Value of transvaginal sonography in diagnosing heterotopic pregnancy after in-vitro fertilization with embryo transfer

A Rare Case of Spontaneous Heterotopic Pregnancy at 12 weeks of Gestation Following Natural Conception With Literature Review

BACKGROUND

Spontaneous heterotopic pregnancy is an uncommon and possibly serious problem characterized by maternities at unique implantation sites, with only one occurring in the intrauterine cavity. Its incidence is approximately 1 in 30,000 natural pregnancies, posing significant threats to maternal health. The complexity of clinical and laboratory findings complicates its diagnosis, necessitating a high index of suspicion for prompt intervention.

CASE PRESENTATION

We reported the case of a 36-year-old woman diagnosed with heterotopic pregnancy at 12 weeks of gestation following spontaneous conception, who presented with severe abdominal pain. Initial beta-human chorionic gonadotropin (β-hCG) levels were 57,278.00 mIU/mL. Transvaginal ultrasound (TVUS) revealed a single live fetus in the uterus, estimated at 12 weeks and six days, alongside a thick-walled cystic structure in the right ovary and an irregular hypoechoic mass inferior to the right ovary. An urgent laparoscopic salpingectomy was performed under general anesthesia, revealing a distended right fallopian tube (3.5 cm) with a thickened appearance, bluish-purple discoloration, and a 2 mm rupture with active bleeding surrounded by clots. Histopathological examination confirmed ectopic pregnancy. Postoperative β-HCG levels were 49,213 mIU/mL and 57,577 mIU/mL on the second and third days, respectively.

CONCLUSION

Clinicians should maintain vigilance for heterotopic pregnancy, especially in the absence of infertility treatments or known risk factors. Lower quadrant abdominal or pelvic pain should prompt consideration of heterotopic pregnancy, as the presence of an intrauterine pregnancy does not exclude a concurrent ectopic pregnancy.

The effect of surgical treatment of tubal pregnancy on concurrent intrauterine pregnancy after in vitro fertilization

Whether surgical treatment of tubal pregnancy affects the outcomes of concomitant live normally sited (eutopic) pregnancies is unknown. The purpose of this study was to investigate the outcomes of live eutopic singleton pregnancies following surgical treatment for concomitant fallopian pregnancies. A total of 446 patients who conceived tubal heterotopic pregnancies (HPs) via in vitro fertilization-embryo transfer and underwent surgical treatment to remove ectopic pregnancies (EPs) were included. For each study patient, one matched patient who conceived a live eutopic singleton pregnancy was selected randomly as a control. The rates of early miscarriage, late miscarriage, live birth, preterm birth, low birth weight and perinatal mortality were not significantly different between the study and control groups. The birth weight were also similar between these two groups. However, the caesarean section rate was significantly higher in the study group than that in the control group(P < 0.001). Additionally, laparotomy and laparoscopy for tubal HPs yielded similar pregnancy outcomes. Compared with controls, patients who conceived tubal pregnancies and concomitant live eutopic singleton pregnancies had similar pregnancy outcomes after proper surgical treatment of EPs. These findings can be used for counselling women who have conceived tubal HPs regarding the risks associated with surgical treatment.

Diagnosis of 42 Cases of Intrauterine Twin Pregnancy Complicated With Ectopic Pregnancy: A Retrospective Cohort Study

OBJECTIVES

The coexistence of intrauterine twin pregnancy and ectopic pregnancy (EP), known as heterotopic pregnancy, is a rare but potentially life-threatening condition. In this study, we aimed to investigate the pregnancy outcomes in women with intrauterine twin pregnancies complicated with EP after assisted reproductive technology.

METHODS

This retrospective study analyzed the medical records of 42 women diagnosed with intrauterine twin pregnancies complicated with EP via ultrasound or surgery at our hospital between January 2005 and December 2020. We collected data on patient general characteristics, high-risk factors, clinical symptoms, ultrasound features, treatment methods, and pregnancy outcomes.

RESULTS

Among the 42 included women, 47.6% (20/42) had a history of tubal surgery, while 52.4% (22/42) and 47.6% (20/42) received the transfer of 2 and 3 embryos, respectively. In terms of treatment, 21.4% (9/42) women received expectant management, whereas 78.6% (33/42) underwent surgical treatment, with laparoscopic surgery accounting for 71.4% (30/42). Tracking the pregnancy outcomes revealed a live birth rate of 81.0% (34/42) and a full-term birth rate of 50.0% (21/42). The preterm birth rate was 31.0% (13/42), with a breakdown of 1 singleton (7.7%, 1/13) and 12 twin births (92.3%, 12/13) among the total 13 premature deliveries. Among the neonates, 33.3% (14/42) were singletons and 47.6% (20/42) twins. Caesarean section accounted for 31 out of 34 deliveries (91.2%).

CONCLUSIONS

Though the incidence of EP in twin pregnancies has declined in the last decade, early diagnosis and proper management are still crucial for favorable outcomes in twin pregnancies with EP.

Is expectant management feasible for select patients diagnosed with a heterotopic tubal pregnancy following in vitro fertilization/intracytoplasmic sperm injection?

BACKGROUND

Heterotopic pregnancy (HP) is a rare type of pathological pregnancy, and the most common site of concomitant ectopic pregnancy (EP) is the fallopian tube. Some studies have shown that expectant treatment could be considered because some EPs tend to regress spontaneously. However, data on the expectant treatment of HP are lacking. This study aimed to examine the outcomes of eutopic pregnancies following expectant management of concomitant tubal EP after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

METHODS

This was a retrospective, observational matched cohort study. All patients who conceived with tubal HP (HTP) via IVF/ICSI and were treated expectantly between January 2010 and December 2021 were enrolled. Each HTP patient managed expectantly (A) was randomly matched with one control patient who conceived with a solely eutopic pregnancy (B) and one HTP patient who underwent surgical therapy (C) from our clinical database according to predefined criteria. The expectant group and the control groups were matched for maternal age (MA; ±1 year), gravidity (0; ≥1) and gestational age (GA) at presentation (± 2 days). The pregnancy outcomes of the study group and the control groups were compared.

RESULTS

More than three-quarters of the EPs in patients treated expectantly were inhomogeneous solid masses (n = 95, 76.6%), and an empty gestational sac was the second most common (n = 18, 14.5%). The rates of live birth (76.6%, 79.0%, 73.4%; P = 0.647 (A versus B); P = 0.557 (A versus C)) and early miscarriage (21.8%, 19.4%, 25.8%; P = 0.637 (A versus B); P = 0.456 (A versus C)) in the expectant group were similar to those in the eutopic group and those in the surgical group. There were no significant differences in of the preterm birth rate (7.3%, 7.3%, 7.3%; P = 1.000 (A versus B); P = 1.000 (A versus C)), perinatal mortality (1.0%, 1.0%, 1.1%; P = 1.000 (A versus B); P = 1.000 (A versus C)), GA at delivery (38.7 ± 2.1, 38.4 ± 2.4, 38.5 ± 2.3 weeks; P = 0.286 (A versus B); P = 0.425 (A versus C)) or birth weight (3294.8 ± 507.2, 3238.2 ± 646.1, 3194.5 ± 452.9 g; P = 0.498 (A versus B); P = 0.157 (A versus C)).

