|Year : 2013 | Volume
| Issue : 1 | Page : 43-45
Heterotopic pregnancy with live infant
Emmanuel Ikechukwu1, Moshood Adeleni2
1 Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, P.M.B. 2370, Sokoto, Nigeria
2 Department of Obstetrics and Gynaecology, Federal Medical Centre Birnin-Kebbi, Kebbi State, Nigeria
|Date of Web Publication||7-Mar-2013|
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, P.M.B. 2370 Sokoto
Source of Support: None, Conflict of Interest: None
| Abstract|| |
We report a case of combined intrauterine and tubal pregnancy in a 35-year-old para 4+2, 4 alive. The patient presented at our gynecological emergency unit with three weeks' history of lower abdominal pain. Her last childbirth was 2 years and her last menstrual period 12 weeks prior to presentation. A pelvic scan revealed an intrauterine gestation co-existing with an ectopic pregnancy. She had an emergency laparotomy with right salpingectomy. The post-operative period was unremarkable. The intrauterine pregnancy was supervised and she carried it to term and eventually had an uneventful vaginal delivery of a live male infant.
| Abstract in French|| |
Nous rapportons un cas de combiné grossesse intra-utérine et tubaire dans un paragraphe 35-year-old 4+ 2, 4 en vie. Le patient s'est présenté dans notre unité d'urgence gynécologique avec l'histoire de trois semaines de douleurs abdominales basses. Son dernier accouchement a été 2 ans auparavant et ses dernières menstruations 12 semaines avant la présentation. Un balayage pelvien a révélé une gestation intra-utérine cohabiter avec une grossesse extra-utérine. Elle avait une laparotomie d'urgence avec salpingectomie droite. La période postopératoire était banale. La grossesse intra-utérine a été supervisée et elle a porté à terme et finalement eu un accouchement sans incident d'un enfant de sexe masculin direct.
Mots clés: Grossesse hétérotopique, vivre le nourrisson, gestation
Keywords: Heterotopic pregnancy, live infant, term pregnancy
|How to cite this article:|
Ikechukwu E, Adeleni M. Heterotopic pregnancy with live infant. Ann Afr Med 2013;12:43-5
| Introduction|| |
Naturally occurring heterotopic pregnancy, first described by Duverney in 1708 at autopsy but now commonly diagnosed in life, is rare.  With the rising incidence of ectopic pregnancies due to increasing risk factors and rising incidence of multiple pregnancies due to expansion of assisted reproductive technologies in infertile couples, the chances of heterotopic pregnancies are increasing in many centers. , We hereby present a case of heterotopic pregnancy in a natural conception cycle in a 35-year-old multipara.
| Case Report|| |
A 35-year old female gravida 7 Para 4 +2 4 alive, last child-birth 2 years and last menstrual period 12 weeks prior to presentation came to our gynecological clinic on 22 March 2008 with 3 weeks' history of lower abdominal pain. The pain was mild and colicky. She had no vaginal bleeding, dizziness or urinary symptoms. She did not know the age after which she attained menarche but menstruated for five days in a regular cycle of 28 days. She had 4 normal deliveries at home and 2 spontaneous abortions at 8 and 10 weeks gestation successively. She had no uterine evacuation thereafter. She was the first wife in a polygamous family of 2 wives. She was a house wife while her husband was a farmer.
