopic pregnancy in the left tube [Figure 3]. They have treated the ectopic pregnancy conservatively with KCL in a private hospital and advised follow-up. She did not go for follow-up but came with ruptured ectopic and hemorrhagic shock. Emergency laparotomy with left salpingectomy was done. Postoperative ultrasound showed triplet intrauterine pregnancy [Figure 4]. She was treated conservatively with progesterone for intrauterine pregnancy. On follow-up, at 16 weeks of gestation, ultrasound showed single intrauterine gestation and the other two sacs vanished. At 24 weeks of gestation, ultrasound showed severe oligohydramnios with no gross fetal anomalies. She aborted spontaneously at 26 weeks.
Figure 3: Laparotomy image showing ruptured left ectopic pregnancy

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Figure 4: Ultrasound image showing three intrauterine gestational sacs

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Case 3 Elderly Primi with intrauterine pregnancy and left ruptured ectopic pregnancy

Primi with 35 years came with complaints of spotting pervagina since 2 days. She had infertility treatment with induction of ovulation and IUI. Ultrasound showed intrauterine pregnancy of 9 weeks with cardiac activity and ruptured ectopic in the left tube with the haemoperitoneum of 200 ml. Emergency laparotomy was done. Intraoperatively, there was a ruptured left tubal pregnancy, and salpingectomy was done [Figure 5]. Postoperatively, she had threatened abortion for which conservative management was done with progesterone up to 36 weeks and elective lscs was done at 38 weeks of gestation and delivered a male baby of 3 kg.
Figure 5: Laparotomy image showing ruptured left ectopic pregnancy

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  Discussion Top


Heterotophic pregnancy should be suspected in any patient with missed periods complaining of pain in the lower abdomen, who had treatment for infertility with induction of ovulation, as clinical features are nonspecific.[2] Most of the heterotophic pregnancies are diagnosed late as no single investigation can predict the presence of heterotrophic pregnancy. Heterotophic pregnancy demonstrates normal hCG values due to the presence of the normal intrauterine gestation. Heterotopic pregnancies can pose a diagnostic dilemma because an early transvaginal ultrasound may not diagnose an ex-utero gestation in all cases. A diagnosis of a pseudosac should be made with caution, as even in the presence of a pseudo sac there can be a high false-positive diagnosis of an ectopic pregnancy.[3] Sensitivity of TVS is only 56% at 5–6 weeks. Sometimes the presence of a haemorrhagic corpus luteum can confuse and delay the diagnosis of a heterotopic pregnancy.[4] Significant morbidity and occasional mortality have been reported as a result of a delay in diagnosis.[5] In our cases, early diagnosis was done.

Tal et al. reported that 70% of the heterotophic pregnancies are diagnosed between 5 and 8 weeks of gestation, 20% between 9 and 10 weeks, and only 10% after 11 weeks.[6] We diagnosed our cases between 8 and 10 weeks. Most of the heterotophic pregnancies reported have single intrauterine pregnancy. Triplet and quadruplet intrauterine pregnancy is very rare. We are reporting one case of heterotophic pregnancy with triplet intrauterine pregnancy. The management of heterotopic pregnancy is laparoscopy or laparotomy for the tubal pregnancy.[7] Cases of successful outcome of heterotophic pregnancies have been reported in the literature,[8],[9] as in the above two cases.


  Conclusion Top


Early diagnosis and management of heterotophic pregnancy and conservative management of intrauterine pregnancy will result in good neonatal outcome.

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.

Acknowledgements

It is with glorious veneration and intensive gratitude that I would like to thank my esteemed teacher Dr. B.Kavitha MD (OBG) Professor and Unit Head, Department of Obstetrics and Gynaecology, Mamata General Hospital, Khammam, for her valuable suggestions and generous support. I feel privileged to have worked under her guidance.

I am deeply indebted and feel immense pleasure to express my sincere gratitude to my professor Dr. G.C. Prabhakar MD, DGO (OBG) Professor and Head of the Department, Department of Obstetrics and Gynaecology for his constant guidance throughout the study.

I sincerely thank Dr. T. Usha Rani MD (OBG) Assistant professor, Department of Obstetrics and Gynaecology for her cordial support and constant motivation throughout the study.

I would like to acknowledge the service provided by the library for all the medical resources.

Last but not least, I thank all the subjects of the study for their cooperation without which the study would not have been possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Glassner MJ, Aron E, Eskin BA. Ovulation induction with clomiphene and the rise in heterotophic pregnancies: A report of 2 cases. J Reprod Med 1990;35:175-8.  Back to cited text no. 1
    
2.
Perkins JD, Mitchell MR. Heterotopic pregnancy in a large inner-city hospital: A report of two cases. J Natl Med Assoc 2004;96:363-6.  Back to cited text no. 2
    
3.
Ahmed A, Tom B, Calabrese P. Ectopic pregnancy diagnosis and the pseudo-sac. Fertil Steril 2004;81:1225-8.  Back to cited text no. 3
    
4.
Sohail S. Haemorrhagic corpus luteum mimicking heterotopic pregnancy. J Coll Phys Surg Pak 2005;15:180-1.  Back to cited text no. 4
    
5.
Mistry BM, Balasubramaniam S, Silverman R, Sakabu SA, Troop BR. Heterotopic pregnancy presenting as an acute abdomen: A diagnostic masquerader. Am Surg 2000;66:307-8.  Back to cited text no. 5
    
6.
Tal J, Haddad S, Gordon N, Timor-Tritsch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: A literature review from 1971 to 1993. Fertil Steril 1996;66:1-12.  Back to cited text no. 6
    
7.
Gruber I, Lahodny J, Illmensee K, Losch A. Heterotopic pregnancy: Report of three cases. Wien Klin Wochenschr 2002;114:229-32.  Back to cited text no. 7
    
8.
Bakhsh AH, Khoori E, Mousari S. Heterotopic pregnancy following ovulation induction by clomiphene and a healthy live birth: A case report. J Med Case Rep 2008;2:390.  Back to cited text no. 8
    
9.
Noor N, Bano I, Parveen S. Heterotopic pregnancy with successful pregnancy outcome. J Hum Reprod Sci 2012;5:213-4.  Back to cited text no. 9
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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