Pseudogestational Sac Delaying Diagnosis of Ectopic Pregnancy: A Case Report.

BACKGROUND: Diagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation. CASE REPORT: We present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an "intrauterine gestational sac" along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to "clinically correlate."

Spontaneous Heterotopic Pregnancy with Ovarian Localization: Case Report.

Heterotopic pregnancies are a rare phenomenon defined by the simultaneous occurrence of intrauterine and extrauterine pregnancy. The incidence of heterotopic pregnancy occurring through natural fertilization is low but is increased by risk factors such as assisted reproductive techniques or pelvic inflammatory disease increase. We report the case of a 36-year-old female patient in the 6th week of pregnancy who presented to the emergency unit with severe acute lower abdominal pain. Laboratory chemistry and sonography revealed a suspected heterotopic pregnancy. The patient was admitted for observation. The sonographic reevaluation on the next day confirmed the suspicion of extrauterine gravidity with intact intrauterine gravidity with additional decreasing hemoglobin and hematoperitoneum, so that laparoscopy was indicated. Intraoperatively, the mass on the left ovary was removed without complications. The patient could be discharged quickly postoperatively after a complication-free course and gave birth to a healthy child by spontaneous partus in the 38th week of gestation. Due to their rarity, there is limited research related to heterotopic pregnancies, and most scientific articles are case studies. Diagnostically, the most important thing in clinical practice is to think about the possibility of EUG even if there is evidence of an intact IUG. Transvaginal sonography is of particular importance in diagnostics. The performance of prospective cohort studies is desirable for the evidence-based diagnosis and therapy of affected patients in the future.

[Clinical characteristics analysis of heterotopic cervical pregnancy].

Objective: To investigate the clinical characteristics of heterotopic cervical pregnancy (HCP). Methods: A retrospective analysis was conducted based on the general clinical data, assisted reproductive technology (ART) data, diagnosis and treatment data, and pregnancy outcomes of 17 patients diagnosed with HCP who received ART at the Reproductive Medicine Center of Peking University Third Hospital from January 2011 to April 2022. Results: The age of 17 HCP patients was (34.2±1.5) years, all of whom occurred after the application of ART; Among them, 11 cases had a history of uterine cavity operation. All 17 patients had vaginal bleeding, with only 1 case accompanied by abdominal pain. The gestational age at the diagnosis of HCP was [6+2 (5+2-6+4)] weeks. Two patients underwent conservative observation and were closely followed up. Both of them had intrauterine pregnancy until full-term and underwent cesarean section; One patient underwent ultrasound-guided cervical pregnancy reduction surgery, resulting in miscarriage due to premature rupture of membranes at 18+1 weeks of intrauterine pregnancy; One patient underwent ultrasound-guided cervical pregnancy reduction surgery, followed by uterine artery embolization, hysteroscopy, removal of cervical pregnancy lesions, and curettage due to excessive bleeding; One patient underwent uterine artery embolization, hysteroscopy, cervical pregnancy lesion clearance, and curettage due to excessive vaginal bleeding; One patient underwent hysteroscopy examination, cervical pregnancy lesion removal surgery, and uterine curettage due to embryo arrest during intrauterine pregnancy; 11 cases underwent ultrasound-guided cervical pregnancy lesion clearance surgery, all of which resulted in live births. Among the 13 delivery patients, 4 cases were premature and 9 cases were full-term; 5 cases of vaginal delivery and 8 cases of cesarean section. Conclusions: The most common clinical manifestation of HCP is vaginal bleeding. Ultrasound guided cervical pregnancy lesion clearance surgery is safe and feasible, and with good pregnancy outcomes.

[A particular state of shock: spontaneous rupture of a heterotopic pregnancy]. / Cas clinique. Un état de choc particulier : une rupture spontanée de grossesse hétérotopique.

Heterotopic pregnancy is a rare pathology. It is defined as the coexistence of an intrauterine pregnancy and an extrauterine pregnancy, whatever its location. The presence of an intrauterine pregnancy in a woman of childbearing age does not therefore exclude the presence of an associated ectopic pregnancy. Late diagnosis can lead to fatal consequences for the mother, subsequent fertility as well as for the intrauterine pregnancy. We report the case of a 28-year old female patient, without any notion of assisted reproduction, who was admitted to the emergency department for hemorrhagic shock. The diagnosis of ruptured tubal heterotopic pregnancy was made intraoperatively.

