Spontaneous heterotopic pregnancy: Diagnosis and surgical management.

A 28-years-old women, nulliparous primigravida, the patient had no risk factor for heterotopic pregnancy, no pathological history or similar family cases, and no notion of hormonal stimulation and. She has consulted for acute pelvic pain , vaginal bleeding, associated to a 60 days menstruation's delay. In admission, the patient has presented a generalized cutaneous-mucosal paleness, hypotension of 90/46 mmHg, a tachycardia of 100 beats/min and. However, she complained left iliac fossa pain, and an endocervical bleeding. Furthermore, the uterus was increased slightly in size. The patient was immediately conditioned with two large-bore venous lines and vascular filling with macromolecules. Suprapubic and transvaginal ultrasonography revealed an arrested intrauterine pregnancy, with the empty gestational sac measuring 47 mm, corresponding to 10 weeks of pregnancy ( Fig. 1 ). In addition, an adnexal mass was visualized, in favor of a live ectopic pregnancy, with a crown length measured at 16.2 mm, corresponding to 8 weeks of pregnancy, with significant free fluid in the cul-de-sac, Morison's pouch ( Fig. 2 , Fig. 3 ). Hemoglobin level was 8.3 g/dl, β-hCG level 9954 IU/ml. The diagnosis of ruptured ectopic pregnancy was suspected. Fig. 1 Ultrasound image of empty intrauterine gestational sac. Fig. 1 Fig. 2 Endovaginal ultrasound showing heterotopic pregnancy: latero-uterine mass with embryo. Fig. 2 Fig. 3 Ultrasound image of cardiac activity in ectopic pregnancy. Fig. 3 Ultrasound image of empty intrauterine gestational sac. Endovaginal ultrasound showing heterotopic pregnancy: latero-uterine mass with embryo. Ultrasound image of cardiac activity in ectopic pregnancy. Given the state of haemorrhagic shock, an urgent laparotomy was therefore indicated under general anaesthesia and in dorsal recumbency, revealing a 500 ml haemoperitoneum, a ruptured left ectopic pregnancy, and a Fallopian tube, which could not be preserved ( Fig. 4 ). However, the uterus was slightly enlarged and appeared gravid. A left salpingectomy was performed. Fig. 4 Intraoperative image of ectopic pregnancy with hemoperitoneum. Fig. 4 Intraoperative image of ectopic pregnancy with hemoperitoneum. For the arrested intrauterine pregnancy, we evacuated it by gentle suction, and the postoperative period revealed no complications. The patient was discharged on postoperative day 4.

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I declare on my honor that the ethical approval has been exempted by my establishment.

None.

Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

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Dr Bouab Maryem.

In conclusion, practitioners should be aware that clinico-biological or ultrasound confirmation of an intrauterine pregnancy, whether progressive or not, does not exclude the possible association with an ectopic pregnancy, which should be systematically suspected and investigated in any woman presenting with abdominal pain and hypovolemic shock during pregnancy.

Heterotopic pregnancy is a rare form of pregnancy, defined by the coexistence of an ectopic and an intrauterine pregnancy. The first case was described by DUVERNET in 1708 [ 3 ] Frequency has increased with the advent of assisted reproduction techniques, particularly the use of ovulation inducers. The incidence of heterotopic pregnancy is estimated at 1/30,00, greater than 1/100 when associated with in vitro fertilization, and 1/900 if associated with clomiphene citrate [ 1 ]. Important risk factors for the development of a heterotopic pregnancy include family history, history of pelvic inflammation, endometriosis, tubal disease, embryo transfer technique, use of clomiphene or other techniques [ 4 ]. The diagnosis of heterotopic pregnancy is a challenge for emergency gynecologists. It is often delayed due to the early visualization of an intrauterine sac, which confuses the physician, and the late detection of adnexal anomalies. Clinical symptomatology is often related to a threatened or ongoing abortion, so an intrauterine pregnancy should not formally exclude an associated ectopic pregnancy [ 5 ]. The most common functional signs are abdominal pain, vaginal bleeding, pelvic mass and peritoneal irritation [ 6 ]. If not diagnosed in time, it can progress to hemoperitoneum following rupture of the ectopic pregnancy, or even hemorrhagic shock [ 7 ]. The first-line paraclinical examination is suprapubic and transvaginal pelvic ultrasound. It enables diagnosis of the two concomitant pregnancies, specifying the vitality or otherwise of the intrauterine pregnancy and the location of the ectopic pregnancy [ 8 ]. The visualization of hemoperitoneum supports the diagnosis [ 9 ]. Therapeutic management of heterotopic pregnancies involves rapid intervention on the ectopic pregnancy, while respecting the intrauterine pregnancy if it has progressed, in order to preserve the patient's fertility [ 10 ]. It consists mainly of a salpingectomy, salpingotomy or oophorectomy. Manipulation of the uterus must be kept to a minimum, in order to preserve the intrauterine pregnancy [ 6 ]. Systemic methotrexate (MTX) is proscribed in progressive intrauterine pregnancy, but in abdominal heterotopic pregnancy, MTX may be used for the remaining abdominal trophoblastic tissue [ 11 ].

Heterotopic pregnancy is a rare form of pregnancy, defined by the coexistence of an ectopic and an intrauterine pregnancy [ 1 ]. The most common ectopic pregnancies are located on the fallopian tubes. Diagnosis of a heterotopic pregnancy is challenging for practitioners . The main treatment consists on removing the ectopic pregnancy while preserving the intrauterine pregnancy. We report a rare case of spontaneous heterotopic pregnancy associating a ruptured tubal pregnancy with a non-progressive intrauterine pregnancy. This case was reported according to SCARE 2023 criteria [ 2 ].

The authors declare having no conflicts of interest for this article.