CONCLUSION

Expectant management was an option for select women with HTP. The prognoses of the concomitant eutopic pregnancies were comparable to those of the solely eutopic singleton pregnancies and the HTPs managed surgically. The application of this protocol in clinical practice significantly reduces the need for surgical or medical treatment of EP. Notably, close follow-up is required, and patients need to be vigilant and have immediate access to medical resources in case of an emergency.

Heterotopic Triplet Pregnancy After Assisted Reproductive Techniques: A Systematic Review

Heterotopic pregnancy is defined as the simultaneous presence of an intrauterine and an extrauterine pregnancy and is considered a rare condition. As a part of this entity, heterotopic triplet pregnancy, defined as the presence of three embryos, with at least one being ectopic, is exceedingly rare. In recent years, the broad use of assisted reproductive techniques to help infertile couples has contributed to the constant rise of non-spontaneous heterotopic triplets. An analysis of all the cases reported in the English literature could provide useful messages to clinicians. This literature review had the aim to provide an analytic overview of all the cases of heterotopic triplet pregnancy after ovulation induction and assisted reproductive techniques published in the English literature by searching the National Library of Medicine (PubMed), Scopus, and Google Scholar until December 2023. We identified 57 articles of heterotopic triplets after assisted reproductive techniques and recorded the year, maternal age, gravida/para, medical history, medication used and mode of conception, number of embryos and stage of cells transferred, number of embryos in utero and ectopic embryos, time of diagnosis after ovulation induction or embryo transfer, symptoms, rupture of the ectopic pregnancy with hemoperitoneum, complications in pregnancy, obstetric outcome, weeks of delivery, birth-weight status and sex of the infants. Although this situation could be life-threatening and should alert the medical community, misdiagnosis or delayed diagnosis is still present. The commonest site of ectopic is in the salpinx. Currently, there is no consensus on the treatment strategy for heterotopic triplets, and all the data is derived from case reports. It is important to highlight the current recommendation of transferring one, or at most two, fertilized embryos during a single ovarian-controlled cycle to minimize the risk of multiple gestations and associated complications. Clinicians must remain vigilant, as pregnancies following in vitro fertilization (IVF) are considered "high-risk." Complications, such as multiple pregnancies, preterm delivery, or maternal-fetal health issues, may arise. Early diagnosis, appropriate surgical or conservative interventions, and rigorous follow-up are essential to ensure optimal maternal and fetal outcomes.

Surgical treatment of fallopian tubal pregnancy and interstitial pregnancy has no differential effect on intrauterine pregnancy after in vitro fertilization-embryo transfer

BACKGROUND

Due to the specific nature of interstitial pregnancy (IP), there are significant risks to both the mother and the foetus in women with a heterotopic interstitial pregnancy (HIP). IP alone has been analysed as a site-specific ectopic pregnancy (EP) in previous studies; however, according to the latest European Society of Human Reproduction and Embryology criteria, IP is classified as a tubal pregnancy. If IP can be classified as a tubal pregnancy, then there is no difference in the effects of these two methods on intrauterine pregnancies (IUPs). Under the premise of timely surgery, disposing of IPs and tubal pregnancy (excluding IPs) should also have no differential effect on IUPs.

METHODS

Patients with heterotopic fallopian tubal pregnancy (HP-tube) and HIP seen at our hospital from January 2005 to December 2020 were included. All included patients were diagnosed by transvaginal sonography (TVS), and EPs were confirmed by surgery and pathological analysis. The IUP outcomes after surgical treatment of the EPs were compared between the HP-tube group (n = 464) and the HIP group (n = 206). The outcomes of IUPs were evaluated in patients with HIP who underwent either laparoscopy (169 cases) or laparotomy (36 cases).

RESULTS

There was no significant difference in postoperative miscarriage (6.90% vs. 6.80%, odds ratio (OR) = 1.859, 95% confidence interval (CI) (0.807-4.279), p = 0.145); early spontaneous miscarriage (19.61% vs. 18.93%, OR = 0.788, 95% CI (0.495-1.255), p = 0.316); or late miscarriage (0.43% vs. 0.49%, OR = 0.823, 95% CI (0.070-9.661), p = 0.877) between the HP-tube group and the HIP group. There was no significant difference between the two groups in terms of preterm birth (7.33% vs. 6.80%, OR = 1.044, 95% CI (0.509-2.139), p = 0.907), live birth rate (71.60% vs. 73.30%, OR = 1.010, 95% CI (0.670-1.530), p = 0.980), or perinatal mortality rate (2.00% vs. 0.65%, OR = 0.580, 95% CI (0.030-3.590), p = 0.620). Compared to laparotomy for HIPs, laparoscopic treatment was associated with similar rates of postoperative miscarriage (5.33% vs. 13.90%, p = 0.076), live birth rate (72.80% vs. 75.00%, p = 0.948), caesarean Sect. (83.90% vs. 77.80%, p = 0.414).

CONCLUSIONS

After early diagnosis and treatment of EPs, patients in the HP-tube and HIP groups achieved comparable outcomes. Laparotomy and laparoscopy for treating HIPs yielded similar pregnancy outcomes.

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.

Ultrasound manifestations and clinical analysis of 50 cases of heterotopic pregnancy

OBJECTIVE

To investigate the value of ultrasonography in the diagnosis of heterotopic pregnancy and the follow-up.

METHODS

A retrospective analysis of 50 cases of clinically diagnosed heterotopic pregnancy in our hospital was performed, the clinical characteristics and ultrasonographic manifestations of the patients were summarized, the reasons for initial ultrasound missed diagnosis and misdiagnosis were analyzed, and the pregnancy outcomes were followed up.

RESULTS

Among the 50 cases, the initial ultrasound diagnoses of intrauterine pregnancy were all gestational sac type, 32 cases of ectopic pregnancy were located in the fallopian tube, and 10 cases were located in the uterine horn, 1 case at cervix, and 1 case at caesarean section scar. Forty-one cases were consistent with surgery and/or pathology, representing initial ultrasound diagnosis coincidence rate of about 82%. Six cases were missed in the initial ultrasound examination (12%), and three cases were misdiagnosed (6%). The maximum diameter of the intrauterine gestational sac was 9-48 mm, the average was about 24.90 ± 9.56 mm, the maximum diameter of the ectopic pregnancy gestational sac or mass was 11-63 mm, and the average was about 31.45 ± 13.82 mm (p < 0.05). Intrauterine pregnancy outcomes were followed up, 45 patients with complete data and 5 patients were lost to follow-up. The follow-up rate was about 90%.

