Laparoscopic resection of a salpingectomy stump remnant during early pregnancy: the diagnostic challenge posed in diagnosing a heterotopic stump pregnancy.

In this report, we present a case of a woman admitted in her first trimester of pregnancy with significant intraperitoneal haemorrhage from a left tubal stump remnant occurring concurrent to a viable intrauterine pregnancy. The patient was resuscitated and treated successfully with laparoscopic removal of her stump remnant to achieve haemostasis. However, despite extensive investigation, the pathology of her haemorrhagic stump remained inconclusive. Stump ectopic pregnancy is an established phenomenon, although it presents a diagnostic challenge when occurring as a heterotopic pregnancy. Further, persisting trophoblastic tissue is a rare but established feature of incomplete removal of ectopic pregnancy post salpingectomy. Here, we discuss challenges of diagnosis in such cases and present a case report of a presumed stump remnant heterotopic pregnancy from spontaneous conception.

Challenges in the diagnosis and management of a ruptured heterotopic gestation following ultrasound-guided embryo transfer in low resource settings: a case report.

BACKGROUND: Heterotopic pregnancies are increasing in incidence with the advent of rising prevalence of in vitro fertilization and embryo transfer (IVF-ET) globally. Although rare, this condition is a serious potentially life-threatening gynaecological complication. CASE PRESENTATION: We present the case of a 36-year-old Ghanaian woman who conceived following IVF and presented two weeks after confirmation of intrauterine gestation with sudden onset lower abdominal pain. A diagnosis of ruptured heterotopic pregnancy was made, laparotomy and salpingectomy was done followed with further management of the intrauterine gestation. CONCLUSION: To the best of our knowledge, this is the first reported case of heterotopic pregnancy in Ghana. A high index of suspicion for heterotopic pregnancy is required even in the presence of a confirmed intrauterine gestation following IVF-ET.

Case Report of an exceptional spontaneous abdominal heterotopic pregnancy with superfetation: Diagnosis and treatment: Heterotopic pregnancy with superfetation (8+1 WG & 5+4 WG).

Heterotopic pregnancy is an extremely rare condition in which an intrauterine and an extrauterine pregnancy co-exist. In spontaneous conceptions, heterotopic pregnancy occurs in only 1/30 000 pregnancies. The treatment of heterotopic pregnancy must be as minimally invasive as possible to preserve the development of the intrauterine pregnancy. Superfetation, defined as the coexistence of 2 or more foetuses of different gestational ages, remains particularly exceptional and poorly explained (second ovulation? embryonic diapause?). Here, we present an extremely rare case of a spontaneous heterotopic evolutive pregnancy with superfetation, consisting of an embryo in the pouch of Douglas estimated at 8 + 1 weeks of gestation (WG) and a progressive intrauterine pregnancy estimated at 5 + 4 WG. We treated the extrauterine pregnancy with an intra-cardiac injection of potassium chloride echo-guided via the vaginal route, and the patient then underwent exploratory laparoscopy 9 days later and lavage and aspiration of the abdominal heterotopic pregnancy due to pain and biological inflammatory syndrome probably caused by pelvic mass syndrome and peritoneal irritation from the foetal necrosis. She has not yet given birth and is currently at 36 WG.

The risk factors for miscarriage of viable intrauterine pregnancies in patients with heterotopic pregnancy after surgical intervention.

