Heterotopic pregnancy

Heterotopic Cesarean Scar Pregnancy: A Case Report

Heterotopic pregnancy is a rare condition with an intrauterine pregnancy coexisting with extrauterine pregnancy. It is considered a rare condition, with an incidence of one in 30,000 spontaneous pregnancies. Because of its rarity, there are no international management guidelines. It is associated with increased maternal morbidity and mortality. Heterotopic pregnancy is a challenging condition to diagnose because it can be missed due to the intrauterine pregnancy. The most common signs and symptoms to support and help us reach a diagnosis would be adnexal mass, abdominal pain, and enlarged uterus. In this case report, we aim to compare the clinical course and the outcome of intrauterine gestation while coexisting with scar pregnancy and the management options. This case report concerns a 34-year-old pregnant woman with a heterotopic pregnancy managed in Bahrain Defence Force Hospital.

A Spontaneous Tubal Heterotopic Triplet Pregnancy Resulting in Viable Twin Deliveries

There are limited U.S. reports of spontaneous triplet heterotopic pregnancies discussing both maternal and fetal outcomes. A 34-year-old patient at 7 weeks of gestation presented to the emergency department with abdominal pain. She was diagnosed with a spontaneous heterotopic triplet pregnancy, consisting of a twin monochorionic-diamniotic intrauterine gestation and a ruptured left ectopic pregnancy. She underwent a laparoscopic unilateral salpingectomy. Her antepartum course was complicated by gestational diabetes mellitus and fetal growth restriction. Delivery of liveborn twins was via a cesarean delivery at 32 weeks. Timely intervention and management of a ruptured spontaneous triplet heterotopic pregnancy can result in a viable twin delivery with overall favorable maternal and newborn outcomes, although long-term implications due to prematurity and other twin sequelae exist.

Study on diagnosis and management strategies on heterotopic pregnancy: a retrospective study

Heterotopic pregnancy (HP) is a rare but potentially life-threatening event with a high risk of maternal death, which also jeopardise the coexisting intrauterine pregnancy (IUP), thus an early accurate diagnosis and prompt treatment can decrease adverse complications. We aimed to explore the early predictors for pregnancy outcomes of HP. We reviewed patients with HP following assisted reproductive technology in our institution between January 2013 and December 2020. The relationships between pregnancy outcomes and clinical features were analysed by logistic regression. We found that 29 patients (72.5%) of HP were accurately diagnosed by transvaginal ultrasonography (TVS). Eighteen patients in the surgery group had live births, three of whom delivered preterm. Additionally, the miscarriage rate was lower for patients with IUP cardiac activity than those without (16.7% vs. 90.0%, p < .001). Further by logistic regression analysis, an IUP with cardiac activity at HP diagnosis was identified as favourable independent predictor of live birth (p < .001). Therefore, early diagnosis and prompt surgical intervention are recommended to prevent the development of HP.Impact of statementWhat is already known on this subject? Heterotopic pregnancy (HP) has long been thought to be a rare but potentially life-threatening event with a high risk of complications. The early diagnosis of HP is challenging due to the co-existence of a viable intrauterine pregnancy (IUP) and the absence of typical clinical symptoms.What do the results of this study add? This stduy showed that symptoms combined with routine transvaginal ultrasonography (TVS) scans reduce the rates of misdiagnosis of HP and prompt surgical intervention after diagnosis may minimise the incidence of miscarriage of the IUP.What are the implications of these findings for clinical practice and/or further research? An IUP with cardiac activity at HP diagnosis is a predictor of a favourable prognosis of HP, and laparoscopy under general anaesthesia is effective and safe during the first trimester of pregnancy. Awareness, assessment and early interventions in view of symptoms combined with routine TVS is recommended to reduce the risk of miscarriage and ensure a favourable live birth rate.

Spontaneous Heterotopic Pregnancy: A Case Report

Spontaneous heterotopic pregnancy is a rare clinical condition which is a potentially dangerous condition where at least two pregnancies are present simultaneously at different implantation sites and only one is located in the intrauterine cavity. It is a life-threatening condition with an incidence estimated as 1 in 30,000 natural conceptions. Being rare it's challenging to diagnose such conditions due to complex clinical and laboratory findings. In view of the survival of maternal as well as intrauterine pregnancy, a high index of suspicion leading to timely diagnosis and appropriate intervention is needed. We are reporting a case of a 28-year-old female with heterotopic pregnancy at 8 weeks of gestation following natural conception diagnosed by ultrasound and managed successfully by laparoscopic salpingectomy. Intrauterine pregnancy was continued normally till term with no complications. Hence, with timely diagnosis and early intervention, maternal and fetal survival is possible.