CONCLUSION

Combining the patient's medical history and clinical characteristics can reduce missed diagnosis and misdiagnosis of heterotopic pregnancy. Ultrasonography has important value in the assessment of intrauterine pregnancy growth and development, and the integrity of maternal uterus.

Spontaneous heterotopic pregnancy: Diagnosis and surgical management

INTRODUCTION

Heterotopic pregnancy is a rare form of pregnancy, defined by the coexistence of an ectopic and an intrauterine pregnancy. The diagnosis of heterotopic pregnancy remains one of the greatest challenges of the gynecological-obstetrical emergencies.

CASE PRESENTATION

We report a rare case of spontaneous heterotopic pregnancy of a 28-year-old woman, diagnosed with a heterotopic pregnancy by ultrasound and treated by laparotomy in emergency obstetrical department of Ibn Rochd University Hospital of Casablanca.

DISCUSSION

Heterotopic pregnancy is a rare form of pregnancy, defined by the coexistence of an ectopic and an intrauterine pregnancy. The most common functional signs are abdominal pain, vaginal bleeding, pelvic mass and peritoneal irritation. The first-line paraclinical examination is suprapubic and transvaginal pelvic ultrasound. Therapeutic management of heterotopic pregnancies involves rapid intervention on the ectopic pregnancy, while respecting the intrauterine pregnancy if it has progressed, in order to preserve the patient's fertility.

CONCLUSION

Diagnosis of heterotopic pregnancy is often difficult and management should be initiated as soon as possible given the risk of maternal mortality.

Heterotopic pregnancy with superfetation following ovarian stimulation: A case report

Heterotopic pregnancy (HP) is a rare phenomenon. Despite its rarity, there has been a notable increase in its incidence in recent decades due to the greater use of in vitro fertilization (IVF). However, information about the relation between ovarian stimulation and HP is scarce. We report a case of HP after ovarian stimulation using clomiphene citrate. A 26-year-old pregnant woman presented to the emergency department with mild vaginal bleeding, and abdominal pain. She had a history of pelvic inflammatory disease (PID) and left salpingectomy due to a previous ectopic pregnancy. She had undergone ovarian stimulation with clomiphene citrate three months earlier. Transvaginal ultrasound revealed an eight-week-old ruptured tubal pregnancy with an intrauterine ten-week-old gestational sac confirming superfetation HP. An urgent laparoscopic right salpingectomy was performed and the extrauterine pregnancy was successfully removed with the preservation of the intrauterine embryo. The course of the intrauterine pregnancy was uneventful and the patient gave birth to a healthy boy via cesarean section. Women receiving ovarian stimulation are at an increased risk of developing HP especially when they also have other predisposing factors for HP. Thus, close monitoring using transvaginal ultrasound with extra attention to the adnexa is required for a timely diagnosis and management of HP.

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.

Laparoscopic management of a second trimester ruptured spontaneous heterotopic tubal pregnancy mimicking ovarian tumour, a case report

BACKGROUND

Laparoscopic surgery in the second trimester of pregnancy is a high risk and demanding operation. Especially when dealing with adnexal pathology, the surgeon should balance between the effort to establish adequate visualisation of the operating field with minimal uterine manipulation and use of energy application to avoid any potential adverse effects on the intrauterine pregnancy.

OBJECTIVE

The video shows laparoscopic surgery performed in the second trimester of pregnancy and highlights modifications to technique to ensure safety. Materials and Methods: We present a case report of spontaneous heterotopic tubal pregnancy that mimicked an ovarian tumour and was managed surgically with a laparoscopy in the second trimester. During surgery, a previously ruptured left tubal pregnancy (? ectopic) was the cause for a concealed hematoma in the pouch of Douglas, misdiagnosed as ovarian tumour. This is one of the few cases of heterotopic pregnancy treated by laparoscopy in the second trimester of pregnancy.

RESULTS

The patient was discharged the day 2 post-operatively, the intrauterine pregnancy progressed, and the patient delivered with a planned caesarean section on the 38th week.

CONCLUSIONS

Laparoscopic surgery, with adjustments, is a safe and effective method to manage adnexal pathology during a second trimester pregnancy.

Heterotopic Pregnancy: Case Series and Review of Diagnosis and Management

Introduction

Heterotopic pregnancy (HP) refers to the simultaneous presence of intrauterine pregnancy (IUP) and ectopic pregnancy, which is very rare but potentially life-threatening. The spontaneous incidence of HP in the general population is 1/30,000. With the widespread use of assisted reproductive technology (ART), the incidence rises to 1/1,000. Aims and Methods. This is a prospective case series looking at the cases of heterotopic pregnancies presenting to the early pregnancy unit (EPU) in a tertiary maternity hospital, from November 2015 to November 2016. The clinical presentation, ultrasound findings, and laparoscopy findings were all documented. The incidence of HP was calculated and compared with the quoted incidence in the literature. Outcomes. Five women with HP presented to the EPU over the course of a year. The first case describes a spontaneous HP with a previous salpingostomy. The second case describes an HP following ovulation induction. The third case describes a spontaneous HP with no known risk factors. The fourth and fifth cases describe heterotopic pregnancies following in vitro fertilisation with more than one embryo. All five cases of HP underwent laparoscopy and salpingectomy with uneventful recovery. The three women who had a viable IUP had no further complications in their pregnancies.

Conclusion

Early and accurate diagnosis of HP can be challenging. An early transvaginal ultrasound plays an important role in making the diagnosis in women with risk factors and following ART. A high index of suspicion is required for timely diagnosis and appropriate intervention, especially in spontaneous HP.

Successful Management of Triplet Heterotopic Pregnancy (Interstitial) With an Intrauterine Monochorionic Diamniotic Twin Pregnancy Through Laparoscopy: A Case Report

The simultaneous occurrence of intrauterine (IU) and extrauterine pregnancies is known as heterotopic pregnancy, an uncommon clinical condition that is challenging to manage. It can be a potentially fatal illness if it remains unnoticed. This is a case report of a woman who had heterotopic triplets after transferring two embryos produced through in vitro fertilization. An ultrasound scan diagnosed live interstitial heterotopic pregnancy and an intrauterine monochorionic twin pregnancy. Laparoscopic resection of interstitial heterotopic pregnancy was done. The monochorionic twin pregnancy was closely monitored by serial ultrasound, and at 36 weeks of gestation, two healthy twins were delivered by cesarean section. The fetal growth parameters were monitored, and a dopplers study was conducted to assess fetal blood flow. Even in heterotopic pregnancy, timely diagnosis and therapeutic intervention can preserve IU pregnancy with a successful outcome. Early meticulous monitoring and early detection can lead to a favorable outcome. Even in heterotropic pregnancy, a meticulous evaluation can lead to favorable outcomes by conserving IU pregnancy, and timely intervention can prevent maternal motility.