To summarize the clinical characteristics and explore the risk factors for miscarriage of a viable intrauterine pregnancy following surgical intervention in patients with heterotopic pregnancy (HP). A total of 106 women diagnosed with HP that underwent surgical intervention in the Women's Hospital School of Medicine Zhejiang University between January 2014 and December 2021 were included in this retrospective study. They were divided into a miscarriage group (n = 13) and an ongoing pregnancy group (n = 93) according to the outcomes of the HP within 2 weeks after surgery. Data regarding clinical characteristics, surgical conditions, postoperative recovery, and complications were collected and compared between the groups. Logistic multivariate analysis was performed to explore the risk factors for miscarriage in patients with HP within 2 weeks of surgical intervention. Among the 106 women with HP, 80 had tubal HP, 8 had cornual HP, and 18 had interstitial HP. Eighty-seven (82.1%) patients developed clinical symptoms that manifested primarily as abnormal vaginal bleeding and/or abdominal pain, whereas 19 (17.9%) patients had no clinical symptoms. The mean gestational age on the day of surgery was 7.2 weeks (inter-quartile range, 6.4-8.3). The miscarriage rate within 2 weeks of surgical intervention was 12.3% in patients with HP. Compared to the ongoing pregnancy group, the miscarriage group had a higher body mass index, earlier gestational age at treatment, and higher volume of hemoperitoneum (P < .05 for all). Logistic multivariate analysis indicated that the women with a hemoperitoneum volume > 200 mL had significantly higher risk of miscarriage after adjusting covariates [OR (odds ratio) = 5.285, 95% CI (confidence interval) (1.152-24.238), P < .05]. Hemoperitoneum volume was independently associated with miscarriage of viable intrauterine pregnancies in patients with HP within 2 weeks of surgical intervention.

Mature Cystic Teratoma Mimics Heterotopic Pregnancy on Sonograph.

INTRODUCTION: Mature cystic teratomas (MCTs) present clinically with a wide host of different symptomatic manifestations. Because they are often comprised of multiple tissue types, imaging can also take on many different forms making the diagnosis of MCT difficult in certain situations. In this case, we present a patient who had a MCT that mimicked a heterotopic pregnancy on sonograph. CASE PRESENTATION: A 21-year-old female G1P0 at approximately six weeks gestation by last menstrual period presented to the emergency department with a chief complaint of vaginal bleeding that began the previous day. A transvaginal ultrasound demonstrated a viable intrauterine pregnancy with fetal cardiac activity and an additional structure in the left adnexa resembling a gestational sac and fetal pole absent of cardiac activity. Obstetrics was consulted, and a preliminary diagnosis of heterotopic pregnancy was made. Diagnostic laparoscopy with intraoperative ultrasound revealed a 3 cm cyst in the left ovary that appeared to contain serous fluid. Aspiration and subsequent dissection of the cyst revealed material consistent with a mature cystic teratoma confirmed by pathologic analysis. DISCUSSION: This case highlights the importance of ultrasound in detecting adnexal masses while also exposing some of its limitations. Due to their variable presentation and potential to mimic other insidious pathologies, MCTs must always be considered when identifying adnexal structures on ultrasound.

Conservative Management of Heterotopic Pregnancy: A Case Report and Review of Literature.

BACKGROUND Tubal heterotopic pregnancy is an extremely rare complication of pregnancy, in which there is a simultaneous presence of a pregnancy in the uterine cavity and in an ectopic location, most commonly in the fallopian tube. The management of such cases is not clearly established. In the case of a desire to maintain an intrauterine pregnancy, the surgical procedure consisting of a salpingectomy or salpingostomy is the most common. Such a procedure is effective, but it involves potential complications typical of surgeries, so, in some cases, it seems reasonable to apply the expectant management. CASE REPORT A 31-year-old woman was admitted to the clinic due to pain in the right lower abdomen. An ultrasound examination revealed a gestational sac in the uterine cavity corresponding to 5 weeks of pregnancy with a yolk sac. A twin sac was found in the right fallopian tube. Due to the patient's mild symptoms, absence of bleeding into the peritoneal cavity, concerns about the safety of the embryo and the pregnant woman in case of surgery, conservative management was decided. On the 20th day, the patient was discharged from the clinic with a viable intrauterine pregnancy and a partially absorbed ectopic pregnancy. CONCLUSIONS In the case of an ectopic tubal pregnancy, if there are no symptoms of bleeding into the peritoneal cavity, it is possible to adopt a safe conservative approach with strict patient observation.

