Apstrakt
Background: Heterotopic pregnancy occurs when both intrauterine and ectopic pregnancies coexist simultaneously. Its occurrence in natural conception is qui t e rare , howe ve r, i t i s mor e frequently encountered following assisted conception, especially when multiple embryos are transferred [1,2,3]. Diagnosis in its early stage has been reported to be a dilemma due to the concomitant presence of an intrauterine gestation posing significant challenges with
management and clinical outcome [4,5]. Prognosis is noted to vary based on the time of diagnosis and option of management deployed [5], however, live birth rates of about 66.7% have been reported in literature [6]. This case report highlights the clinical
dilemma associated with a heterotopic pregnancy following in vitro fertilization (IVF) in a low-resource setting. Case presentation and management: A 35-year-old G3P1 (1 alive) civil servant who had IVF on account of secondary infertility of 3 years duration.
She had spontaneous vertex delivery of a life female neonate 6 years prior to presentation and left total salpingectomy following ruptured ectopic gestation about 3 years earlier. There was a history of pelvic inflammatory disease on at least 2 occasions. A
hysterosalpingogram (HSG) revealed absent left tube and patent right tube with perifimbrial adhesions. She had IVF using the long protocol. 8 metaphase II oocytes were aspirated and inseminated with her husband’s sperm. She had 2 blastocyts transferred, and a pregnancy test done 2 weeks later was positive. An obstetric scan done at 6 weeks revealed an intrauterine gestation compatible with her date and a concomitant right tubal ectopic gestation. She had transvaginal injection of potassium chloride as part
of conservative management. Resolut ion of the ectopic occurred, however she developed oped right hematosalpinx and persistent lower abdominal pain. She subsequently had a right total salpingectomy at a gestational age of 8 weeks. She continued luteal support till 14 weeks and pregnancy remained +1
Reference
Chen TS, Wu MH. Heterotopic pregnancy after
in vitro fertilization in a patient with distal tubal
hypoplasia. Gynecol Minim Invasive Ther. 2017
Oct-Dec;6(4):217-218.
Yu Y, Xu W, Xi e Z, Hu a ng Q a nd Li S.
Management and outcome of 25 heterotopic
pregnancies in Zhejiang, China. Eur J Obstet
Gynecol Reprod Biol. 2014 Sep;180:157-161.
Barrenetxea G, Barinaga-Rementeria L, Lopez
de Larruzea A, et al. Heterotopic pregnancy:
two cases and a comparative review. Fertil Steril.
Fe b; 87( 2) : 4 17. e 9-1 5. doi : 10 . 101 6/
j.fertnstert.2006.05.085
Net MAC, Novais IG, Maia SF, et al. Heterotopic
p r e gna n c y a f t e r i n v i t r o f e r t i l i z a t i o n /
intracytoplasmic sperm injection: case report.
Obstet Gynecol Int J. 2018;9(6):480 481. DOI:
15406/ogij.2018.09.0039
Jeon JH, Hwang YI, Shin IH, et al. The Risk
Factors and Pregnancy Outcomes of 48 Cases
of Heterotopic Pregnancy from a Single Center.
J Korean Med Sci. 2016 Jul;31(7):1094-1099.
Soriano D, Vicus D, Schonman R, et al. Longterm
outcome after laparoscopic treatment of
het er ot opi c pregnancy: 19 cas es. J Mi ni m
Invasive Gynecol. 2010 May-Jun;17(3):321-4.
doi: 10.1016/j.jmig.2010.01.016.
Eom JM, Choi JS, Ko JH, et al. Surgical and
obstetric outcomes of laparoscopic management
for women with heterotopic pregnancy. J Obstet
Gynaecol Res. 2013 Dec;39(12):1580-1586.
Lin CK, Wen KC, Sung PL, et al. Heterotopic
triplet pregnancy with an intrauterine, a tubal, and
a cervical gestation following in vitro fertilization
and embryo transfer. Taiwan J Obstet Gynecol.
Jun;52(2):287-289.
Li JB, Kong LZ, Yang JB, et al. Management of
Heterotopic Pregnancy: Experi ence From 1
Tertiary Medical Center. Medicine (Baltimore).
01 6 Fe b; 9 5( 5) : e 25 70 . do i : 1 0. 1 09 7 /
MD.0000000000002570.
