Quadruplet Heterotopic
Pregnancy: a Case Report
......................................................................................................................................................................
Rema Khlaif
Omosh
Iman Abdulla Fayez
Nancy Dari Alfayez
Manar Mohammad Abu Karaki
Royal Medical Services
Jordan
Correspondence:
Dr. Rema Khlaif Omosh JBOG
Royal Medical Services
Jordan
Email:
remaomosh@yahoo.com
ABSTRACT
Background: Heterotopic pregnancy is
a condition in which pregnancy occurs synchronously
intrauterine and extrauterine. The estimated
incidence following spontaneous conception
is below 1/30,000. On the other hand, the
incidence in artificial reproductive techniques
has been reported to be as high as 1/100.
Case: This case report is of a 20 year
old woman, nulliparous, who presented to
the emergency department with acute abdominal
pain post ovulation induction with human
menopausal gonadotrophins and intrauterine
insemination. Examination revealed acute
surgical abdomen. Ultra-sonographic examination
showed viable triplet intrauterine gestation
of 10 weeks and presence of right complex
adnexal mass. Laparotomy was done and the
patient was found to have right tubal ectopic
pregnancy that was managed by salpingostomy.
Post operative period was uneventful and
patient was discharged with viable three
embryos and she was followed as an outpatient
in a high risk pregnancy clinic.
Comment: Though the incidence of heterotopic
pregnancy is low following spontaneous pregnancy
but a high index of suspicion must be considered
in any patient with intrauterine pregnancy
who presented with abdominal pain and adnexal
mass and particularly if conception occurs
after artificial reproductive techniques.
This approach would avoid maternal morbidity
and mortality.
Key words: Heterotopic
pregnancy, Adnexal mass, Artificial reproductive
techniques, Ectopic pregnancy
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A 20 year old woman, nulliparous,
presented to the emergency room (ER) with a chief
complaint of right sided abdominal pain associated
with vaginal spotting. She had right sided abdominal
discomfort and dull aching pain for the last four
weeks, but she developed more intense colicky
pain over the last three hours prior to her presentation
to the ER.
On history review she was found to have 2 years
of infertility and she was followed in our infertility
clinic. She was diagnosed as a case of unexplained
infertility and accordingly she underwent ovulation
induction treatment by human menopausal gonadotrophin
(HMG) and intrauterine insemination (IUI). Eventually,
she got pregnant and her clinical pregnancy was
documented by ultrasonography (US) examination.
She was found to have three intrauterine gestational
sacs. Folic acid 5mg was prescribed to her since
the time of IUI.
At time of presentation to the ER she was 10 weeks
pregnant. History was negative regarding previous
episodes of the same pain or any previous medical
conditions and she had no past history of abdominal
surgical procedures. Additionally she had no bowel
or urinary symptoms.
She was in pain, anxious, had
low grade fever and other vital signs were stable.
She had generalized lower abdominal tenderness
but localized right iliac fossa rebound tenderness.
Per vaginal examination showed closed cervix,
minimal spotting and mild cervical excitation.
US examination showed a viable intrauterine triplet
pregnancy with crown rump length of 9 weeks plus
2 days, 9 weeks plus 4 days and 10 weeks. Interestingly,
there was a right complex adnexal mass of 7 x
8 cm and minimal free fluid in pouch of Douglas.
Her complete blood count (CBC) was normal except
for the presence of mild leukocytosis. The patient
was admitted to the ward and evaluated by the
surgical team who raised the suspicion of appendicular
mass.
She underwent laparatomy and
was found to have a normal appendix and a right
sided intact ampullary ectopic pregnancy and salpingostomy
was performed. The left tube and both ovaries
were normal.
Care was taken in handling the uterus and the
right ovary to avoid any possible damage to the
intrauterine pregnancy and particularly not to
damage the corpus lutea .
Postoperatively the patient had an uneventful
recovery. Ultrasound confirmed the viability of
the three fetuses and histopathology confirmed
the diagnosis. She was discharged two days after
laparotomy and followed as an outpatient. At time
of writing this report she is now 23 weeks of
gestation and her pregnancy is smooth with regular
ante natal care.
Heterotopic pregnancy is defined
as the presence of multiple gestations with one
being in the uterine cavity and the other outside
the uterus, commonly in the tube (Karli 4).
Today there is an increase in the use of artificial
reproductive techniques and fertility drugs to
improve fertility rate. This raises the patient's
risk of having a heterotopic pregnancy due to
the combined effect of hyperstimulation and
simultaneous transfer of more than one embryo
into the uterus (M. Liu 8 ). Other risk factors
which are responsible for infertility like PID
and previous tubal surgeries also contribute to
heterotopic pregnancy ( Luo X. 5) .
Diagnosing heterotopic pregnancy
is still a challenge for the obstetricians and
many cases are diagnosed very late( Karim IM 7).The
diagnostic role of serum B-hcg level in heterotopic
pregnancy is debatable . The normal algorithm
for the rapid rise in the serum B-hcg in early
pregnancy cannot be used due to the presence of
the intrauterine gestation which could lead to
false assurances ( David K 12 ). Likewise, abdominal
and pelvic ultrasound also fails to demonstrate
the ectopic component or it is misinterpreted
due to the presence of the intrauterine pregnancy
(Nnoli 1).
Laparoscopic salpingostomy or
salpingectomy is preferred over laparatomy to
minimize manipulation of the pregnant uterus .
If the hemodynamic status is compromised, laparotomy
is the only choice ( Maalt ME 10 ). For an unruptured
ectopic pregnancy, systemic methotrexate is contraindicated
because of the viable intrauterine pregnancy (Asha
Baxi 2).
As no single investigation
can predict the coexisting heterotopic pregnancy
, it should be suspected in any pregnant woman
in her early weeks of gestation who presents with
lower abdominal pain even with a documented intrauterine
pregnancy . This is particularly important following
fertility treatment.
Demonstration of an intrauterine pregnancy is
no longer a reliable indicator for excluding an
ectopic pregnancy.
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