On examination she was healthy-looking, afebrile and neither pale nor jaundiced. Her pulse was 80 beats/min, full and regular. Her blood pressure was 100/70 mmHg. The chest was clinically normal. Abdominal examination revealed an 8 cm by 8 cm oval mass in the right iliac fossa which was mildly tender and mobile. The main findings on vaginal examination were closed cervical os, bulky uterus of about 12 weeks' gestational size and 8 cm by 8 cm tender right adnexal mass. There was no fullness in the pouch of Douglas. A diagnosis of right ovarian cyst (? twisted) coexisting with intrauterine pregnancy was made. She had an urgent abdomino-pelvic ultrasound scan which revealed a bulky uterus containing a well defined gestational sac with fetal pole exhibiting cardiac activities, crown rump length of 32 mm which was equivalent to a gestational age of 10 weeks + 3 days and a separate gestational sac in the right adnexum with no fetal pole [Figure 1]. There was no fluid collection in the pouch of Douglas. The conclusion was viable intrauterine pregnancy co-existing with an ectopic gestation. She was prepared for an emergency laparotomy. Intravenous fluid of dextrose saline was commenced. Her packed cell volume was 29% and her urinalysis was normal. Her blood group was O positive and two units of blood were grouped and cross-matched for her. One hour after the decision to undertake laparotomy was taken, her lower abdominal pain became worse and there was marked tenderness over the lower abdomen. However, her general condition remained stable. Laparotomy was performed 20 min thereafter and the findings were hemoperitoneum of about 200 mL, intact uterus of about 12 weeks' gestational size, slow leaking right ampullary pregnancy and grossly normal ovaries/right Fallopian tube More Details [Figure 2]. She had partial right salpingectomy. The surgery was performed under general anesthesia and there was minimal handling of the uterus to prevent initiation of uterine contractions. The total estimated blood loss was 400 ml and one unit of blood was transfused intra-operatively. Her post-operative management included, intravenous fluid for 24 h, intramuscular pentazoscine 60 mg hourly for 48 hours, intravenous ceftriaxone 1g 12-hourly for 48 h and bed rest for 5 days. Her post-operative course was uneventful. Histology of the specimen confirmed tubal ectopic pregnancy. The intrauterine pregnancy was supervised. It was carried to term and she had a spontaneous vaginal delivery on 9 October 2008 (at 39 weeks'-gestation) of a live male baby with Apgar scores of 8 and 10 at first and fifth minutes respectively and birth weight of 3.2 kg. The puerperium was uneventful.
|Figure 1: Pelvic ultrasound scan showing intra-uterine and ectopic gestation|
Click here to view
| Discussion|| |
Heterotopic pregnancy (co-existence of intrauterine and ectopic pregnancies) in a natural conception cycle is a rare event and the incidence is 1 in 30,000 pregnancies. , However, in the last three decades, its incidence has been rising in step with increasing risk factors for ectopic pregnancy, increasing use of ovulation induction and new assisted reproductive techniques for the treatment of infertile couples. ,, The most important aid in the diagnosis of heterotopic pregnancy is the utilization of high-resolution transvaginal ultrasonography.  In high-risk patients, especially those who have conceived with assisted reproductive technique, a routine ultrasound scanning for ectopic or heterotopic pregnancy at 4 and 6 weeks after transfer of embryos is recommended.  On the other hand, abdominal pain, rebound tenderness, fluid in the pouch of Douglas (POD) at transvaginal scan (TVS) examination and low blood hemoglobin concentration are independent predictors of tubal rupture or active bleeding. , In our case, the patient falls into the category of naturally occurring heterotopic pregnancy. Persistent lower abdominal pain in the presence of 12 weeks'-history of amenorrhea drew attention to the ectopic aspect of the condition which was confirmed by pelvic ultrasonography.
Opinions vary in the management of heterotopic pregnancy. Operative intervention is still the mainstay of management  and it has been reported that laparotomy/laparoscopy does not seem to interrupt intrauterine pregnancy.  However, some authors have reported a 40% loss of viable intrauterine pregnancy following surgical treatment of heterotopic pregnancy.  The use of medical treatment such as intramuscular administration of methotrexate is limited to cases where the intrauterine pregnancy is not viable.  Ultrasound-guided intra-cardiac instillation of potassium chloride to the tubal pregnancy (if viable) is an advocated option of management.  Our patient had laparotomy with salpingectomy because her tubal pregnancy had ruptured. Her further management to term was uneventful and she had a normal vaginal delivery of a male infant.