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.

Successful Ultrasound-Guided Methotrexate Intervention in the Treatment of Heterotopic Interstitial Pregnancy: A Case Report and Literature Review

PURPOSE

This study aims to share the experience of minimally invasive ultrasound-guided methotrexate intervention in the treatment of heterotopic interstitial pregnancy (HIP) with good pregnancy outcomes, and to review the treatment, pregnancy outcomes, and impact on the future fertility of HIP patients.

METHODS

The paper describes the medical history, clinical manifestations, treatment history, and clinical prognosis of a 31-year-old woman with HIP, and reviews cases of HIP from 1992 to 2021 published in the PubMed database.

RESULTS

The patient was diagnosed with HIP by transvaginal ultrasound (TVUS) at 8 weeks after assisted reproductive technology. The interstitial gestational sac was inactivated by ultrasound-guided methotrexate injection. The intrauterine pregnancy was successfully delivered at 38 weeks of gestation. Twenty-five HIP cases in 24 studies published on PubMed from 1992 to 2021 were reviewed. Combined with our case, there were 26 cases in total. According to these studies, 84.6% (22/26) of these cases were conceived by in vitro fertilization embryo transfer, 57.7% (15/26) had tubal disorders, and 23.1% (6/26) had a history of ectopic pregnancy; 53.8% (14/26) of the patients presented with abdominal pain and 19.2% (5/26) had vaginal bleeding. All cases were confirmed by TVUS. In total, 76.9% (20/26) of intrauterine pregnancies had a good prognosis (surgery vs. ultrasound interventional therapy 1:1). All fetuses were born without abnormalities.

CONCLUSIONS

The diagnosis and treatment of HIP remain challenging. Diagnosis mainly relies on TVUS. Interventional ultrasound therapy and surgery are equally safe and effective. Early treatment of concomitant heterotopic pregnancy is associated with high survival of the intrauterine pregnancy.

Middle-East obgyn graduate education (MOGGE) foundation practice guidelines: diagnostic approach to pregnancy of unknown location: practice guideline no. 03-O-21

Background

Pregnancy of unknown location (PUL) is a term used to describe failure of visualization of intrauterine or extrauterine gestational sac in a woman with a positive pregnancy test.

Body of the abstract

Ectopic pregnancy (EP) accounts for 1–2 % of all pregnancies. EP contributes to maternal mortality of a known cause by 4% in developed countries. However, case fatality rate may be 10 times higher in low-resource countries. This may be attributed to delayed diagnosis and lack of resources. PUL is a temporary term that may eventually lead to diagnosis of viable intrauterine pregnancy, pregnancy loss, or more seriously, EP.

Conclusion

This guideline appraises current evidence on assessment of PUL and early diagnosis of EP particularly in low-resource settings.

Should expectant management of heterotopic pregnancy be considered?

KEY MESSAGE

Both expectant and interventional managements are acceptable in selected cases, when heterotopic pregnancy is diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

PURPOSE

Heterotopic pregnancy, though relatively rare, is potentially a life-threatening condition. The aim of the study is to compare expectant versus interventional management of heterotopic pregnancies.

METHODS

This is a retrospective cohort study including all women diagnosed with heterotopic pregnancy on ultrasound from March 2011 to December 2020 in a single medical center. Expectant and interventional management outcomes were compared. Primary outcome was defined as live birth.

RESULTS

Forty-one women were diagnosed with heterotopic pregnancy during the study period. Management was expectant in 10 (24.4%) and interventional in 31 (75.6%) of the women. Expectant management was considered when the patient was stable, and the attending physician decided that the ectopic pregnancy did not continue to develop. Interventions included laparoscopic salpingectomy (n = 26), laparoscopic cornual resection (n = 2), laparotomic cornual resection (n = 1) and gestational sac aspiration (n = 2). The intra-uterine pregnancy continued to develop in 6 (60.0%) and 22 (81.5%) of the women in the expectant and interventional groups, respectively (p = 0.52). All women managed expectantly reached term delivery, as opposed to 17/22 (77.3%) in the intervention management group (p = 0.60). Multivariate analysis found serum β-hCG level as the only independent parameter associated with ongoing pregnancy rate (B = 0.001, p = 0.04).

CONCLUSIONS

Both expectant and interventional management were found to be acceptable when heterotopic pregnancy was diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

Heterotopic pregnancy: Five case reports diagnosed in 2021

Introduction and importance

Heterotopic pregnancy is the occurrence of pregnancies in at least two different implantation sites in the same time. The diagnosis is one of the most difficult of the gynecological emergencies. In 2021 this pathology still underdiagnosed and remains unknown by physicians. Most patients are admitted in critical stage.

Cases presentations

We reported 5 cases of heterotopic pregnancies in symptomatic women admitted from January 2021 to December 2021, in maternity department, mother and child hospital abderrahim Harouchi, Ibn Rochd University Hospital of Casablanca. The frequency of this pathology in our hospital in 2021 is about 10% of ectopic pregnancies (5/52 cases of ectopic pregnancies). All the cases were received in critical phase of the pathology (vascular collapsus or hemodynamic shock). The mean diagnostic was suspected in gray scale ultrasound that show an intrauterine pregnancy associated with adnexal mass corresponding to hematosalpinx or gestational sac in the uterine tubes with medium to high abundance hemoperitoneum. All of our cases were treated by laparotomy in emergency after resuscitation measures.

Clinical discussion

The existence of intrauterine pregnancy does not exclude an ectopic pregnancy and often confuses the physician who consults the patient in early stage of symptoms. The clinical symptomatology is often related to a threatened or ongoing abortion, the diagnosis of heterotopic pregnancy is usually made in the stage of hemoperitoneum secondary to a rupture of the ectopic pregnancy. The standard treatment is conservative surgery, preferably by laparoscopy. The manipulation of the uterus must be careful to preserve the intra uterine pregnancy. Laparotomy retains its indications especially in forms with hemorrhagic shock. The abortion is not rare after surgery. A progestin treatment is always indicated.

Conclusion

The diagnosis of heterotopic pregnancy should not be delayed by the discovery of an intra-uterine gestational sac in symptomatic women and the adnexa must be systematically examined in the first trimester sonographic exam. The Diagnosis is often difficult and management should be initiated as soon as possible given the risk of maternal mortality.

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Heterotopic pregnancy is the occurrence of pregnancies in at least two different implantation sites in the same time.

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The diagnosis of heterotopic pregnancy should not be delayed by the discovery of a intra uterin gestational sac in symtomatic women and the adnexa must be systematically examined in the first trimester by sonographic exam.

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The main treatment consists of removing the ectopic pregnancy, while preserving the intra uterine pregnancy, that make the second challenge after diagnoses.