Keywords

case reports; ectopic pregnancy; laparoscopy; ultrasound.

Association of menstrual blood volume and reproductive outcomes in patients with caesarean scar pregnancy managed using uterine artery embolization and curettage

This study aimed to assess the association of menstrual blood volumes (MBV) and reproductive outcomes in patients after uterine artery embolization (UAE) combined with curettage for caesarean scar pregnancy (CSP). This retrospective observational study enrolled women who underwent UAE plus curettage for CSP at the Interventional Department of Henan Provincial People's Hospital between December 2012 and December 2017. The primary outcome was pregnancy rate and the secondary outcomes were live birth rate (LBR) and interpregnancy interval. This study finally included 37 women (16 women with normal MBV and 21 women with decreased MBV) with pregnancy intention after UAE plus curettage for CSP. The pregnancy rate in women with normal MBV was higher than those with decreased MBV (81.3% vs. 47.6%; P = 0.048). There were no differences between the two groups regarding the interpregnancy interval (18.4 ± 8.7 vs. 22.2 ± 10.0 months, P = 0.233), and LBR (63% vs. 38%, P = 0.191). In conclusion, Women with normal MBV after UAE combined with curettage for CSP management might have a higher pregnancy rate compared with patients with decreased MBV, but there were no differences in LBR between the two groups.

Heterotopic pregnancy with superfetation following ovarian stimulation: A case report

Heterotopic pregnancy (HP) is a rare phenomenon. Despite its rarity, there has been a notable increase in its incidence in recent decades due to the greater use of in vitro fertilization (IVF). However, information about the relation between ovarian stimulation and HP is scarce. We report a case of HP after ovarian stimulation using clomiphene citrate. A 26-year-old pregnant woman presented to the emergency department with mild vaginal bleeding, and abdominal pain. She had a history of pelvic inflammatory disease (PID) and left salpingectomy due to a previous ectopic pregnancy. She had undergone ovarian stimulation with clomiphene citrate three months earlier. Transvaginal ultrasound revealed an eight-week-old ruptured tubal pregnancy with an intrauterine ten-week-old gestational sac confirming superfetation HP. An urgent laparoscopic right salpingectomy was performed and the extrauterine pregnancy was successfully removed with the preservation of the intrauterine embryo. The course of the intrauterine pregnancy was uneventful and the patient gave birth to a healthy boy via cesarean section. Women receiving ovarian stimulation are at an increased risk of developing HP especially when they also have other predisposing factors for HP. Thus, close monitoring using transvaginal ultrasound with extra attention to the adnexa is required for a timely diagnosis and management of HP.

Quadruplet Heterotopic Pregnancy Following In Vitro Fertilization and Embryo Transfer with Laparotomic Removal of Ruptured Twin Tubal Ectopic Pregnancy: A Case Report

Heterotopic pregnancy (HP) is a rare occurrence in natural pregnancies. However, it can be a life-threatening condition and should be taken into account in all assisted reproductive treatments. Diagnosis and treatment of ectopic pregnancy are challenging issues in patients with HP. Here, we report a rare case of quadruplet HP following an in vitro fertilization-embryo transfer with a viable twin intrauterine pregnancy and ruptured live twin left tubal ectopic pregnancy. A 35-year-old woman (gravida 5, para 1, ectopic pregnancies 2, and abortion 1) was presented to the Emergency Department of Arash Women's Hospital (Tehran, Iran) in March 2021 with abdominal pain. The patient was at six weeks and five days of pregnancy following in vitro fertilization-embryo transfer. Transvaginal sonography (TVS) revealed a live twin intrauterine pregnancy with a ruptured live twin left tubal ectopic pregnancy. The latter was removed via laparotomy to preserve the intrauterine pregnancy. The patient subsequently delivered a female infant at 38 weeks of pregnancy.