Quadruplet Heterotopic Pregnancy Following In Vitro Fertilization and Embryo Transfer with Laparotomic Removal of Ruptured Twin Tubal Ectopic Pregnancy: A Case Report.

Heterotopic pregnancy (HP) is a rare occurrence in natural pregnancies. However, it can be a life-threatening condition and should be taken into account in all assisted reproductive treatments. Diagnosis and treatment of ectopic pregnancy are challenging issues in patients with HP. Here, we report a rare case of quadruplet HP following an in vitro fertilization-embryo transfer with a viable twin intrauterine pregnancy and ruptured live twin left tubal ectopic pregnancy. A 35-year-old woman (gravida 5, para 1, ectopic pregnancies 2, and abortion 1) was presented to the Emergency Department of Arash Women's Hospital (Tehran, Iran) in March 2021 with abdominal pain. The patient was at six weeks and five days of pregnancy following in vitro fertilization-embryo transfer. Transvaginal sonography (TVS) revealed a live twin intrauterine pregnancy with a ruptured live twin left tubal ectopic pregnancy. The latter was removed via laparotomy to preserve the intrauterine pregnancy. The patient subsequently delivered a female infant at 38 weeks of pregnancy.

Missed Spontaneous Heterotopic Pregnancy: A Case Report of a Ruptured Tubal Pregnancy after Induced Abortion.

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Treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy after in vitro fertilization and embryo transfer.

OBJECTIVE: To compare the treatment effects of laparoscopy versus laparotomy on heterotopic pregnancy (HP) after in vitro fertilization-embryo transfer (IVF-ET). METHODS: The retrospective case-control study enrolled 109 patients diagnosed with HP after IVF-ET treatment in our hospital from January 2009 to March 2020. All patients received surgical treatment by either laparoscopy or laparotomy. Data for general characteristics, diagnostic features, surgical parameters, as well as perinatal and neonatal outcomes were collected. RESULTS: Sixty-two patients received laparoscopy and 47 received laparotomy. Significantly lower percentage of large hemoperitoneum (P = 0.001), shorter surgery duration (P < 0.001), less intraoperative blood loss (P = 0.001), higher rates of general anesthesia (P < 0.001), and lower cesarean section rates for singletons (P = 0.003) were found in the laparoscopy group. The perinatal and neonatal outcomes were comparable between the two groups. When interstitial pregnancy was considered alone, the surgical blood loss was significantly reduced in the laparoscopy group (P = 0.021), but there was no significant difference in hemoperitoneum, surgery duration, or perinatal and neonatal outcomes in singletons. CONCLUSION: Both laparoscopy and laparotomy are effective surgical treatments for HP after IVF-ET. Laparoscopy is minimally invasive but laparotomy can be an alternative in emergency situations.

Ultrasound in Pregnancy.

This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.

Laparoscopic management of second trimester ruptured cornual heterotopic pregnancy with subsequent live birth delivery: A case report and literature review.

OBJECTIVE: Heterotopic pregnancy (HP) is the coexistence of extra- and intrauterine gestation implantation sites. A rare case of a second-trimester ruptured cornual HP (CHP) treated with laparoscopic cornual resection with the primary repair is presented. Risk factors, clinical presentations, treatments, and outcomes of CHPs are also reviewed. CASE REPORT: A 35-year-old pregnant woman with CHP presented with lower abdominal pain with hemoperitoneum and her hemoglobin level dropped. Laparoscopic management of a ruptured HP was performed, leaving the surplus intrauterine fetus intact. She delivered a 2360 g male infant via cesarean section at 34 weeks' gestation due to preterm premature rupture of membranes. We found a well-healed wound over the left uterine cornua during the cesarean section. CONCLUSION: Ruptured CHP is a rare but life-threatening complication of an obstetric emergency. Although the pregnant uterus becomes congested and fragile, using reliable laparoscopic energy devices and barbed sutures, successful treatment is feasible.

