Spontaneous Heterotopic Pregnancy: As One of the Most Challenging Emergency Cases in Obstetrics

Case Report

Austin J Obstet Gynecol. 2023; 10(3): 1221.

Spontaneous Heterotopic Pregnancy: As One of the Most Challenging Emergency Cases in Obstetrics

Fatima Katti¹*; Ebraheem Jawabrah¹; Huda Barghash¹; Mohammad Abbas Katti²; Haitham Abbassi³

¹Department of Obstetrics and Gynecology, Damascus University, Damascus, Syria

²Faculty of Medicine, Damascus University, Damascus, Syria

³Head of Department of Obstretrics and Gynecology, Damscus University, Damascus, Syria

*Corresponding author: Fatima Katti Department of Obstetrics and Gynecology, Damascus University, Damascus, Syria. Email: fatimakatti95@gmail.com

Received: August 03, 2023 Accepted: September 18, 2023 Published: September 25, 2023

Abstract

Spontaneous Heterotopic Pregnancy “SHP”: is defined as the presence of multiple gestations, in which, intrauterine and extrauterine pregnancy occur simultaneously, it is a life-threatening condition that requires immediate and accurate diagnosis and treatment.

Here, we present a case of a 38-year-old pregnant female who conceived spontaneously, at her sixth week of gestation, was presented to the emergency department with acute pain in lower abdomen and minimal vaginal bleeding, she underwent previous falsely reassuring ultrasound imaging for two times and her symptoms were ignored until the diagnosis was finally made by us. Pelvic ultrasound showed evidence of an IUP and a left adnexal mass, raising suspicion for a heterotopic pregnancy. An urgent exploratory laparotomy and a left salpingectomy were performed, postoperative, the patient recovered well but she had an early pregnancy loss at 8 weeks of gestation.

Clinicians should keep in mind that confirmation of an Intrauterine Pregnancy (IUP) should not preclude the existence of a heterotopic pregnancy.

Keywords: Spontaneous heterotopic pregnancy; Case report; Diagnosis; In vitro fertilization

Introduction

The coexistence of intrauterine pregnancy and ectopic pregnancy is called a Heterotopic (HT) pregnancy.

It is usually a consequence of Assisted Reproductive Technologies "ART" such as IVF and induction of ovulation, with an estimated incidence at between 1 to 3 in 100 pregnancies [1,2]. But there are cases that occur in the absence of any risk factor, in these cases, a spontaneous heterotopic pregnancy "SHP" represents a huge diagnostic challenge due to the rarity of the condition on the one hand (its incidence in the natural conceptions is: 1 per 30000 pregnancies) [1,2] and on the other hand it is a life-theratening condition that may be fatal to the mother if the diagnosis is delayed.

We brought the light to this rare case of SHP resulting from a normal conception without any risk factor, in which, the diagnostic opportunity was missed more than once which led to delay the diagnosis.

Case Presentation

A 38-year-old pregnant female (G3, P2) at her sixth week of gestation through natural conception with no previously fertility treatment, was presented to the emergency department with acute lower abdominal pain, most severe in the left side of the lower abdomen, associated with minimal vaginal bleeding, Obstetrical history included two spontaneous vaginal delivery. The medical, surgical, and family histories were unremarkable.

These symptoms started 5 days ago, and the patient consulted her doctor for this complaint, but he diagnosed an intrauterine pregnancy IUP, and attributed the interpretation of the symptoms as being due to fatigue caused by travel (the patient had returned from Germany a few days ago). However, the pain persisted and increased in intensity which prompted her to see another obstetrician, and again the symptoms were explained by being normal and may accompany any pregnancy! Unfortunately, the patient was sent home to return after two days later to our hospital with acute abdomen and hemodynamic instability: (her pressure was 80/50 mmHg, heart rate was 120 beats/min, there was also weakness and generalized paleness).

The clinical examination of the abdomen revealed guarding, rigidity and severe rebound tenderness of the lower abdomen which was pronounced in the left iliac fossa. The vaginal examination showed a closed cervix with motion tenderness as well as there was blood in the vaginal vault.

On further investigation, transvaginal ultrasonography was performed and showed intra uterine gestational sac measuring 5 weeks and 5 days (Figure 1). A left adnexal mass measured 5.3×6.4 cm, but no fetal pole was identified (Figure 2). The right adnexa were normal. There was also a medium volume of free fluid in the pelvis (Figure 3).