La grossesse hétérotopique est une pathologie rare. Elle est décrite comme la coexistence d'une grossesse intra-utérine et d'une grossesse extra-utérine, quelle que soit la localisation de cette dernière. Nous rapportons le cas d'une patiente âgée de 28 ans, sans notion de procréation médicalement assistée, qui a été admise aux soins d'urgence dans un état de choc hémorragique. Le diagnostic de grossesse hétérotopique tubaire rompue a été posé en peropératoire. Malgré la rareté de cette entité, il est fondamental pour les cliniciens de la connaître afin d'évoquer la possibilité de ce diagnostic. L'échographie endovaginale précoce est l'examen de choix pour l'aide au diagnostic. Ce dernier reste néanmoins difficile en raison d'une symptomatologie déroutante. La présence d'une grossesse intra-utérine chez une femme en âge de procréer n'exclut dès lors pas la présence d'une grossesse ectopique associée. Le diagnostic tardif peut conduire à des conséquences fatales pour la maman, pour sa fertilité ultérieure ainsi que pour l'évolution de la grossesse intra-utérine.

Heterotopic pregnancy after bilateral salpingectomy, IVF and multiple embryos transfer. A case report and systematic review of the literature.

Heterotopic pregnancy after bilateral salpingectomy is an extremely rare complication of in vitro fertilisation/embryo transfer cycles. We report a case of a ruptured abdominal pregnancy on the omentum which was the stimulus to conduct the first systematic review on this complication according to 'PRISMA' guidelines (PROSPERO R.No CRD42020134104). PubMed, EMBASE and OpenAIRE databases were systematically reviewed for studies reporting (a) cases or case series of, (b) heterotopic pregnancies after, (c) prior bilateral salpingectomy, and (d) embryo transfer cycles. Twenty-two articles met the selection criteria including, with our case, 28 cases. Based on the results, clinical manifestations and laboratory findings can be unspecific or misleading. Transvaginal ultrasound is the main diagnostic tool as the ectopic foetus is more frequently located in the intramural part of the fallopian tubes, the tubal stump or the ovaries. Laparotomy or laparoscopy are the main treatment options with adequate perinatal outcome.

Management of 14 patients with cornual heterotopic pregnancy following embryo transfer: experience from the past decade.

OBJECTIVE: There are two major management approach for cornual heterotopic pregnancy, transvaginal cornual embryo reduction with ultrasound guidance, or laparoscopic cornual resection. This no consensus on the optimal management for cornual heterotopic pregnancy. Here, we are trying to determine the optimal management approach for patients with viable cornual heterotopic pregnancy following embryo transfer. METHODS: This is a retrospective cohort study conducted at the locally largest reproductive center of a tertiary hospital. A total of 14 women diagnosed as viable cornual heterotopic pregnancy following embryo transfer. Six patients were treated with cornual pregnancy reduction under transvaginal ultrasound guidance without the use of feticide drug (treatment 1), and eight patients were treated with laparoscopic cornual pregnancy resection (treatment 2). RESULTS: All 14 patients of cornual heterotopic pregnancy following embryo transfer due to fallopian tubal factor, among which, 12 patients had cornual pregnancy occurred in the ipsilateral uterine horn of tubal pathological conditions. Nine (64.29%) showed a history of ectopic pregnancy. Thirteen (92.86%) patients were transferred with two embryos and only one patient had single embryo transferred. Six patients received treatment 1, and 2 (33.33%) had uterine horn rupture and massive bleeding which required emergency laparoscopic surgery for homostasis. No cornual rupture occurred among patients received treatment 2. Each treatment group had one case of spontaneous miscarriage. The remaining 5 cases in treatment 1 group and the remaining 7 cases in treatment 2 group delivered healthy live offspring. CONCLUSION: Patients with tubal factors attempting for embryo transfer, especially those aiming for multiple embryos transfer, should be informed with risk of cornual heterotopic pregnancy and the subsequent cornual rupture. Compared with cornual pregnancy reduction under transvaginal ultrasound guidance, laparoscopic cornual resection might be a favorable approach for patients with viable cornual heterotopic pregnancy.

A unique case of diagnosis of a heterotopic pregnancy at 26 weeks - case report and literature review.

BACKGROUND: Heterotopic pregnancy (HP) is a rare condition when at least two pregnancies are present simultaneously at different implantation sites and only one located in the uterine cavity. The majority of cases are diagnosed in the first trimester. CASE PRESENTATION: We present a unique case of HP diagnosed at 26 weeks of spontaneous pregnancy in a patient without any relevant risk factors. We performed an extensive review of HP cases from MEDLINE (PUBMED) published in English between 2005-2019 to prove this case's uniqueness. A 24-year-old woman presented because of threatened preterm birth. Despite treatment, pain aggravated, without progression of labor. An emergency ultrasound exam revealed free fluid in the abdominal cavity. Suspicion of active bleeding prompted the medical team to perform an exploratory laparotomy. The surgery team found a ruptured heterotopic pregnancy. This was an unexpected cause of nontraumatic hemoperitoneum at such advanced gestational age. The postoperative period was uneventful, and the intrauterine pregnancy continued to term. The final review included 86 out of 124 records. A total number of 509 cases were identified, but not all of them had complete data. The maximum reported gestational age at the time of diagnosis was 16 weeks of pregnancy, while our case became symptomatic and was diagnosed at 26 weeks of pregnancy. CONCLUSIONS: Regardless of pregnancy age, HP can be a cause of hemoperitoneum, and it should be included in the differential diagnosis of acute abdomen in the second trimester.