The good outcome as in this case is not always the rule. Approximately two-thirds of intrauterine pregnancies in heterotopic pregnancies are delivered alive while one-third are aborted. , The lesson from this case is the need for increased surveillance for the occurrence of heterotopic pregnancy in Nigeria considering the high rate of multiple pregnancies and pelvic inflammatory disease/ectopic pregnancies in the country. ,,
| References|| |
|1.||Reece EA, Petrie RH, Sirmans MF, Finster M, Todd WD. Combined intrauterine and extra uterine gestations: A Review. Am J Obstet Gynaecol 1983;146:323-30. |
|2.||Tat J, Haddad S, Gordon N, Timor-Trisch I. Heterotopic pregnancy after ovulation induction and assisted reproductive technologies: A literature review from 1971 to 1993. Fertile Steril 1996;66:1-12. |
|3.||Adenkunle DA, Ekomaye H, Olaitan PB. Heterotopic pregnancy with a live female infant: A case report. Internet J Obstet Gynaecol 2007;7:26-8. |
|4.||Yao M, Tulandi T. Current status of surgical and non-surgical treatment of ectopic pregnancy. Fertil Steril 1997;67:421-33. |
|5.||Ahove OI, Sotiloye OS. Heterotopic pregnancy following ovulation stimulation with clomiphene: A report of 3 cases. West Afr J Med 2000;19:77-9. |
|6.||Luo X, Lim CE, Huang C, Wu J, Wang W, Cheng NC. Heterotopic pregnancy following in vitro fertilization and embryo transfer: 12 cases report. Arch Gynaecol Obstet 2009;280:325-9. |
|7.||Baxi A, Kaushal M, Karmalkar HK, Sahu P, Kadhi P, Daval B. Successful expectant management of tubal heterotopic pregnancy. J Hum Reprod Sci 2010;3:108-10. |
|8.||Govindarajan MJ, Rajan R. Heterotopic pregnancy in natural conception. J Hum Reprod Sci 2008;1:37-8. |
|9.||Demirel LC, Bodur H, Selam B, Lembet A, Ergin T. Laparoscopic management of heterotopic caesarean scar pregnancy with preservation of intrauterine gestation and delivery at term: Case report. Fertil Steril 2009;91:1293.e5-7. |
|10.||Drivy V, Hadj S, Bordes A, Genod A, Salle B. Case of progressive intrauterine pregnancy after surgical treatment of corneal pregnancy. Fertil Steril 2007;87:190.e1-3. |
|11.||Louis-Slyvester C, Morice P, Chapron C. The role of laparoscopy in the diagnosis and management of heterotopic pregnancies. Hum Reprod 1997;12:1100-2. |
|12.||Lavanya R, Deepika K, Patil M. Successful pregnancy following medical management of heterotopic pregnancy. Hum Reprod Sci 2009;2:35-40. |
|13.||Clayton H, Schieve L, Peterson H, Jamieson D, Reynolds M, Wright V. A comparison of heterotopic and intrauterine-only pregnancy outcomes after assisted reproductive technologies in the United States from 1999 to 2002. Fertil Steril 2007;82:303-9. |
|14.||Marcus SF, Macnamee M, Brinsden P. Heterotopic pregnancies after in vitro fertilization and embryo transfer. Hum Rep 1995;10:1232-6. |
|15.||Aneziokoro EA. Heterotopic pregnancy with live twins. Afr J Rep Health 2002;6:117-9. |
|16.||Aisien AO, Olarewaju RS, Imade GE. Twins in Jos: A seven-year retrospective study. Med Sci Momt 2000;6:945-50. |
|17.||Gharoro EP, Igbase AA. Ectopic pregnancy revisited in Benin City Nigeria: Analysis of 152 cases. Act Obstet Gynaecol Scand 2002;81:1139-43. |
[Figure 1], [Figure 2]