Spontaneous Heterotopic Pregnancy in Natural Conception: A Case Report

Abstract Category: Practice Innovation / Evidence-Based Practice Purpose: Heterotopic pregnancy (HP) is the concurrent development of an intrauterine pregnancy and an ectopic pregnancy. It is associated with significant risk of maternal and fetal morbidity and mortality, it can even increase the maternal mortality risk up to 90 times greater than that of a normal intrauterine pregnancy when the ectopic is implanted in the abdomen. The incidence of HP is not uncommon and it ranges from 1 in 30,000 pregnancies in natural conception cycles and can go up to 1 in 3900 pregnancies because of invent of assisted reproduction techniques (ART). Current case is relatively rare case of heterotopic pregnancy in a patient with natural conception, who also reported a strong family history of multiple gestation pregnancies. Patient was born as a product of twin pregnancy as well. Findings: 28 year old Hispanic White nonsmoker female with PMH of liposuction of abdomen and tonsillectomy, presented to emergency room (ER) with complaint of sever abdominal pain, dyspnea associated with chest pressure, and pelvic pain. At presentation, patient stated that she is 7 weeks pregnant. Family history later explored was significant for multiple gestation in her grandmother, mother, and her sister. Quantitative hCG was 111,360.0 MIU/ML. TV US showed heterotopic pregnancy. Since this was a desired pregnancy, patient opted to preserve intrauterine pregnancy (IUP) despite risks and to proceed with removal of ruptured ectopic. Laparoscopy with right partial salpingectomy, lysis of adhesions and evacuation of hemoperitomeum was performed successfully. Uterus was not explored in order to keep IUP alive. Patient was discharged home in a stable condition on post op day 1 in stable condition. Patient had to visit ER again in next couple of days with complaint of vaginal bleeding. Stat TV US confirmed abortion with no intrauterine cardiac activity. Dilatation and Curettage was performed. Discussion: HP poses unique therapeutic challenges, as its clinical presentation can easily be confused with other normal and abnormal pregnancy manifestations. Management include least invasive therapy to remove tubal pregnancy and preserve the IUP as systemic medical therapy such as methotrexate is contraindicated in the presence of a viable intrauterine gestation. Although the incidence of HP has increased tremendously over the last decade because of assisted reproduction techniques (ART), yet the other possible causes of heterotopic pregnancy should not be ignored in clinical practice. According to U.S. statistics, about two-thirds of the increase in the twin birth rate in the last three decades is likely associated with assisted reproductive technology (ART) and non-ART infertility treatments and rest of one third could be related to other factors including family history of multiple gestation in father and mother side, use of hormones, diet, and race. Implications for Practice: Current study signifies the importance of collecting family history of multiple gestations in child bearing age women and counseling them accordingly regarding the potential benefits and risks of multiple gestations. Women with multiple gestations are at increased risk of complications and adverse pregnancy outcomes. This can have a significant psychosocial and economic impact on women and the families requiring emotional and psychological support. The role of a family physician can be crucial in alleviating such emotional burden and improving the quality of life in these women and families