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A high index of suspicion: the key to an early diagnosis of heterotopic pregnancy.
Abstract Number: S-30
Abstract Type: Case Report/Case Series
30 year old G3P0 at 8 weeks gestation presented to the emergency department with complaints of nausea, vomiting, and abdominal pain for one month. Her past medical history was significant for previous gonorrhea infection and ruptured left sided ectopic pregnancy. Sonographic examination confirmed an intrauterine pregnancy and a mass in the right fallopian tube. The differential diagnosis for the mass included a possible ectopic pregnancy.
The patient was admitted, observed, and later discharged once her symptoms abated with timely outpatient follow up arrangements. She returned within hours of discharge with severe abdominal pain, dizziness, and hemodynamic instability. Her initial blood pressure was 74/26, heart rate was in the 140s, and the FAST ultrasound showed free fluid in the upper quadrants bilaterally. She underwent an emergent exploratory laparotomy, which revealed massive hemoperitoneum and bleeding in the right fallopian tube, with its contents consistent with decidual tissue. The patient was stabilized after a right salpingectomy with an estimated blood loss of 2200ml for which she was appropriately transfused. The patient did well postoperatively and a repeat transvaginal ultrasound was positive for cardiac motion, indicating a viable intrauterine pregnancy. Her perioperative course was unremarkable and she was discharged on post-operative day 4.
This case demonstrates the difficulty of definitively diagnosing a heterotopic pregnancy. The incidence of heterotopic pregnancy is 1:30,000 pregnancies, although the incidence can be much greater in some high-risk groups (1). Patients who undergo assisted reproductive techniques (ART) are at greater risk for heterotopic pregnancies. One study reported a heterotopic pregnancy incidence of 1.5 per 1,000 ART pregnancies when looking at all registered ART pregnancies in the United States from 1999 to 2002 (2). Other risk factors include history of ectopic pregnancies, prior pelvic surgery, and pelvic inflammatory disease. Undiagnosed heterotopic pregnancies are unfortunately quite common; with one literature review reporting that 25% (n=80) were definitively diagnosed by ultrasound and 75% were diagnosed at laparoscopy or laparotomy (3). Using beta-human chorionic gonadotropin as a diagnostic tool is obscured by the presence of the intrauterine pregnancy (IUP). Despite the difficulties in diagnosing heterotopic pregnancies, performing early transvaginal sonograms and maintaining a higher index of suspicion in patients with multiple risk factors and tailoring anesthetic management to address the need for resuscitation, can reduce the number of poor outcomes from this rare condition.
1. Shetty SK. J Clin Diagn Res. 2013 Dec;7(12):3000-1.
2. Clayton HB. Fertil Steril. 2007 Feb;87(2):303-9.
3. Barrenetxea G. Fertil Steril. 2007 Feb;87(2):417.e9-15.