Management of heterotopic pregnancy: clinical analysis of sixty-five cases from a single institution

Objective

This retrospective study aims to analyze the influence of different treatment modalities on viable intrauterine pregnancy and to summarize the clinical features of heterotopic pregnancy (HP) patients.

Material and methods

All patients diagnosed with HP between January 2012 and December 2022 in Tianjin Central Obstetrics and Gynecology Hospital were reviewed retrospectively.

Results

This study diagnosed 65 patients using transvaginal ultrasound (TVS), including two cases of natural pregnancy, seven cases of ovulation induction pregnancy, and 56 cases after in vitro fertilization and embryo transfer (IVF-ET). The gestational age was 50.2 ± 13.0 days at the time of diagnosis. The most frequent manifestations were abdominal pain (61.5%) and vaginal bleeding (55.4%), while 11 patients (16.9%) had no symptoms before the diagnosis. The primary treatment was expectant and surgical management, including laparotomy and laparoscopic surgery. In the expectant management group, four patients were transferred to surgery due to rupture of ectopic pregnancy or ectopic pregnancy mass gradually enlarged. In the surgical management group, 53 patients underwent laparoscopic surgery, and six underwent laparotomy. The laparoscopic group's mean operation time was 51.3 ± 14.2 min (range: 15-140 min), and the median intraoperative blood loss was 20 mL (range 5-200 mL). In contrast, the laparotomy group's mean operation time was 80.0 ± 25.3 min (range 50-120 min), and the median intraoperative blood loss was 22.5 mL (range 20-50 mL). Four patients had postoperative abortions. Sixty-one newborns had no birth abnormalities, and no developmental malformations were discovered after a median follow-up of 32 months.

Conclusion

Expectant treatment has a high failure rate in HP, and laparoscopic surgery is a safe and effective treatment for removing ectopic pregnancy without increasing the risk of abortion or newborn birth defects.

Heterotopic Pregnancy: Case Series and Review of Diagnosis and Management

Introduction

Heterotopic pregnancy (HP) refers to the simultaneous presence of intrauterine pregnancy (IUP) and ectopic pregnancy, which is very rare but potentially life-threatening. The spontaneous incidence of HP in the general population is 1/30,000. With the widespread use of assisted reproductive technology (ART), the incidence rises to 1/1,000. Aims and Methods. This is a prospective case series looking at the cases of heterotopic pregnancies presenting to the early pregnancy unit (EPU) in a tertiary maternity hospital, from November 2015 to November 2016. The clinical presentation, ultrasound findings, and laparoscopy findings were all documented. The incidence of HP was calculated and compared with the quoted incidence in the literature. Outcomes. Five women with HP presented to the EPU over the course of a year. The first case describes a spontaneous HP with a previous salpingostomy. The second case describes an HP following ovulation induction. The third case describes a spontaneous HP with no known risk factors. The fourth and fifth cases describe heterotopic pregnancies following in vitro fertilisation with more than one embryo. All five cases of HP underwent laparoscopy and salpingectomy with uneventful recovery. The three women who had a viable IUP had no further complications in their pregnancies.

Conclusion

Early and accurate diagnosis of HP can be challenging. An early transvaginal ultrasound plays an important role in making the diagnosis in women with risk factors and following ART. A high index of suspicion is required for timely diagnosis and appropriate intervention, especially in spontaneous HP.

Successful Ultrasound-Guided Methotrexate Intervention in the Treatment of Heterotopic Interstitial Pregnancy: A Case Report and Literature Review

PURPOSE

This study aims to share the experience of minimally invasive ultrasound-guided methotrexate intervention in the treatment of heterotopic interstitial pregnancy (HIP) with good pregnancy outcomes, and to review the treatment, pregnancy outcomes, and impact on the future fertility of HIP patients.

METHODS

The paper describes the medical history, clinical manifestations, treatment history, and clinical prognosis of a 31-year-old woman with HIP, and reviews cases of HIP from 1992 to 2021 published in the PubMed database.

