Successful Pregnancy Outcome in a Heterotopic Abdominal Pregnancy A Case Report

Backgrounds: Heterotopic pregnancy is the existence of both intrauterine pregnancy and ectopic pregnancy simultaneously. Het- erotopic pregnancy (HP) has been a rare type of multifetal pregnancy. Heterotopic abdominal pregnancy (HAP) is a very rare diag- nosis with very few reported cases.Case Presentation: We reported a rare case of HAP in a 32-year-old woman (G2L1) with a history of 13 weak amenorrhea and mild pelvic pain presenting with two live fetuses in the 13th week. The patient also did not mention any risk factor of ectopic pregnancy such as pelvic inflammatory disease, assisted reproductive techniques, endometriosis, and multiparity. Diagnosis of HAP was per- formed with the use of sonography and magnetic resonance imaging. We managed the patient with emergency laparotomy due to acute abdominal pain a few hours after admission. Laparotomy revealed the rupture of the left fimbria with 500 cc hemoperi- toneum. The excision of the ectopic gestational sac in the cul-de-sac and left salpingectomy with preserving the intrauterine fetus was performed. The patient finally gave birth to one live term birth.Conclusions: Physicians should consider the possibility of HP in women with spontaneous pregnancy and abdominal pain. Both sonography and MRI should be performed to help timely diagnosis. Keywords:Abdominal Pregnancy, Ectopic Pregnancy, Heterotopic Pregnancy, Live Birth .Material and Method: CASE PESENTATIONA 32 –year-old woman G2L1 with a sonography based on 13w+3d twin pregnancy with an alive fetus in uterine cavity and another in abdominal cavity was referred to our hospital for termination the heterotopic (abdominal) pregnancy. She had a transvaginal sonography in 7th weeks of pregnancy with single alive 7 weeks embryo in uterine cavity and in 13th weeks in screening sonogram a heterotopic pregnancy was reported. A magnetic resonance imaging was done and confirm the diagnosis[fig1].in admitted period for elective surgery she suddenly presented an acute abdomen with nausea and vomiting, heart rate was 104 and blood pressure was 100/60,in abdominal examination she had rebound tenderness, Her hemoglobin at the time of admission was 10 and after this situation became9.7; so, emergency laparotomy was done. After midline incision about 300cc blood and 100cc clot was suctioned and after abdominal exploration a 12 weeks large uterus with normal right tube and both ovaries was seen ,in posterior cul de sac there was a gestational sac with alive fetus and adherent and ruptured left fimberia. After bringing out the pregnancy conception[figure2] left salpingectomy was done, and bleeding area sutured and again the pelvic cavity explored for any remnant conception and one unit packed cell was transfused during operation. After the operation fetal heart beat of intrauterine fetus was checked and it was normal. of no wasting time the patient wasn’t in shock before laparotomy .after operation she was stable without any contraction her hemoglobin was 8.5. few a days after good condition she was discharged. Fortunately she gave birth her child in 36w +4d without any problem .Result: Two implantation sites for pregnancy, one in uterine cavity ,the other in ectopic places like fallopian tube ,abdomen, spleen, cervical ,broad ligament, ovarian Is called heterotopic pregnancy with prevalence of 1 in 30,000 pregnancy (1).It is still a question whether abdominal pregnancyishappened when fertilization of sperm and ovum, with primary implantation in the abdomen or a result of a tubal abortion(5,6). Risk factors for abdominal pregnancy include, pelvic inflammatory disease, , tubal damage, assisted reproductive techniques, endometriosis and multiparity(8).This kind of pregnancy has critical type of complications. Patients present late because of live fetus in uterine cavity and limited usefulness of HCG titration.In this condition, different sites of implantation causes different signs and symptoms, like acute abdomen, vaginal bleeding, abdominal pain because of fetal movement, bowel obstruction(8). Heterotopic pregnancy is difficult to diagnose and need awareness and attention of sinologist . If sonography facilities couldn’t help, Magnetic Resonance Imaging will be a good method(9)..there are many types of terminationin ectopic embryo or fetus of heterotopic pregnancy: surgical, medical and expectant management .the administration of potassium chloride, methotroxate and hyperosmolar glucose is a nonsurgical(10), that depending on the implantation site , gestational age and surgeon experience the choice could be different. The goal of surgical intervention is to remove the extrauterine pregnancy without injury to normal intrauterine fetus(11*).In surgical method the key is removing placenta, because bleeding from implantation site can lead to life-threatening maternal hemorrhage. if it remains in placental site ,ligating the umbilical cord.After this choice the patient can be followed without further intervention or using arterial embolization or methotrexate (8).The other important aspect of these pregnancies is increased risk for spontaneous abortion of intra uterine one;The main principle duringsurgery is attention to maternal bleeingwith caring of the intrauterine pregnancy and minimal manipulation of the uterus. Intrauterinepregnancy is expected to develop normally.Conclusion: In conclusion, physicians should consider the possi- bility of HP in pregnant women with abdominal or pelvic pain and both sonography and MRI should be performed In such a case, the bimanual examination should not be in the first line plan. If a bimanual examination is required to perform, it should be done cautiously and gently because it may lead to severe bleeding. In our case, this might happen and lead to acute abdominal bleeding.