1. Abstract Heterotopic pregnancy is defined by the presence of an intrauter- inepregnancy and anectopicpre gnancyinany location, mostlyin the uterine tubes. It is a rare obstetric pathology. However, in re- centyears its incidence has increased due to assisted reproduction treatments. His diagnosis remains a challenge. Ultrasound is the mostimportant too linitsdiag nosisandear lyidentification. Lapa- roscopy remains the definitive method of extrauterine pregnancy. Wepresentthecaseofa39-year-oldpatient,withagestationof6 weeks by date of last menstrual period, with a diagnosis of heter- otopic pregnancy, where the extrauterine pregnancy is located in the uterine tube.
2. Introduction Heterotopic pregnancy is defined by the presence of an intrauter- inepregnancy and an ectopicpre gnancyinanylocation, mostlyin theuterinetubes[1]. The firstcase was described by Duberneyin 1708 in the findings of an autopsy in France [1-3]. This type of pregnancyisextremelyrare, occurringin1in30,000 to 50,000 spontaneous pregnancies. However, in recent years its incidence has increased due to assisted reproduction treatments, increasing by up to 1% in pregnancies achieved through these techniques[1,2,4,5].Othersreportanincreasedincidenceofap- proximately 1 in 3,900 pregnancies achieved by infertility treat- ment [6]. Thelocationofectopicpregnancyismorefrequentintheuterine tubes inupto 90%ofcases, followedbythe ovary(1-3%),cervix (1%),interstitial(1%),abdominal(1%),andcaesareansectionscar (1-3%) [2]. In relation to the clinical picture, it can be asymptomatic in 24% of cases, abdominal pain in 72% and 54% have vaginal bleeding. In heterotopic pregnancy the chances of miscarriage are doubled [7, 8]. Early diagnosis is often extremely difficult because intrauterine pregnancy masks ectopic pregnancy [9]. Determination of human chorionic gonadotropin level and transvaginal ultrasound are the most useful options for diagnosis [1, 2, 6]. Early management is essential to avoid serious maternal complications, since it is as- sociated with high maternal morbidity and mortality [1, 9]. The main objective in the treatment of this pathology is to terminate theextrauterinepregnancywithoutaffectingtheviableintrauterine pregnancy [2, 9-11]. Expectant management, ultrasound-guided local injection of hy- pertonic solutions, and laparoscopic surgery are options for the treatmentofthisdisease.Thebestoptionwilldependontheexpe- rienceofthetreatingphysician,aswellastheclinicalandhemod- ynamic status of the patient [1]. Fetalprognosisismostlyuncertain,evenaftertreatmentasap- proximately35%ofcasesconverttospontaneousabortions[9].
3. Case Report 39-year-old patient, second pregnancy, no family history, no per- sonalhistory,nosurgicalhistory,bloodgroupORh+,nonreactiveserologicaltests (HIV,RPR), witha6-week pregnancybydateof last menstrual period. It brings the result of a particular transvag- inal ultrasound that concludes with a left tubal ectopic pregnancy of 6 weeks+ 4 daysanda humanchorionicgonadotropinlevelof 23710mU/mL.Shegoestotheemergencyroomduetoslightvag- inal bleeding 3 days ago associated with pelvic pain. On physical examination,hehasbloodpressureof110/70mmHg,heartrateof 88beatsperminute,respiratoryrateof16perminute,temperature to hospitalize the patient with the diagnosis of uncomplicated left adnexal ectopic pregnancy to the gynecology service for medical management and hemodynamic monitoring. of 36.70.Abdominal examination showed no evidence of perito- neal signs. Vaginal examination revealed scant vaginal bleeding. Laboratory tests reported a hemoglobin of 12.8 gr/dl, leukocytes of 10,900 cells/mm3, coagulation profile within normal param- eters, glucose of 80 mg/dl, urea of 21 mg/dl, creatinine of 0.30 mg/dl,non-reactiveCovid-19antigen,negativeurinalysis,human chorionic gonadotropin level of 25500mU/mL.Atransvaginal ul- trasoundwasperformedthatreportedauterussizeof90mm,endo- metrium of 7mm, a gestational sac of 13mm with the presence of an active embryo of 8mm in the left adnexa, free douglas cul-de- sac,concludinguncomplicatedectopicpregnancy.Itwasdecided http://www.acmcasereports.com/ During hospitalization, a transvaginal ultrasound was performed in the infertility service, the findings being the presence of a ges- tational sac in the uterine cavity with an inactive embryo of 6mm byCrown–RumpLength(CRL).Attheleftparaovarianlevel,ges- tational sac is evident with an active embryo of 5mm by crown– rump length, heartbeats at 156 per minute, heterotopic pregnancy is concluded (Figure 1-3). It is decided to schedule for surgery. A laparoscopic left salpingectomy was performed, the findings being the presence of a 3x2cm violaceous tumor in the left tube, at the level of the ampullary area. In addition, manual uterine as- piration was performed, with the findings being the extraction of uterineremains,regularquantity,withoutbadodor.Theresultsof the pathologies confirm the presence of pregnancy. Thepatientevolvedfavorably,hercontrolhemoglobinwas12.2gr/ dl.Soshewasdischargedthenext day.
