We report two cases of heterotopic pregnancy presenting at our hospital. Both  were imaged by transabdominal and transvaginal ultrasound. The diagnosis of heterotopic pregnancy was suspected and appropriate management was instituted  prior to the onset of complications.

Case 1

A 30 year old woman of Caucasian origin presented to the Emergency Department with a history of sudden generalised abdominal pain radiating to the right shoulder.

She was 8 weeks pregnant by natural conception and there was no history of abortion, infertility, pelvic inflammatory disease or  abdominal surgery. She was assessed clinically and was sent home after a few hours when the pain subsided. She was scheduled for an elective ultrasound evaluation at the time.

She returned the next day to the ED with a recurrence of pain and a  drop in Hemoglobin level from (140mg/dl to 90mg/dl), requiring  the immediate transfusion of four units of blood.

She was referred for an urgent ultrasound examination which demonstrated haemoperitoneum associated with an adnexal mass identified as a ruptured ectopic pregnancy in addition to a live intrauterine pregnancy.

The patient underwent an emergency laparotomy and left salpingo-oophorectomy. Evacuation of the intrauterine pregnancy was  performed at the same time, at the request of the patient.

Histopathology confirmed a heterotopic gestation.

Fig.: Coexistent intra and extrauterine gestations

Fig.: Transvaginal ultrasound image of a complex left adnexal mass

Fig.: Transvaginal ultrasound image of a viable intrauterine foetus

Fig.: Transvaginal ultrasound image of a left adnexal mass showing a yolk sac within a gestational sac

Fig.: Transvaginal ultrasound image demonstrating an intrauterine gestational sac with a foetal node and yolk sac

Fig.: Ultrasound image of a complex left adnexal mass showing peripheral blood flow

Fig.: Transabdominal ultrasound image showing an intrauterine gestation

Fig.: Transabdominal image showing an intrauterine gestation and a coexistent left ectopic pregnancy

Case 2

 A 22 yr old female patient of Caucasian origin presented to the ED with a history of severe lower abdominal pain and a background history of 10 weeks amenorrhea. She had undergone ovulation induction with Clomiphene. There was no past history of abortion, infertility, pelvic inflammatory disease or  abdominal surgery. 

Sonographic assessment demonstrated a viable  intra-uterine pregnancy of 11 weeks duration. Concomitant surrounding haemorrhage and a right adnexal mass was noted, suggesting a co-existent ruptured ectopic pregnancy. 

She underwent  emergency laparotomy and a right salpingo-oopherectomy.

Histopathology confirmed the diagnosis of an ectopic pregnancy.

The patient continued  to term and had a normal delivery of her surviving intrauterine pregnancy.

Fig.: Transabdominal ultrasound image demonstrating an early viable intrauterine gestation

Fig.: Transabdominal ultrasound image of a concurrent complex right adnexal mass

Fig.: Transabdominal ultrasound image demonstrating a viable intrauterine gestation

Fig.: Transabdominal ultrasound image demonstrating a viable intrauterine gestation

Fig.: Ultrasound of a complex right adnexal lesion. Magnified view suggests a foetal pole in the dependent part of the mass

Fig.: Transabdominal ultrasound image showing fluid in Morrison's pouch