Abdominal heterotopic pregnancy post-IVF double embryo transfer

Uterosacral ligament (USL) is an uncommon site of implantation for abdominal ectopic pregnancies. This is the first case of USL heterotopic pregnancy post invitro fertilisation (IVF). The patient presented 6 weeks after a double embryo transfer with acute onset abdominal pain and was diagnosed with a suspected live tubal ectopic pregnancy with a viable intrauterine pregnancy on ultrasound. A diagnostic laparoscopy revealed an ectopic pregnancy implanted on the left USL which was resected and confirmed on histology. The patient was discharged well on postoperative day 2 with a viable intrauterine pregnancy. This case highlights the importance of considering non-tubal heterotopic pregnancies in the context of risk factors including IVF with double embryo transfer presenting with abdominal pain.

The risk of miscarriage following surgical treatment of heterotopic extrauterine pregnancies

STUDY QUESTION

What is the risk of loss of a live normally sited (eutopic) pregnancy following surgical treatment of the concomitant extrauterine ectopic pregnancy?

SUMMARY ANSWER

In women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine ectopic pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy.

WHAT IS KNOWN ALREADY

Previous studies have indicated that surgical treatment of the concomitant ectopic pregnancy in women with live eutopic pregnancies could be associated with an increased risk of miscarriage. The findings of our study did not confirm that.

STUDY DESIGN, SIZE, DURATION

A retrospective observational case–control study of 52 women diagnosed with live eutopic and concomitant extrauterine pregnancies matched to 156 women with live normally sited singleton pregnancies. The study was carried out in three London early pregnancy units (EPUs) covering a 20-year period between April 2000 and November 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women attended EPUs because of suspected early pregnancy complications. The diagnosis of heterotopic pregnancy was made on ultrasound scan and women were subsequently offered surgical or expectant management.

There were three controls per each case who were randomly selected from our clinical database and were matched for maternal age, mode of conception and gestational age at presentation.

MAIN RESULTS AND THE ROLE OF CHANCE

In the study group 49/52 (94%) women had surgery and 3/52 (6%) were managed expectantly. There were 9/52 (17%, 95% CI 8.2–30.3) miscarriages <12 weeks’ gestation and 9/49 (18%, 95% CI 8.7–32) miscarriages in those treated surgically. In the control group, there were 28/156 (18%, 95% CI 12.2–24.8) miscarriages <12 weeks’ gestation, which was not significantly different from heterotopic pregnancies who were treated surgically [odds ratio (OR) 1.03 95% CI 0.44–2.36]. There was a further second trimester miscarriage in the study group and one in the control group. The live birth rate in the study group was 41/51 (80%, 95% CI 66.9–90.2) and 38/48 (79%, 95% CI 65–89.5) for those who were treated surgically. These results were similar to 127/156 (81%, 95% CI 74.4–87.2) live births in the control group (OR 0.87, 95% CI 0.39–1.94).

LIMITATIONS, REASONS FOR CAUTION

This study is retrospective, and the number of patients is relatively small, which reflects the rarity of heterotopic pregnancies. Heterotopic pregnancies without a known outcome were excluded from analysis.

WIDER IMPLICATIONS OF THE FINDINGS

This study demonstrates that in women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy. This finding will be helpful to women and their clinicians when discussing the options for treating heterotopic pregnancies.

STUDY FUNDING/COMPETING INTEREST(S)

This work did not receive any funding. None of the authors has any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Research Registry: researchregistry6430.

The rising incidence of heterotopic pregnancy: Current perspectives and associations with in-vitro fertilization

Heterotopic pregnancy is the simultaneous occurrence of an intrauterine and ectopic pregnancy. This study aims to review the current literature regarding heterotopic pregnancy with a focus on its diagnosis and associations with in-vitro fertilization (IVF). Studies have shown that ovarian hyperstimulation syndrome and multiple embryo transfer during IVF are associated with an increased risk of heterotopic pregnancy. Tubal abnormalities such as pelvic inflammatory disease and previous tubal or abdomino-pelvic surgery have also been identified as risk factors. Diagnosis is challenging as the falsely reassuring presence of an intrauterine fetus frequently delays early intervention. Treatment should be individualised, but is often prompt surgical intervention, and focuses on terminating the ectopic pregnancy while minimizing harm to the mother and intrauterine fetus.

Heterotopic tubal pregnancy with a naturally conceived live twin intrauterine pregnancy in a patient with systemic lupus erythematosus: A case report

Heterotopic pregnancy (HP) is defined as the simultaneous occurrence of an intrauterine and extrauterine gestation. Risk factors contributing to this condition are similar to those which contribute to ectopic pregnancy. While a triple heterotopic gestation through natural conception is uncommon, here we present the case of a patient with spontaneous intrauterine twins and a concurrent tubal extrauterine gestation, where the patient also had systemic lupus erythematosus. During the seventh week of gestation, the patient presented with acute abdomen signs and hemodynamic instability; a decision was taken to perform an emergency laparotomy. Haemoperitoneum, a total torsion of the right ovary with salpinx, a ruptured tubal pregnancy and subsequent necrosis were found intraoperatively. The patient was discharged on the sixth postoperative day and monitored throughout her whole pregnancy, with the intrauterine pregnancy progressing uneventfully. Two healthy neonates were delivered by cesarean section at 36 weeks of gestation. In conclusion, physicians treating women of reproductive age should be aware of possible HP, even in the absence of risk factors.

Anesthetic Management of a Patient With a Ruptured Heterotopic Pregnancy for Emergency Exploratory Laparotomy

Heterotopic pregnancy (HP) is an uncommon clinical condition characterized by the coexistence of intrauterine and extra-uterine pregnancies. HP is a diagnostic challenge as the typical methods for the early diagnosis of ectopic pregnancy are confounded by the simultaneous presence of intrauterine pregnancy (IUP). Ruptured HP is a potentially life-threatening obstetric emergency and can result in significant morbidity and mortality. Early diagnosis is the key to a favorable outcome. With the increasing number of patients undergoing artificial reproductive technology (ART), which is an important risk factor for HP, the odds of encountering HP patients are also growing. Anesthesiologists are challenged by the need to manage a bleeding obstetric patient while simultaneously ensuring the safety of the IUP. We present perioperative management of a patient with bleeding ruptured HP for emergency laparotomy who went on to have a successful twin delivery 37w3d via cesarean section.

Diagnosis and Management of Ectopic Pregnancy: A Comparative Review of Major National Guidelines

Importance

Ectopic pregnancies (EPs) represent a severe early pregnancy complication that is associated with increased risks of maternal morbidity and mortality. Over the years, there has been a significant reduction in the mortality from this complication by improving the diagnostic tools and the treatment options.

Objective

The aim of this study was to review and compare the recommendations from published guidelines on this potentially fatal condition.

Evidence Acquisition

A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence on EP was carried out.