4. Discussion Heterotopicpregnancyisarareobstetricpathologythatcanoccur spontaneouslyoraftertheuseofassistedreproductivetechniques [3, 4, 7]. There are other risk factors for heterotopic pregnancy such as pelvic inflammatory disease, pelvic surgery, and damage orpreviouspathologyofthefallopiantubes[3].Ithasbeenreport- that 50% of cases do not present identifiable risk factors [4]. Ourcasedidnothaveanyriskfactorsandconceivedspontaneous- ly, which is why it is more difficult to detect. In 95% of cases, ectopic pregnancy occurs in the fallopian tube, butitcanalsobefoundinthecervix,cesareansectionscar,ovary, interstitialsegmentandabdominalcavity.3Ramírezetal.12men- tions a review by Reece that estimated that 94% of extrauterine pregnancies related to heterotopic were tubal and 6% ovarian. In ourcase,theectopicpregnancywaslocatedintheleftuterinetube, confirming its high frequency in that area. The clinical picture of heterotopic pregnancy varies widely, the most frequent being abdominal pain (80%), vaginal bleeding (50%) and hypovolemic shock (13%). It may be asymptomaticin 24% [1-3]. Therefore, early management is essential to avoid serious maternal complications, since it is associated with high morbidityandmortality[1,9].Oanceaetal[9].Carriedoutasys- tematic review on spontaneous heterotopic pregnancy where the majority presented abdominal pain as the main symptom. Yu etal [8] carried out a retrospective study in 25 cases, where 68% of thepatientspresentedabdominalpainand/orvaginalbleedingand the remaining 32% were asymptomatic. Our case presented scant vaginal bleeding associated with pelvic pain. Transvaginal ultrasound is a valuable tool in the diagnosis of het- erotopic pregnancy combined with the measurement of human chorionicgonadotropin.Therearenospecificinvestigationsavail- able to detect this pathology, or even resort to exploratory lapa- roscopyorlaparotomyincaseswheretheultrasoundfindingsare notclear[9].Thedetectionrateinasymptomaticwomenis15.8% andcanvaryfrom41to84%inwomenwithpelvicpain[10].The most frequent ultrasound images are the adnexal mass and free fluid in the cul-de-sac of Douglas, in the presence of intrauterine pregnancy [13]. ed It is not easy to make the diagnosis when the embryo is not iden- tified in the ectopic pregnancy [10]. The visualization of the em- bryonic cardiac activity of the ectopic pregnancy and of the in- trauterine embryo constitute a pathognomonic sign of heterotopic pregnancy [10]. In patients with a known history of in vitro ferti- lization who are considered at high risk of presenting heterotop-ic pregnancy, their evaluation is carried out from early stages of pregnancy with ultrasound control, finding a reported sensitivity, specificity,positivepredictivevalueandnegativepredictivevalue of 92 %, 100%, 100%, and 99%, respectively [4]. Early diagnosis of heterotopic pregnancy is often extremely dif- ficult because an elevated serum human chorionic gonadotropin levelandanintrauterineembryoseenonultrasoundsuggestanor- malpregnancy,andalmostnoonelooksforaheterotopicpregnan- cy if the patient is asymptomatic [3]. In most cases, the diagnosis of heterotopic pregnancy is late, when rupture occurs and there is presence of hemoperitoneum [9]. About70%ofheterotopicpregnanciesarediagnosedbetween5-8 weeksofgestationalage,20%between9and10weeks,and10% beyond11weeks[2-4,10,14].Ourcasewasdiagnosedat6weeks gestational age. of Thetreatmentofheterotopicpregnancywilldependonthecondi- tion of the patient,the size and site of the extrauterinepregnancy, if she has had previous pregnancies, the viability of the intrauter- ine and extrauterine gestation, and the experience of the doctors [3].Themainobjectiveistoterminatetheextrauterinepregnancy without affecting the viable intrauterine pregnancy. Management includesseveraloptionsfromwatchfulwaitingtoultrasound-guid ed local injection of potassium chloride or hyperosmolar glucose. Theuseofmethotrexateiscontraindicatedinthepresenceofalive intrauterinepregnancy.Laparoscopyremainsthedefinitivemeth- od of extrauterine pregnancy. Laparotomy has been reserved for patients with hemoperitoneum and hemodynamic instability [2, 10, 11, 13, 15]. The prognosis of intrauterine pregnancies is influenced by early management,withabortionsreportedinbetween50%and66%of cases.Oneinthreewillmiscarry.2.4Survivalratesofintrauterine gestationhaveincreasedfrom35%to54%in1970,toabout70% today.4 Talbot et al [11]. mention a substantial improvement in the survival rate, between 48% and 51% in 1957; to 69% in 2007. Yu et al [8]. carried out a retrospective study where most of the patients had successful perinatal results. 88% of the patients de- liveredlivenewbornswithoutcongenitalanomalies,andthreepa- tients(12%)whounderwentsurgicaltreatmentforremovalofthe ectopicpregnancymiscarried.Lietal[16].Foundanoverallabor- tion rate of 14.8% in the group that was managed surgically [14].
5. Conclusion Heterotopic pregnancy is a rare obstetric pathology, its diagnosis remains a challenge, it can occur spontaneously or after the useof assisted reproduction techniques, which has increased its inci- denceinrecentyears.Ultrasoundisthemostimportanttoolinthe diagnosisandearlyidentificationofheterotopicpregnancies.Lap- aroscopyremainsthedefinitivemethodofextrauterinepregnancy.
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Alan Francis Miranda Flores. Heterotopic Pregnancy: Case Report. Annals of Clinical and Medical Case Reports 2022