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