Heterotopic pregnancy: Simultaneous viable and nonviable pregnancies.

Heterotopic pregnancy occurs when a patient has simultaneous intrauterine and ectopic pregnancies. Rates of heterotopic pregnancy have been rising with increased availability and access to in vitro fertilization and other advanced fertility technologies. Symptoms of heterotopic pregnancy are nonspecific, such as vague abdominal pain, so transvaginal ultrasound is a crucial part of the diagnostic process. Laparoscopy is the most commonly performed treatment of the ectopic pregnancy; other options include localized injections of methotrexate and/or potassium chloride. Following definitive termination of the ectopic pregnancy, many patients will successfully deliver the intrauterine pregnancy at term. Early identification of heterotopic pregnancy can reduce maternal morbidity and mortality.

Should sexual intercourse be avoided during the embryo transfer cycle? Life-threatening ruptured heterotopic pregnancy after single thawed embryo transfer: case report and review of the literature.

BACKGROUND: To report the life-threatening complication of a raptured heterotopic pregnancy occurring from thawed single embryo transfer. CASE REPORT: A 33-year-old woman underwent in vitro fertilization (IVF) under a step-up regimen. After oocyte collection, blastocysts were frozen, and a single frozen-thawed blastocyst was then transferred according to the natural cycle. On day 17 after embryo transfer, an intrauterine pregnancy was confirmed. On day 28, she complained of sudden abdominal pain and ultrasonography revealed marked fluid retention in the peritoneal cavity. Emergency laparoscopy was performed, revealing hemoperitoneum and a ruptured interstitial heterotopic pregnancy (HP), which was then resected laparoscopically. Because sexual intercourse had occurred shortly before the transfer, a HP comprising a spontaneous pregnancy and a pregnancy achieved by assisted reproductive technology was assumed. The fetus in the uterus survived and was delivered. CONCLUSION: In this case, however, despite the single embryo transfer during the natural-cycle frozen-thawed embryo transfer process, the risk of life-threatening complication as a HP as a consequence of spontaneous pregnancy after sexual intercourse remained.

The Risk Factors and Pregnancy Outcomes of 48 Cases of Heterotopic Pregnancy from a Single Center.

The purpose of this study was to investigate risk factors that are associated with heterotopic pregnancy (HP) following in vitro fertilization (IVF)-embryo transfer (ET) and to demonstrate the outcomes of HP after the surgical treatment of ectopic pregnancies. Forty-eight patients from a single center, who were diagnosed with HP between 1998 and 2012 were included. All of the patients had received infertility treatments, such as Clomid with timed coitus (n = 1, 2.1%), superovulation with intrauterine insemination (n = 7, 14.6%), fresh non-donor IVF-ET (n = 33, 68.8%), and frozen-thawed cycles (n = 7, 14.6%). Eighty-four additional patients were randomly selected as controls from the IVF registry database. HP was diagnosed at 7.5 ± 1.2 weeks (range 5.4-10.3) gestational age. In six cases (12.5%), the diagnosis was made three weeks after the patients underwent treatment for abortion. There were significant differences in the history of ectopic pregnancy (22.5% vs. 3.6%, P = 0.002). There were no significant differences in either group between the rates of first trimester intrauterine fetal loss (15.0% vs. 13.1%) or live birth (80.0% vs. 84.1%) after the surgical treatment for ectopic pregnancy. The risk factors for HP include a history of ectopic pregnancy (OR 7.191 [1.591-32.513], P = 0.010), abortion (OR 3.948 [1.574-9.902], P = 0.003), and ovarian hyperstimulation syndrome (OHSS) (OR 10.773 [2.415-48.060], P = 0.002). In patients undergoing IVF-ET, history of ectopic pregnancy, abortion, and OHSS may be risk factors for HP as compared to the control group of other IVF patients. The surgical treatment of HP does not appear to affect the rates of first trimester fetal loss or live birth.

Spontaneous Heterotopic Pregnancy Presenting with Hemoperitoneum.

