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RCOG World Congress 2023
June 12 - 14, 2023 | London, UK
EP.1534
Heterotopic pregnancy in a patient with spontaneous conception with no risk factors
Part of Topic
High Risk Pregnancy
When to “THINK ECTOPIC”– A case report on heterotopic pregnancy in a patient with
spontaneous conception with no risk factors
V.J. Meegoda1, K.G. Hewawitharana1, K.V.H. Nimana1, A Fernando1
1University professorial unit of Obstetrics & Gynecology, Colombo South Teaching Hospital., Colombo, Sri Lanka
INTRODUCTION
·Heterotopic pregnancy (HP) is a rare and potentially fatal condition where simultaneous gestations occurs at multiple implantation sites.
·It rarely occurs in spontaneous conception (1:30,000) but becoming commoner with ART 1:100 -1:500.
·Identification of an IUP can divert attention from the possibility of a concurrent ectopic pregnancy (EP).
·Known risk factors for HP are, Assisted reproductive techniques (ART), use of contraception, PID, prior abdominal surgeries, endometriosis, STDs.
·Majority of these cases go undiagnosed until there is rupture of the ectopic pregnancy that accompanies the intrauterine pregnancy. A delayed diagnosis can result in complications.
CASE PRESENTATION
·Primigravida with no risk factors for EP presented at 5+2 weeks following spontaneous conception.
·Patient had abdominal pain without peritonism, while maintaining hemodynamic stability.
·Serum beta HCG was 1326mIU/ml on admission and was raised only by 88% within 48 hours.
·Trans-vaginal-scan (TVS) revealed an intra-uterine gestational sac, increased vascularity of the right sided adnexa and free fluid in POD, thus raising the suspicion of a HP.
·A diagnostic laparoscopy was carried out to confirm the diagnosis - A right-side ruptured tubal ectopic was identified and a salpingectomy was performed. Post-operative and repeated TVS in two weeks revealed a growing IUP.
DISCUSSION
·Early diagnosis of HP is difficult as clinical symptoms are lacking and careful sonographic examination is required. In the presence of a re-assuring IUP, HP is easily misdiagnosed as a luteal cyst.
·The method of making a definitive diagnosis with time has shifted from a surgical approach to ultrasonography.
·The suspicion of a tubal pregnancy was raised in our patient purely based on meticulous sonographic (TVS) examination.
·Serum beta-hCG can be misleading in HP as in our case.
·The difficulty of an accurate clinical and sonographic diagnosis in asymptomatic patients can justify laparoscopy as a diagnostic & therapeutic tool.
·After diagnosis, the ectopic component is usually treated surgically, whereas the intrauterine component is expected to develop normally.
·A recent review demonstrated no difference in rates of IUPs after conservative (salpingostomy) or radical (salpingectomy) surgery for tubal EP in fertile patients.
CONCLUSIONS
The rare entity of HP in a woman with no risk factors illustrates the importance of the dictum “THINK ECTOPIC” even when an IUP is present.