RESULTS

The patient was diagnosed with HIP by transvaginal ultrasound (TVUS) at 8 weeks after assisted reproductive technology. The interstitial gestational sac was inactivated by ultrasound-guided methotrexate injection. The intrauterine pregnancy was successfully delivered at 38 weeks of gestation. Twenty-five HIP cases in 24 studies published on PubMed from 1992 to 2021 were reviewed. Combined with our case, there were 26 cases in total. According to these studies, 84.6% (22/26) of these cases were conceived by in vitro fertilization embryo transfer, 57.7% (15/26) had tubal disorders, and 23.1% (6/26) had a history of ectopic pregnancy; 53.8% (14/26) of the patients presented with abdominal pain and 19.2% (5/26) had vaginal bleeding. All cases were confirmed by TVUS. In total, 76.9% (20/26) of intrauterine pregnancies had a good prognosis (surgery vs. ultrasound interventional therapy 1:1). All fetuses were born without abnormalities.

CONCLUSIONS

The diagnosis and treatment of HIP remain challenging. Diagnosis mainly relies on TVUS. Interventional ultrasound therapy and surgery are equally safe and effective. Early treatment of concomitant heterotopic pregnancy is associated with high survival of the intrauterine pregnancy.

Middle-East obgyn graduate education (MOGGE) foundation practice guidelines: diagnostic approach to pregnancy of unknown location: practice guideline no. 03-O-21

Background

Pregnancy of unknown location (PUL) is a term used to describe failure of visualization of intrauterine or extrauterine gestational sac in a woman with a positive pregnancy test.

Body of the abstract

Ectopic pregnancy (EP) accounts for 1–2 % of all pregnancies. EP contributes to maternal mortality of a known cause by 4% in developed countries. However, case fatality rate may be 10 times higher in low-resource countries. This may be attributed to delayed diagnosis and lack of resources. PUL is a temporary term that may eventually lead to diagnosis of viable intrauterine pregnancy, pregnancy loss, or more seriously, EP.

Conclusion

This guideline appraises current evidence on assessment of PUL and early diagnosis of EP particularly in low-resource settings.

Adnexal masses during pregnancy: diagnosis, treatment, and prognosis

Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. Although most adnexal masses in pregnancy can be safely observed and approximately 70% spontaneously resolve, a minority of cases warrant surgical intervention because of symptoms, risk of torsion, or suspicion of malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy because of accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis Simple Rules, and International Ovarian Tumor Analysis Assessment of Different NEoplasias in the adneXa scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant vs surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible because of consistently demonstrated shorter hospital length of stay and less postoperative pain and some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, preterm birth, and low birthweight. The best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester of pregnancy, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12 to 15 mm Hg, intraoperative maternal capnography, pre- and postoperative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxes. Although planning surgery for the second trimester of pregnancy generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed because of gestational age. When performed at a facility with appropriate obstetrical, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for pregnant patients and fetuses.

Daily variations and levels of human chorionic gonadotropin before methotrexate treatment as predictors of treatment success

AIM

The aim of this study is to investigate the role of human chorionic gonadotropin (hCG) daily variations and levels prior to methotrexate treatment as predictors for treatment outcome.

METHODS

This retrospective study included patients who had a sonographically confirmed ectopic pregnancy at the International Peace Maternity and Child Health Hospital between November 2015 and June 2020. The associations of hCG levels and daily variations with the treatment success were evaluated by multivariable logistic regression and receiver operator characteristic (ROC) curve. Establish a nomogram that predicts how methotrexate (MTX) therapy will turn out. The performance of the model was assessed utilizing concordance index, receiver operating characteristic curves, and calibration plots.

RESULTS

The median serum hCG levels before treatment and hCG daily variation in the failure group were higher than those in the success group (487.8 vs. 270.7 IU/L, -1.86% vs. 7.29%, both p < 0.01). According to the ROC curve analysis, the cutoff values of serum hCG level before treatment and daily variations were 617.35 IU/L and 1.76%/day. By multivariable logistic regression analysis, serum hCG levels before treatment (odds ratio [OR]: 1.001, 95% confidence interval [CI]: 1.000 ~ 1.001) and hCG daily variations were independently associated with the treatment success (OR: 1.033, 95% CI: 1.015 ~ 1.052). The nomogram was effective at predicting the outcome of MTX treatment with a receiver operating characteristic area under the curve of 0.717 (p < 0.001). The nomogram's calibration curve was almost parallel to the ideal diagonal line.

CONCLUSION

We successfully created a nomogram based on serum hCG levels before treatment and hCG daily changes to anticipate the result of MTX therapy, which could assist medical professionals in selecting therapeutic schedule for patients with tubal pregnancies.