[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 Interstitial Pregnancy: Early Ultrasound Diagnosis of 179 Cases After In Vitro Fertilization-Embryo Transfer.

OBJECTIVES: What is the role of transvaginal sonography (TVS) in the early diagnosis of hectopic interstitial pregnancy (HIP) after in vitro fertilization-embryo transfer (IVF-ET)? METHODS: A retrospective observational study was conducted from January 2005 to December 2018. Routine two-dimensional and three-dimensional TVS were used to confirm clinical pregnancy. Women were diagnosed with HIP when an intrauterine gestational sac was combined with an extrauterine chorionic sac, which was at least 1 cm away from the uterine cavity and surrounded by a thin myometrial layer (<5 mm). Surgery and pathology results were the gold standard for diagnosing interstitial pregnancy. Non-surgical patients were excluded from the study. The performance of TVS and the pregnancy outcomes of intrauterine pregnancies (IUPs) were evaluated. RESULTS: A total of 97,161 women underwent IVF treatment and TVS examinations in our hospital during this study. Of these, 194 patients were diagnosed with HIP, with an incidence of 0.2% (194/97,161). Surgical and pathological findings confirmed 179 interstitial pregnancies, of which 174 were diagnosed by TVS, 4 were missed, and 1 was misdiagnosed. The sensitivity of TVS diagnosis was 97.8% and the positive predictive value was 99.4%. The mean time to diagnosis was 31 days after transplantation. One hundred and thirty-nine cases of HIP (77.7%) were diagnosed at the time of initial TVS examination. In 132 patients (73.7%), IUPs resulted in live births. CONCLUSIONS: In our practice, most HIPs following IVF-ET can be accurately diagnosed by TVS, which facilitates early management of interstitial pregnancies and enables high live birth rates for IUPs.

Study on diagnosis and management strategies on heterotopic pregnancy: a retrospective study.

Heterotopic pregnancy (HP) is a rare but potentially life-threatening event with a high risk of maternal death, which also jeopardise the coexisting intrauterine pregnancy (IUP), thus an early accurate diagnosis and prompt treatment can decrease adverse complications. We aimed to explore the early predictors for pregnancy outcomes of HP. We reviewed patients with HP following assisted reproductive technology in our institution between January 2013 and December 2020. The relationships between pregnancy outcomes and clinical features were analysed by logistic regression. We found that 29 patients (72.5%) of HP were accurately diagnosed by transvaginal ultrasonography (TVS). Eighteen patients in the surgery group had live births, three of whom delivered preterm. Additionally, the miscarriage rate was lower for patients with IUP cardiac activity than those without (16.7% vs. 90.0%, p < .001). Further by logistic regression analysis, an IUP with cardiac activity at HP diagnosis was identified as favourable independent predictor of live birth (p < .001). Therefore, early diagnosis and prompt surgical intervention are recommended to prevent the development of HP.Impact of statementWhat is already known on this subject? Heterotopic pregnancy (HP) has long been thought to be a rare but potentially life-threatening event with a high risk of complications. The early diagnosis of HP is challenging due to the co-existence of a viable intrauterine pregnancy (IUP) and the absence of typical clinical symptoms.What do the results of this study add? This stduy showed that symptoms combined with routine transvaginal ultrasonography (TVS) scans reduce the rates of misdiagnosis of HP and prompt surgical intervention after diagnosis may minimise the incidence of miscarriage of the IUP.What are the implications of these findings for clinical practice and/or further research? An IUP with cardiac activity at HP diagnosis is a predictor of a favourable prognosis of HP, and laparoscopy under general anaesthesia is effective and safe during the first trimester of pregnancy. Awareness, assessment and early interventions in view of symptoms combined with routine TVS is recommended to reduce the risk of miscarriage and ensure a favourable live birth rate.