BACKGROUND: Heterotopic pregnancy is a condition in which intra- and extrauterine pregnancies occur at the same time. Spontaneous heterotopic pregnancy is a rare event, with incidences ranging from 1 in 30,000 pregnancies to as high as 1 in 6 pregnancies assisted by reproductive technology. CASE REPORT: A 34-year-old woman presented with a 10-week history of amenorrhea, pelvic pain, and generally feeling unwell. Ultrasonography revealed a 10-week intrauterine viable pregnancy and free fluid in the abdominal cavity. Emergency laparotomy was performed and a ruptured tubal ectopic pregnancy was encountered on the right tube with hemoperitoneum. Salpingectomy was performed. Her intrauterine pregnancy was intact with positive fetal cardiac activity when she was discharged. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Heterotopic pregnancy should be kept in the differential diagnosis of any patient with an intrauterine pregnancy presenting with abdominal pain, abdominal tenderness, or free fluid in the abdominal cavity.

[Successful treatment of a cervical heterotopic pregnancy following an in vitro fertilization procedure]. / Tratamiento exitoso de un embarazo heterotópico cervical luego de un procedimiento de fecundación in vitro.

A 37-year-old nulligravida infertile female had a cervical heterotopic pregnancy following an in vitro fertilization procedure. Early intervention on the 6th week of gestation with a manual vacuum aspirator reached to remove the cervical pregnancy. Ligation of the descending cervical branches of the uterine arteries and a cervical cerclage, were placed before the aspiration, for prevention of possible hemorrhage. Successful removal of the cervical pregnancy was achieved with only mild bleeding. An intrauterine pregnancy progressed to viability without complications, resulting in a vaginal delivery of a preterm live-birth at 35.4 weeks, of a male that weighted 2740 g.

[Heterotopic pregnancy during the second trimester is a severe complication of pregnancy]. / Toisen raskauskolmanneksen samanaikainen kohdunulkoinen ja -sisäinen raskaus on vakava raskauskomplikaatio.

Heterotopic pregnancy is a rare form of ectopic pregnancy in which one gestational sac is found in the uterus and another one in an extrauterine location. The spontaneous heterotopic pregnancy of our patient continued until the second trimester. In the 19th week of pregnancy, undiagnosed ectopic pregnancy in the left fallopian tube ruptured into the abdominal cavity, leading to a massive intra-abdominal hemorrhage. Left-side uterine appendages were excised in open surgery, but intrauterine pregnancy continued in vital form. Histologic examination revealed the excised tumor to be an ectopic pregnancy. The hypotension experienced by the patient led, however, to severe brain damage of the intrauterine fetus and induced abortion.

Undiagnosed heterotopic pregnancy, maternal hemorrhagic shock, and ischemic stroke in the intrauterine fetus.

Heterotopic pregnancy occurs rarely following natural conception; however, intrauterine embryo transfer following in vitro fertilization is a known risk factor for its occurrence. A 29-year-old woman presented with acute abdomen at 14w5d gestation following in vitro fertilization-embryo treatment. A ruptured heterotopic gestation in the left fallopian tube was identified at laparoscopy and treated by salpingectomy. Subsequently, at 21-week gestation, routine sonogram demonstrated bilateral ventriculomegaly in the intrauterine fetus. Fetal magnetic resonance imaging was highly suggestive of ischemic brain injury, most likely attributable to the maternal hypovolemic shock because of ruptured heterotopic gestation. The pregnancy was terminated by intracardiac injection and induction of labor. Timely diagnosis of heterotopic pregnancy requires a high index of suspicion as diagnostic delays can have catastrophic consequences for the mother and/or the intrauterine fetus.

[Heterotopic pregnancy after spontaneous conception]. / Heterotopická gravidita po spontánní koncepci.

DESIGN: Case report. SETTING: Departement of Obstetrics and Gyneacology, Silesian Hospital in Opava. METHODS: Case interpretation. CONCLUSION: Heterotopic pregnancy after spontaneous conception is diagnosed with a rare, often difficult to ascertain, however, the increasing incidence has justified its place in the differential diagnosis of acute abdominal not only for women enrolled in the program of assisted reproduction.

Bilateral tubal and intrauterine pregnancies diagnosed at laparoscopy.

A 32-year-old woman had bilateral tubal and intrauterine pregnancies after hyperovulation with clomiphene citrate and subsequent artificial insemination with husband's semen. Laparoscopic surgery revealed bilateral tubal pregnancies. Salpingectomy was performed on the left tube and linear salpingotomy was performed on the right tube. The postoperative course was uneventful. The patient delivered a healthy girl vaginally at 39 weeks' gestation. Only eight cases with bilateral and intrauterine pregnancy have been reported. The live birth rate of bilateral tubal pregnancy and intrauterine pregnancy is 60% (6/10), which is similar to that of heterotopic pregnancy. Laparoscopic surgery is effective for confirming the diagnosis and treating heterotopic pregnancy.