Spontaneous Heterotopic Pregnancy: Diagnosis and Management

Background

Heterotopic pregnancies albeit rare are conceivably life-threatening if missed. With the development of assisted reproductive techniques, the incidence has increased. Confirmation of an intrauterine pregnancy (IUP) should not preclude the existence of a heterotopic pregnancy.

Case

A healthy 27-year-old patient (gravida 4, term 1, preterm 0, abortion 2, living 1) at approximately 5 weeks gestation through natural conception presented to the emergency room with acute abdominal pain and vaginal bleeding. Pelvic ultrasound showed evidence of an IUP and a right adnexal mass, raising suspicion for a heterotopic pregnancy. The patient underwent an uncomplicated laparoscopic right salpingectomy. An IUP was confirmed on ultrasound postoperatively. The patient had an early pregnancy loss at 8 weeks of gestation.

Conclusion

With a high index of suspicion from clinical presentation and pelvic imaging, heterotopic pregnancy, while rare, should not be ruled out.

Should expectant management of heterotopic pregnancy be considered?

KEY MESSAGE

Both expectant and interventional managements are acceptable in selected cases, when heterotopic pregnancy is diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

PURPOSE

Heterotopic pregnancy, though relatively rare, is potentially a life-threatening condition. The aim of the study is to compare expectant versus interventional management of heterotopic pregnancies.

METHODS

This is a retrospective cohort study including all women diagnosed with heterotopic pregnancy on ultrasound from March 2011 to December 2020 in a single medical center. Expectant and interventional management outcomes were compared. Primary outcome was defined as live birth.

RESULTS

Forty-one women were diagnosed with heterotopic pregnancy during the study period. Management was expectant in 10 (24.4%) and interventional in 31 (75.6%) of the women. Expectant management was considered when the patient was stable, and the attending physician decided that the ectopic pregnancy did not continue to develop. Interventions included laparoscopic salpingectomy (n = 26), laparoscopic cornual resection (n = 2), laparotomic cornual resection (n = 1) and gestational sac aspiration (n = 2). The intra-uterine pregnancy continued to develop in 6 (60.0%) and 22 (81.5%) of the women in the expectant and interventional groups, respectively (p = 0.52). All women managed expectantly reached term delivery, as opposed to 17/22 (77.3%) in the intervention management group (p = 0.60). Multivariate analysis found serum β-hCG level as the only independent parameter associated with ongoing pregnancy rate (B = 0.001, p = 0.04).

CONCLUSIONS

Both expectant and interventional management were found to be acceptable when heterotopic pregnancy was diagnosed, with high ongoing intra-uterine pregnancy rate and term deliveries.

Heterotopic pregnancy after bilateral salpingectomy, IVF and multiple embryos transfer. A case report and systematic review of the literature

Heterotopic pregnancy after bilateral salpingectomy is an extremely rare complication of in vitro fertilisation/embryo transfer cycles. We report a case of a ruptured abdominal pregnancy on the omentum which was the stimulus to conduct the first systematic review on this complication according to 'PRISMA' guidelines (PROSPERO R.No CRD42020134104). PubMed, EMBASE and OpenAIRE databases were systematically reviewed for studies reporting (a) cases or case series of, (b) heterotopic pregnancies after, (c) prior bilateral salpingectomy, and (d) embryo transfer cycles. Twenty-two articles met the selection criteria including, with our case, 28 cases. Based on the results, clinical manifestations and laboratory findings can be unspecific or misleading. Transvaginal ultrasound is the main diagnostic tool as the ectopic foetus is more frequently located in the intramural part of the fallopian tubes, the tubal stump or the ovaries. Laparotomy or laparoscopy are the main treatment options with adequate perinatal outcome.

The risk of miscarriage following surgical treatment of heterotopic extrauterine pregnancies

STUDY QUESTION

What is the risk of loss of a live normally sited (eutopic) pregnancy following surgical treatment of the concomitant extrauterine ectopic pregnancy?

SUMMARY ANSWER

In women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine ectopic pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy.

WHAT IS KNOWN ALREADY

Previous studies have indicated that surgical treatment of the concomitant ectopic pregnancy in women with live eutopic pregnancies could be associated with an increased risk of miscarriage. The findings of our study did not confirm that.