Results

All the guidelines point out the crucial role of sonography in the prompt diagnosis of EP and describe similar sonographic findings. There is a consensus on the indications and contraindications to the use of methotrexate, the post-treatment surveillance, and the criteria of expectant management. The indications for a surgical approach are not well established, although the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence agree that a laparoscopy is preferred to laparotomy for hemodynamically stable patients. The latter is considered a better option only in emergency conditions. However, there is controversy in the recommended methotrexate protocols and the evaluation of β-human chorionic gonadotrophin and progesterone levels.

Conclusion

It is of paramount importance to build consistent international protocols, so as to help clinicians all over the world diagnose EPs in the most timely and accurate way and subsequently treat them effectively as a nonurgent medical condition, with the intention to lower the mortality and morbidity rate.

Diagnosis and management of a spontaneous heterotopic pregnancy: Rare case report

Introduction and importance

Heterotopic pregnancy is the occurrence of pregnancies in at least two different implantation sites in the same time. The diagnosis of heterotopic pregnancy remains one of the greatest challenges of the gynecological-obstetrical emergencies.

Case presentation

We report a rare case of spontaneous heterotopic pregnancy of a 32-year-old woman, diagnosed with a heterotopic pregnancy by ultrasound and treated by laparotomy in emergency obstetrical department of Ibn Rochd University Hospital of Casablanca.

Clinical discussion

The existence of intrauterine pregnancy does not exclude an ectopic pregnancy. The occurrence of a spontaneous heterotopic pregnancy without risk factors is a rare event, the clinical symptomatology is often related to a threatened or ongoing abortion, the diagnosis of heterotopic pregnancy is not made until the appearance of signs of hemoperitoneum secondary to a ruptured EP, hence the importance of a systematic ultrasound examination of the adnexa during first trimester ultrasound. The standard treatment is conservative surgery, preferably by laparoscopy. Laparotomy retains its indications especially in forms with hemorrhagic shock. With the aim of preserving intrauterine pregnancy while removing ectopic pregnancy.

Conclusion

The diagnosis of heterotopic pregnancy should not be excluded by the discovery of a UGI in a spontaneous cycle. Diagnosis is often difficult and management should be initiated as soon as possible given the risk of maternal mortality.

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Heterotopic pregnancy is rare when at least two pregnancies are present simultaneously in different implantation sites.

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The diagnostic of heterotopic pregnancy is often delayed due to the visualization of the intrauterine sac.

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Treatment of heterotopic pregnancy aims to preserve the intrauterine pregnancy while removing the ectopic pregnancy.

Late presentation of a heterotopic pregnancy at 19 weeks of gestation leading to maternal collapse: A case report

Background

Heterotopic pregnancy is a rare form of pregnancy that involves implantation of simultaneous pregnancies at two sites. They are normally identified in early gestation when patients become symptomatic with vaginal bleeding or abdominal pain.

Case Presentation

A 35-year-old woman (para 0, gravida 2) presented to the emergency department in haemorrhagic shock at 19 weeks and 5 days of gestation. On assessment she was hemodynamically unstable and was found to have a large hemoperitoneum on ultrasound. She subsequently underwent an exploratory laparotomy and right salpingectomy for a suspected ectopic pregnancy. The postoperative period was uneventful, and the intrauterine pregnancy continued to term.

Conclusion

Heterotopic pregnancy should be included in the differential diagnosis for women presenting with hemoperitoneum even beyond the first trimester.

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Heterotopic pregnancy is the implantation of simultaneous pregnancies at two sites.

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They are normally diagnosed in the first trimester on transvaginal ultrasound.

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We present a case of a heterotopic pregnancy beyond the first trimester.

Spontaneously conceived 17-week heterotopic pregnancy: a challenging and unusual diagnosis

A 37-year-old woman, gravida 2 para 1, arrived in our emergency clinic at 16 2/7 weeks of a spontaneously conceived pregnancy for abdominal pain. She was on oral antibiotics for 2 days to treat a suspected urinary tract infection with no improvement. Blood tests, abdominal ultrasound and intrauterine fetus were all normal. She left our emergency unit with laxatives. Four days later, she returned to our clinic with severe abdominal pain. We repeated abdominal and foetal ultrasonography and identified a left para-uterine 7×5 cm mass. As adnexal torsion was suspected, we performed an emergency laparoscopy. At laparoscopy, we found a left haematosalpinx and realised a left salpingectomy. Histology confirmed the presence of a heterotopic pregnancy (HP). This case illustrates the importance of exploring the adnexa in a gravid woman presenting with abdominal pain in the first and early second trimesters. Although rare, excluding a HP may prevent a life-threatening haemorrhage.

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: a case report

Background

Heterotopic pregnancy describes the occurrence of two pregnancies in different implantation sites simultaneously, which is rare, yet it is a challenge to diagnose such a problem due to complex clinical and laboratory findings. In the current study, we present a case of first trimester heterotopic pregnancy diagnosed by ultrasound (US) and magnetic resonance imaging (MRI) and was managed successfully.

Case presentation

A 22-year-old primigravida lady with spontaneous pregnancy was presented by increasing lower abdominal pain for 5 days with brownish vaginal discharge, nausea, and vomiting episodes. Trans-abdominal and endovaginal ultrasound was performed and revealed a viable intrauterine pregnancy of 8 weeks and 1 day, associated with a heterogeneous complex right adnexal mass. MR imaging revealed a right adnexal mass intimately anterior to the normal right ovary. Laparascopy was done; it revealed a distended right fallopian tube with pregnancy while the right ovary was not seen (impeded in the pouch of Douglas), and right salpingectomy was done. The specimen was sent for histopathology. The patient tolerated the procedure well and was then taken to the recovery room in stable condition. The histopathological report confirmed the diagnosis of ectopic pregnancy.

Conclusion

However, heterotopic is a rare condition, any pregnant woman presenting with alarming abdominal pain and adnexal abnormality; heterotopic pregnancy should be among the differential diagnosis possibilities. The patient should be thoroughly investigated using ultrasound and MRI if needed, to exclude this rare diagnosis and allow on-time proper management.

Treatment of tubal heterotopic pregnancy with viable intrauterine pregnancy: Analysis of 81 cases from one tertiary care center

OBJECTIVES

The aim of our study was to analyze the treatment and pregnancy outcome of tubal heterotopic pregnancy (HP) patients with a viable intrauterine pregnancy (IUP) in our center.

STUDY DESIGN

This was a retrospective analysis of 81 patients with tubal HP and a viable IUP. Patients were divided into either an expectant treatment group (29 patients) or a surgical treatment group (52 patients, 36 laparoscopy and 16 laparotomy). Data related to the basal clinical characteristic of all patients, rescue treatment and ectopic pregnancy (EP) rupture rate in the expectant treatment group, operation details in the surgical treatment group and pregnancy outcomes were collected and analyzed. Subgroup analyses were also performed.

