Triplet heterotopic pregnancy following ovulation induction with clomiphene citrate: a case report and review of literature

Heterotopic pregnancy, though rare is a combined pregnancy in which synchronous intrauterine and extra uterine pregnancy occur. An estimated incidence of between 1/8000 to 1/30,000 has been reported following spontaneous conception. After artificial reproductive techniques, the incidence is as high as 1/100 and after ovulation induction with clomiphene citrate, it is around 1/900. We are reporting a case of 26 year old gravida 2 who conceived after ovulation induction with clomiphene citrate and presented to the emergency department with acute abdominal pain. Ultrasound pelvis showed viable twin intrauterine gestation of 8 weeks along with ruptured ectopic pregnancy on the right tube. After stabilizing the patient, emergency laparotomy and right salpingectomy was performed. Fortunately, the intrauterine twin fetuses grew satisfactorily and patient was delivered by caesarean section at 36 weeks in view of previous lower segment caesarean section with preterm labour. Heterotopic pregnancy must be considered in a patient with amenorrhea, abdominal pain, adnexal mass and enlarged uterus particularly, conception following artificial reproductive techniques or fertility drugs, even though the intrauterine pregnancy has been documented. A high index of suspicion is important to avoid maternal morbidity, sometimes mortality and loss of intrauterine pregnancy