STUDY DESIGN, SIZE, DURATION

A retrospective observational case–control study of 52 women diagnosed with live eutopic and concomitant extrauterine pregnancies matched to 156 women with live normally sited singleton pregnancies. The study was carried out in three London early pregnancy units (EPUs) covering a 20-year period between April 2000 and November 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women attended EPUs because of suspected early pregnancy complications. The diagnosis of heterotopic pregnancy was made on ultrasound scan and women were subsequently offered surgical or expectant management.

There were three controls per each case who were randomly selected from our clinical database and were matched for maternal age, mode of conception and gestational age at presentation.

MAIN RESULTS AND THE ROLE OF CHANCE

In the study group 49/52 (94%) women had surgery and 3/52 (6%) were managed expectantly. There were 9/52 (17%, 95% CI 8.2–30.3) miscarriages <12 weeks’ gestation and 9/49 (18%, 95% CI 8.7–32) miscarriages in those treated surgically. In the control group, there were 28/156 (18%, 95% CI 12.2–24.8) miscarriages <12 weeks’ gestation, which was not significantly different from heterotopic pregnancies who were treated surgically [odds ratio (OR) 1.03 95% CI 0.44–2.36]. There was a further second trimester miscarriage in the study group and one in the control group. The live birth rate in the study group was 41/51 (80%, 95% CI 66.9–90.2) and 38/48 (79%, 95% CI 65–89.5) for those who were treated surgically. These results were similar to 127/156 (81%, 95% CI 74.4–87.2) live births in the control group (OR 0.87, 95% CI 0.39–1.94).

LIMITATIONS, REASONS FOR CAUTION

This study is retrospective, and the number of patients is relatively small, which reflects the rarity of heterotopic pregnancies. Heterotopic pregnancies without a known outcome were excluded from analysis.

WIDER IMPLICATIONS OF THE FINDINGS

This study demonstrates that in women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy. This finding will be helpful to women and their clinicians when discussing the options for treating heterotopic pregnancies.

STUDY FUNDING/COMPETING INTEREST(S)

This work did not receive any funding. None of the authors has any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Research Registry: researchregistry6430.

Imaging of complications following treatment with assisted reproductive technology: keep on your radar at each step

Since the advent of assisted reproductive technology (ART), the utilization of ART procedures has become increasingly popular among women seeking to establish pregnancy. Radiologists are therefore likely to encounter the various complications of ART therapy. The most common is ovarian hyperstimulation syndrome; others are multiple, ectopic, and heterotopic pregnancies. Ultrasonography is considered the initial modality to investigate ART complications, However, nonspecific symptoms might need the use of an additional imaging modality, such as computed tomography or magnetic resonance imaging, as a problem-solving tool. This article briefly discusses the steps involved in assisted reproduction. Its aim is to help radiologists become familiarized with the multimodality imaging features of the spectrum of ART-related complications. Their key imaging features and differential considerations are emphasized. This will facilitate the provision of precise and timely diagnoses, and aid the avoidance of fatal consequences.

First trimester heterotopic pregnancy with shock treated laparoscopically, followed by uneventful term pregnancy and normal birth

Heterotopic pregnancy (HP), a coexistence of intrauterine and ectopic pregnancies, is extremely rare. Although there have been many reports of maternal outcomes in pregnant women with HP, they have not described fetal neurodevelopmental outcomes and survival. A 30-year-old Japanese woman in early gestation who had undergone two previous cesarean deliveries was transferred to our hospital with vital signs of shock. HP was confirmed by ultrasonography and laparoscopic surgery, and right salpingectomy was performed. At term, a 2,875 g neonate was delivered via cesarean section without any complications.

The rising incidence of heterotopic pregnancy: Current perspectives and associations with in-vitro fertilization

Heterotopic pregnancy is the simultaneous occurrence of an intrauterine and ectopic pregnancy. This study aims to review the current literature regarding heterotopic pregnancy with a focus on its diagnosis and associations with in-vitro fertilization (IVF). Studies have shown that ovarian hyperstimulation syndrome and multiple embryo transfer during IVF are associated with an increased risk of heterotopic pregnancy. Tubal abnormalities such as pelvic inflammatory disease and previous tubal or abdomino-pelvic surgery have also been identified as risk factors. Diagnosis is challenging as the falsely reassuring presence of an intrauterine fetus frequently delays early intervention. Treatment should be individualised, but is often prompt surgical intervention, and focuses on terminating the ectopic pregnancy while minimizing harm to the mother and intrauterine fetus.