RESULTS

In the expectant treatment group, the abortion rate, EP rupture rate and rescue treatment rate were 10.34 % (3/29), 21.14 % (7/29) and 34.48 % (10/29), respectively; subgroup analysis revealed that the rescue treatment rate in patients with EP mass enlargement ≥50 % was 71.43 % (5/7), which was significantly higher than that in patients with EP mass enlargement <50 % (15.00 %, 3/20), with P = 0.011. In the surgical treatment group, the abortion rate of all patients was 15.38 % (8/52); the abortion rate was 22.22 % (8/36) in the laparoscopy subgroup, which was significantly higher than that in the laparotomy subgroup (0.00 %, 0/16), with P = 0.038.

CONCLUSIONS

Surgical treatment is a safe treatment option for tubal HP with a viable IUP, and laparoscopic surgery may be a potential risk factor for abortion. A high risk of failure exists for expectant management of tubal HP with a viable IUP, and EP mass enlargement ≥50 % may be a potential predictor of rescue treatment.

Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study

RESEARCH QUESTION

What is the best intervention time and method for patients who are diagnosed with heterotopic caesarean scar pregnancy (HCSP) wishing to preserve intrauterine pregnancy.

DESIGN

Four patients diagnosed with HCSP from January 2014 to May 2019 were enrolled. Because HCSP is rare, data on 27 published cases were extracted to augment the analysis. Clinical characteristics and medical documents related to fetal reduction and subsequent maternal-neonate outcomes were analysed.

RESULTS

The intervention time was significantly earlier in the full-term birth group (6.76 ± 1.05 weeks) compared with pre-term birth group (8.02 ± 1.55 weeks; P = 0.042). The cumulative full-term delivery rate was 91.48% when the intervention was at 6 weeks' gestation and decreased to 42.02% at 8 weeks. The maternal-neonate outcome was similar among the selective fetal reduction and surgical removal groups as was delivery time (34.68 ± 3.12 versus 34.80 ± 6.64 weeks; P = 0.955). In the four cases undergoing selective fetal reduction, the residual mass grew by 1.16-7.07 times compared with the area before reduction. The maximum size of the residual mass was observed at 12-13 weeks and 22-25 weeks.

CONCLUSIONS

Most patients with HCSP who choose to keep intrauterine pregnancy will be able to carry the fetus to term. Selective fetal reduction would be the first intervention of choice and should take place immediately after diagnosis. The residual mass after reduction could continue to grow throughout the whole pregnancy, although this should not be considered as an indication for termination. With good supervision and careful management, the pregnancy could be maintained and carried to term.

The indicator of clinical outcomes for patients with heterotopic pregnancy following in-vitro fertilization with embryo transfer

OBJECTIVE

To explore the early predictors for pregnancy outcomes in patients with heterotopic pregnancy (HP) following in-vitro fertilization with embryo transfer (IVF-ET).

MATERIAL AND METHODS

This retrospective study reviewed 81 patients with HP following IVF-ET in our institution between January 2003 and September 2017. The relationships between clinical outcomes and general characteristics, sonographic features and different management options were analyzed by logistic regression analysis.

RESULTS

The gestational age at the time of diagnosis was 50.9 ± 12.3 days. Among these cases, 76 were accurately diagnosed by TVS, 1 was misdiagnosed as adnexal torsion by TVS, and 4 were confirmed to have IUPs after the surgical treatment. Hence, the sensitivity of TVS for detecting HP was 93.8% (76/81). However, forty-seven patients (58.0%) had suspected HP when they underwent the initial TVS. Among these patients, live births occurred for 60 patients, 11 of whom delivered preterm. The miscarriage rate was 58.3% (14/24) for patients without IUP cardiac activity at HP diagnosis, and 12.3% (7/57) for patients with IUP cardiac activity; a significant correlation was identified (χ² = 18.651, P < 0.001). Additionally, the abortion rate of patients following fresh non-donor embryo was higher than patients after frozen-thawed embryo (χ² = 10.437, P = 0.001). Further by logistic regression analysis, patients following frozen-thawed embryo and an IUP with cardiac activity at HP diagnosis were identified as two independent factors of pregnancy outcome. (OR = 0.060, 95%CI = 0.008-0.471, P = 0.007; OR = 0.010, 95%CI = 0.001-0.124, P<0.001).

CONCLUSIONS

Patients following frozen-thawed embryo and an IUP with cardiac activity at HP diagnosis could be the independent predictors for a favorable prognosis.

Second Trimester Heterotopic Triplet Pregnancy with Intrauterine Twin Pregnancy and Ruptured Interstitial Pregnancy: A Maternal Near-Miss Case Report

Heterotopic pregnancy is defined as the occurrence of simultaneous intrauterine and extrauterine pregnancies. It is a rare, potentially life-threatening condition and infrequent in natural conceptions. Here, we report a case of spontaneous heterotopic triplet pregnancy with ruptured cornual ectopic pregnancy and simultaneous twin intrauterine pregnancies at 18 weeks of gestation. The event led to miscarriage of all fetuses from both the ectopic and the intrauterine twin pregnancies.

Heterotopic Pregnancy - A Diagnostic Challenge. Six Case Reports and Literature Review

Heterotopic pregnancy is defined as the simultaneous presence of intrauterine and ectopic pregnancies. It is a rare condition, but due to the increasing use of artificial reproductive techniques, the incidence of heterotopic pregnancy is increasing. Most of the patients with heterotopic pregnancy have a previous history of infertility or tubal diseases. In this case series, we are presenting six cases of heterotopic pregnancy. Three of them had a history of assisted reproductive technique: one patient had in vitro fertilization with three embryos transferred, and two patients received follicular stimulating hormone therapy. In one of the cases, heterotopic pregnancy was missed on an initial transabdominal scan, and in the following weeks, it was diagnosed on transvaginal ultrasound. Five patients underwent laparoscopic salpingectomy, and one patient had laparotomy and then a salpingectomy was done. Follow-up ultrasound scans for intrauterine pregnancy (IUP) showed abortion of the IUP, except in one patient who delivered a healthy full-term baby via spontaneous vaginal delivery. Therefore, there is a need to develop diagnostic criteria to rule out heterotopic pregnancy if the patient underwent any type of assisted reproductive techniques. We are emphasizing the need for more careful scanning of the adnexa via transvaginal ultrasound, especially in high-risk patients, even if the intrauterine gestation is confirmed.

Heterotopic pregnancy - how easily you can go wrong in diagnosing? A case study

Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms.

Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms.

Effect of method of anesthesia on the reproductive and obstetric outcomes of heterotopic pregnancies

BACKGROUND

Anesthesia is commonly used for surgical termination of the extrauterine component of heterotopic pregnancy. We sought to evaluate the effects of general and regional anesthesia during salpingectomy on reproductive and obstetric outcomes of heterotopic pregnancies.