Lautmann K, Staboulidou I, Wüstemann M, et
al . He t e r ot opi c pr e gnancy: s i mul t a ne ous
intrauterine and ectopic pregnancy following IVF
tr eat ment with the birth of a healthy chil d.
Ultraschall Med. 2009 Feb;30(1):71-73.
Nabi U, Yousaf A, Ghaffar F, Sajid S and Ahmed
MMH. Heterotopic Pregnancy - A Diagnostic
Challenge. Six Case Reports and Literature
Review. Cureus. 2019 Nov 5;11(11):e6080. doi:
7759/cureus.6080.
Roj ansky N and Schenker J G. Heterotopi c
pregnancy and assisted reproduction—an update.
J Assist Reprod Genet. 1996 Aug;13(7):594-601.
doi: 10.1007/BF02066615.
Shavit T, Paz-Shalom E, Lachman E, Fainaru O
and Ellenbogen A. Unusual case of recurrent
h e t e r o t op i c p r e gna n c y a f t e r bi l a t e r a l
salpingectomy and literature review. Reprod
Biomed Onli ne. 2013 Jan;26(1):59-61. doi:
1016/j.rbmo.2012.10.006.
Alptekin H and Dal Y. Heterotopic pregnancy
following IVF-ET: successful treatment with
sal pi ngost omy under spinal anest hesia and
continuation of intrauterine twin pregnancy. Arch
Gynecol Obstet. 2014 Apr;289(4):911-914.
Yovich JL, McColm SC, Turner SR and Matson
PL. He t e r ot o pi c pr e gna nc y f r om i n vi t r o
fertilization. J In Vitro Fert Embryo Transf. 1985
Sep;2(3):143-50. doi: 10.1007/BF01131502.
Abdalla HI, Ahuja KK, Morris N and Lynn J.
Combined i nt ra-abdominal and int rauterine
pregnancies after gamete intrafallopian transfer.
Lancet . 1986 Nov 15; 2(8516) : 1153-4. doi:
1016/s0140-6736(86)90551-9.
Sal omon LJ , Fe r na nde z H, Cha uve aud A,
Do u me r c S a nd Fr yd ma n R. Su c c e s s f u l
management of a heterotopic Caesarean scar
pregnancy: potassium chloride injection with
preservation of the intrauterine gestation: case
report. Hum Reprod. 2003 Jan;18(1):189-891.
Wang X, Ma D, Zhang Y, et al. Rare heterotopic
pregnancy after frozen embryo transfer: a case
report and literature review. BMC Pregnancy
Childbirth. 2020 Sep 17;20(1):542.
Obajimi GO, Balogun FO, Nwose U and Obajimi
OM. Ri ght a mpu l l a r y e c t opi c pr e gn a nc y
following bilateral tubal ligation using spring clips.
Ann Ib Postgrad Med. 2013 Dec;11(2):34-36.
Luo X, Lim CE, Huang C, et al. Heterotopic
pregnancy following in vitro fertilization and
embryo transfer: 12 cases report. Arch Gynecol
Obstet. 2009 Aug;280(2):325-329.
Franco JG Jr, Martins AM, Baruffi RL, et al.
Best site for embryo transfer: the upper or lower
half of endometrial cavity? Hum Reprod. 2004
Aug;19(8):1785-90.
Sent i l hes L, Boue t PE, Gr omez A, e t al .
Successful expectant management for a cornual
he t e r ot opi c pr e gnanc y. Fe r t i l St e r i l . 2009
Ma r ; 9 1( 3) : 9 3 4. e 11 - 3 . d o i : 1 0. 1 01 6 /
j.fertnstert.2008.09.072
Georgiou EX, Domoney C, Savage P and Stafford
M. Het er ot opic abdomi nal pregnancy wi t h
persistent trophoblasti c t issue. Acta Obst et
Gynecol Scand. 2011 May;90(5):551-553.
Ugur l u c a n FG, Ba s t u E, Doga n M, e t al .
Kalelioglu I, Alanya S, Has R. Management of
cesarean heterotopic pregnancy with transvaginal
ultrasound-guided potassium chloride injection
and gestational sac aspiration, and review of the
literature. J Minim Invasive Gynecol. 2012 SepOct;19(5):671-673.
Melendez J, Paraskevopolou SM, Foo X and Yoong
W. Heterotopic pregnancy: tubal ectopic pregnancy
with a viable IVF intrauterine pregnancy. J Obstet
Gynaecol. 2010;30(7):742-743.