Cervical Twin Heterotopic Pregnancy: Overview of Ectopic Pregnancies and Scanning Detection Algorithm

Background: Ectopic pregnancy is the leading cause of gestation-related deaths during the first trimester. Cervical twin heterotopic pregnancies, when ectopic, constitute a small and rare part of gynecological surgery. Case Presentation: A 30-year-old pregnant woman (gravida 3, para 2) presented with mild pain in the lower abdomen and traces of bleeding per vaginum for three days. Transvaginal ultrasonography revealed a balloon-shaped cervical canal with a visible gestational sac measuring 3.5 × 3.9 cm. A second gestational sac was seen in the uterine cavity. The measurements of the gestational sacs corresponded to 7 + 4 weeks' pregnancy. A decision for medical abortion with mifepristone and misoprostol was made. However, due to an incomplete abortion and continuous bleeding, a curettage was performed. Conclusions: Spontaneous heterotopic pregnancy with the ectopic pregnancy located in the cervix is an extremely rare clinical condition requiring urgent treatment in order to reduce maternal mortality and morbidity and preserve fertility.

Spontaneously conceived heterotopic pregnancy with abdominal pregnancy implanted on the vesicouterine pouch: A case report and literature review

We report the case of a 36-year-old woman with spontaneously conceived heterotopic pregnancy with abdominal pregnancy. She visited the hospital at 5 weeks and 4 days of gestation and transvaginal ultrasonography revealed a normal intrauterine pregnancy. Two days later, she was urgently transported to the hospital due to extreme abdominal pain. Emergent laparotomy was performed to investigate the cause of massive intraperitoneal bleeding, which was confirmed to have been due to an abdominal pregnancy that implanted on the vesicouterine pouch. The hematic mass, including chorionic villi, was successfully removed from the peritoneum. The subsequent course of the intrauterine pregnancy was uneventful and a healthy baby was born at term. To the best of our knowledge, this is an extremely rare case report of a spontaneously conceived heterotopic abdominal pregnancy, in which the intrauterine pregnancy showed a successful outcome despite the collapse of the abdominal pregnancy at a very early stage.

The double corpus luteum: A novel sonographic sign of heterotopic pregnancy

Heterotopic pregnancy is a rare and highly morbid condition with simultaneous intrauterine and extra-uterine pregnancies. The early diagnosis of heterotopic pregnancy is difficult, owing to rarity of the condition and nonspecific clinical and laboratory findings. This case report introduces the "double corpus luteum" sign, a new sonographic and magnetic resonance imaging sign which is easily detectable and should raise the index of suspicion for heterotopic pregnancy. We present a surgically confirmed spontaneous heterotopic and angular pregnancy in a young woman without risk factors or assisted reproductive therapy to illustrate the utility of this novel sign.

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies

OBJECTIVE

To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy.

TARGET POPULATION

All patients of reproductive age.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with positive β-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Spontaneously conceived 17-week heterotopic pregnancy: a challenging and unusual diagnosis

A 37-year-old woman, gravida 2 para 1, arrived in our emergency clinic at 16 2/7 weeks of a spontaneously conceived pregnancy for abdominal pain. She was on oral antibiotics for 2 days to treat a suspected urinary tract infection with no improvement. Blood tests, abdominal ultrasound and intrauterine fetus were all normal. She left our emergency unit with laxatives. Four days later, she returned to our clinic with severe abdominal pain. We repeated abdominal and foetal ultrasonography and identified a left para-uterine 7×5 cm mass. As adnexal torsion was suspected, we performed an emergency laparoscopy. At laparoscopy, we found a left haematosalpinx and realised a left salpingectomy. Histology confirmed the presence of a heterotopic pregnancy (HP). This case illustrates the importance of exploring the adnexa in a gravid woman presenting with abdominal pain in the first and early second trimesters. Although rare, excluding a HP may prevent a life-threatening haemorrhage.

Directive clinique no 414 : Prise en charge des grossesses de localisation indéterminée et des grossesses ectopiques tubaires et non tubaires

OBJECTIF

Fournir un algorithme fondé sur des données probantes pour orienter le diagnostic et la prise en charge de la grossesse de localisation indéterminée et de la grossesse ectopique tubaire ou non tubaire.