METHODS

A two-center, retrospective cohort study was conducted, and 49 heterotopic pregnancies were included. Baseline characteristics, reproductive and obstetric outcomes were compared between the general anesthesia and regional anesthesia groups.

RESULTS

Baseline characteristics were comparable for age, weeks of gestation at diagnosis, and duration of anesthesia. No significant difference was found in pregnancy outcome, perinatal outcome or neonatal weight (P >0.05). The rate of miscarriage in the general anesthesia group was 23.5% versus the regional anesthesia group 15.6% (P >0.05).

CONCLUSION

With respect to reproductive and obstetric outcomes, this retrospective study found no difference between general anesthesia and regional anesthesia used for early heterotopic pregnancy.

Evaluation of clinical effect of transabdominal sonography and transvaginal sonography in early diagnosis of ectopic gestation

Objective:

To analyze the application of transabdominal sonography and transvaginal sonography in early diagnosis of pregnancy and to provide a reference for the selection of diagnosis methods in clinic.

Methods:

One hundred and eighty patients who were admitted into the hospital from February 2013 to February 2014, received clinical diagnosis and were confirmed as ectopic gestation by surgery were selected as research objects. They were examined by transabdominal sonography, transvaginal sonography, and transabdominal sonography in combination with transvaginal sonography respectively. Besides, the ultrasonic performance was observed and compared with surgical pathological results to analyze and compare diagnostic accordance rate.

Results:

The positive rate of transabdominal sonography in combination with transvaginal sonography was much higher than that of transabdominal sonography and transvaginal sonography and the differences had statistical significance (P<0.05). The detection rate of different positive characteristics using the combined examination was much higher than that of transabdominal sonography and transvaginal sonography, and the differences had statistical significance (P<0.05). The detection rates of different types of ectopic gestation and different sizes of mass using transabdominal sonography in combination of transvaginal sonography were higher than that of transabdominal sonography and transvaginal sonography (P<0.05).

Conclusion:

Transabdominal sonography in combination with transvaginal sonography can complement information, improve detection rate, and reduce or avoid misdiagnosis and missed diagnosis, which provides a scientific basis for the formulation of clinical treatment scheme.

Spontaneous Heterotopic Pregnancy: Dual Case Report and Review of Literature

Introduction. Heterotopic pregnancy is a rare complication usually seen in populations at risk for ectopic pregnancy or those undergoing fertility treatments. It is a potentially dangerous condition occurring in only 1 in 30,000 spontaneous pregnancies. With the advent of Assisted Reproduction Techniques (ART) and ovulation induction, the overall incidence of heterotopic pregnancy has risen to approximately 1 in 3,900 pregnancies. Other risk factors include a history of pelvic inflammatory disease (PID), tubal damage, pelvic surgery, uterine Mullerian abnormalities, and prior tubal surgery. Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. Most commonly, heterotopic pregnancy is diagnosed at the time of rupture when surgical management is required. Case. This paper represents two cases of heterotopic pregnancies as well as a literature review. Conclusion. Heterotopic pregnancy should be suspected in patients with an adnexal mass, even in the absence of risk factors. Clinicians must be alert to the fact that confirming an intrauterine pregnancy clinically or by ultrasound does not exclude the coexistence of an ectopic pregnancy. A high index of suspicion in women is needed for early and timely diagnosis, and management with laparotomy or laparoscopy can result in a favorable and successful obstetrical outcome.

Diagnostic Methods of Ectopic Pregnancy and Early Pregnancy Loss: a Review of the Literature

This review article presents recent evidence on early pregnancy loss and ectopic pregnancy. In the light of recent evidence, the β-hCG discriminatory zone may be extended in clinically stable cases without evidence of bleeding. A possible cut-off is 4300 mIU/ml, which corresponds to when a sonographer should detect an intrauterine pregnancy. Embryonic demise can be confirmed when a transvaginal ultrasound finding shows no heartbeat in an embryo of more than 7 mm CRL, no embryo in a gestational sac having a mean sac diameter of more than 25 mm, or no appearance of an embryo within 7-10 days after the primary examination. These are considered definitive signs of embryonic demise. Suggestive signs of embryonic demise require closer monitoring of the pregnancy.

Management of Heterotopic Pregnancy: Experience From 1 Tertiary Medical Center

The objective of this study is to summarize the experiences of our department in the management of heterotopic pregnancy (HP) and to analyze the influence of different treatment modality on the viable intrauterine pregnancy.There were 64 patients diagnosed as HP in the Department of Gynecology and Obstetrics in our hospital between January 2003 and June 2014, 52 HP patients with viable intrauterine pregnancy were included and analyzed in our study. Interventions included expectant management, surgical management and transabdominal sonographic guided transvaginal aspiration of ectopic gestational embryo (embryo aspiration) management.Main outcome measures are maternal outcome and pregnancy outcome.In expectant management group, 4 patients suffered rupture of ectopic pregnancy, 6 patients transferred to surgical management, 1 patient suffered a fever of 40.4°C, the abortion rate was 5% (1/20). In surgical management group, emergency surgery was performed in 9 patients with unstable hemodynamics and 3 patients with stable hemodynamics, 1 patient suffered uterine rupture 5 weeks later and dead fetus was demonstrated, 1 patient suffered urinary retention postoperative, the abortion rate was 14.8% (4/27). In embryo aspiration management group, 1 patient needed another embryo aspiration, all patients were eventful and no abortion was observed.In our retrospective study, transabdominal sonographic guided aspiration of ectopic gestational embryo has the best maternal outcome and the lowest abortion rate, surgical management group shows the highest abortion rate, and expectant management presents the worst maternal outcome.

Risk Factors and Early Predictors for Heterotopic Pregnancy after In Vitro Fertilization

This study investigated the risk factors and early predictors for heterotopic pregnancy (HP) after in vitro fertilization and embryo transfer (IVF-ET). From January 2008 to January 2013, 41 cases of HP and 72 cases of intrauterine twin pregnancy after IVF-ET were recruited and retrospectively analyzed. Compared with intrauterine twin pregnancy group, the HP group had a lower basal luteinizing hormone (LH) level (P = 0.005) and more cases had a history of hydrosalpinx (P = 0.008). After 14 days of IVF-ET, the serum β-HCG (β-human chorionic gonadotropin), E2 (Estradiol) and P (Progesterone) levels were lower in HP group (P<0.001, respectively). Moreover, vaginal bleeding and abdominal pain were the significant features of HP before diagnosis (P<0.001, respectively). Further by logistic regression, serum β-hCG, P levels on the 14th day after ET, and vaginal bleeding were identified as the independent factors of HP. These results indicate that when two or more embryos transferred in IVF procedure, β-hCG, P levels on the 14th day after ET, and vaginal bleeding could be taken as predictors for HP.

Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies

BACKGROUND

Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment.

METHODS

The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected.

RESULTS

A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence.

CONCLUSIONS

EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.