2019 Research Forum

INTERESTING ECTOPIC STUDY – RECORD REVIEW STUDY

Julia Canders, MD - Chief Resident (R4) Ob/Gyn, Kern Medical, Bakersfield California (Principal Investigator, Primary Author) Sally Wonderly, MD, FACOG - Associate Faculty Ob/Gyn, Kern Medical, Bakersfield (Investigator Sponsor, Second Author)

Discussion

Heterotopic pregnancy refers to simultaneous pregnancies at two different implantation sites. The vast majority of heterotopic pregnancies refer to a combination of intrauterine and ectopic pregnancies. Clinically, heterotopic pregnancies imitate symptoms of threatened abortion, ruptured corpus luteum cyst, ectopic pregnancy at other locations, and other benign gynecologic phenomenon and are often misdiagnosed until more advanced gestational age. We present a case of subacute, clinically stable heterotopic pregnancy via natural conception with live IUP and partially ruptured left adnexal ectopic pregnancy at approximately 7wks gestation. Introduction A 19-year-old woman with known IUP at 7 1/7 weeks presented to ER complaining of lingering mild left lower quadrant pain for the past 3wks, worsening in the last 24hr with new onset of light spotting. Transvaginal US noted IUP at 7 1/7 weeks with left complex mass with anechoic region suspicious for heterotopic pregnancy with blood in the pelvis [Figure 1 and Figure 2]. Patient pulse tachycardic to 109bpm, hemoglobin/hematocrit stable 11.9/35.7, however abdominal rebound, guarding, and positive Rovsing’s sign was noted on physical exam. Diagnosis of heterotopic pregnancy with ruptured left ectopic gestation made in light of imaging findings including IUP and left complex mass, blood in pelvis, patient tachycardia, and surgical abdomen. The patient underwent emergency laparoscopy. There was a partially ruptured ectopic pregnancy at the infundibulum of the left fallopian tube, along with hemoperitoneum that was evacuated [Figure 3, 4, 5, 6]. Left salpingectomy was performed. The intrauterine live gestation remained present. The patient had positive heart tones through 18wks gestation documented in outpatient clinic with us, until she transferred care out of the state. Records from new OB clinic pending. Case Report

ULTRASONOGRAPHIC FINDINGS

Conclusions The incidence of heterotopic pregnancy used to be rare, 1: 30,000 pregnancies, however now with advanced reproductive technologies and consideration of subjective and objective clinical findings heterotopic diagnoses are being recognized more readily and made at earlier gestational ages accounting for the overall incidence of heterotopic pregnancy increasing significantly to ~1: 3900 pregnancies. References Heterotopic pregnancy symptoms are often vague and can mirror those of other obstetric and gynecological conditions. Symptoms may include vaginal bleeding, abdominal or pelvic pain, presence of pelvic mass, and enlarged uterus. Due to the presence of an IUP on early imaging many heterotopic pregnancies are missed originally and are often not diagnosed until a more advanced gestational age, averaging around 16 weeks. Unfortunately, with the advancing gestational age brings a higher incidence of rupture and hemodynamic instability at the time of diagnosis. If clinical suspicioun is low, after identifying an intrauterine pregnancy, the ectopic pregnancy may be falsely labeled a corpus luteum cyst. However, advanced ectopic gestations containing a yolk sac or fetal pole with cardiac activity make this diagnosis easier to make. Similarly, the presence of free fluid within the abdomen may be a sign of tubal rupture, but also may be falsely labeled ascites associated with ovarian hyperstimulation syndrome. Unfortunately, HCG levels are not useful in diagnosing heterotopic pregnancy as they reflect primarily the IUP.

Figure 2 Transvaginal ultrasound showing left complex complex mass with central hypoechogenicity, peripheral 'ring of fire' vascularity

Figure 1 Transvaginal ultrasound showing intrauterine gestation with CRL measuring 7 1/7 weeks

INTRAOPERATIVE FINDINGS

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Figure 3 Left fallopian tube with ectopic pregnancy, and hemoperitoneum

Figure 4 Partially ruptured left ectopic pregnancy

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Figure 6 Pelvis status post left salpingectomy removal of ectopic pregnancy, normal right fallopian tube, ovary, and uterus

Figure 5 Another view of partially ruptured left ectopic pregnancy

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