POPULATION CIBLE

Toutes les patientes en âge de procréer. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive a pour objectif de bénéficier aux patientes ayant obtenu un résultat positif pour la sous-unité bêta de la gonadotrophine chorionique et de fournir aux médecins un algorithme normalisé pour l'expectative et le traitement pharmacologique ou chirurgical en cas de grossesse de localisation indéterminée et de grossesse ectopique tubaire ou non tubaire. DONNéES PROBANTES: Les termes de recherche suivants ont été entrés dans les bases de données PubMed-Medline et Cochrane en 2018 : cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography et prenatal. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des publications supplémentaires ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Obstétriciens-gynécologues, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

Acute abdomen or life-threatening heterotopic pregnancy with tubal rupture: where does imaging play a role?

Heterotopic pregnancy (HP) is a rare, potentially life-threatening complication of an intrauterine pregnancy with a simultaneous ectopic pregnancy. There is a higher incidence with assisted reproduction techniques (ART) and radiology can be pivotal in its diagnosis. A 28-year-old woman underwent ART and at 7 weeks' gestation presented with acute right iliac fossa pain. Transvaginal ultrasound (US) imaging confirmed a viable intrauterine pregnancy. The patients' pain persisted however, and transabdominal US demonstrated a complex, heterogeneous right adnexal mass. Subsequent magnetic resonance imaging (MRI) confirmed an HP with a ruptured ectopic and haemoperitoneum. Emergency laparoscopic surgery and right salpingo-oopherectomy were performed without complication. We highlight the importance of considering HP as a diagnosis in the acute gravid abdomen, especially when initial investigations have confirmed a viable intrauterine pregnancy. Furthermore, this case highlights MRI as a useful modality in complex cases due to its high soft tissue contrast resolution using non-ionising radiation.

Management strategies of heterotopic pregnancy following in vitro fertilization-embryo transfer

OBJECTIVE

The purpose of this study was to evaluate the efficiency and safety of different treatment modalities for heterotopic pregnancy (HP) in vitro fertilization-embryo transfer (IVF-ET) cycles to avoid influence on intrauterine pregnancy (IUP).

MATERIALS AND METHODS

Cases of HP (n = 90) were from the IVF/ICSI registry database at the Reproductive Hospital Affiliated to Shandong University. An additional 360 women were randomly selected as controls. The primary outcome to examine the risk factors, diagnostic modalities and the impact of different treatment modalities for HP.

RESULTS

Our results showed that surgical treatment had a certain effect on improving the live-birth rate, although the effect was not statistically significant (87.9% vs. 70.8%, P = 0.055). The risk factors for HP included previous tubal surgery and hydrosalpinx. Fourteen days after embryo transfer, the serum levels of β-human chorionic gonadotropin (β-hCG) and estradiol (E2) were lower in the HP group than in the IUP group (P < 0.05). Furthermore, age and endometrial thickness showed a significant difference between the early abortion and the live-birth groups of HP.

CONCLUSIONS

In our retrospective study, we supported early surgical laparoscopic intervention to minimize the incidence of abortion of IUP, which resulted in a better live-birth rate. A history of ectopic pregnancy and previous tubal surgery may increase the risk of HP. Low levels of serum β-hCG and E2 on the 14th day after embryo transfer could indicate the incidence of HP.

Ruptured Heterotopic Pregnancy: A Rare Encounter in Acute Surgical Care Settings

Heterotopic pregnancy is a rare, life-threatening clinical entity with an overall incidence of about 1:30,000 in spontaneous natural conception cases, especially in cases of delayed diagnosis or conflicting clinical features. Here, we present an unusual case of heterotopic pregnancy in a 22-year-old multigravida presented to the emergency department (ED) with a clinical picture of the acute abdomen following recent abdominal trauma. Abdominal ultrasound revealed hemoperitoneum and a single viable intrauterine pregnancy at seven weeks' gestation. Following surgical exploration, the patient underwent removal of the ectopic pregnancy tissue with right salpingectomy. Since the presence of a conflicting history or equivocal physical signs and symptoms makes it difficult to diagnose heterotopic pregnancy, ED physicians and surgeons must consider the diagnosis even when dealing with viable intrauterine pregnancies. Besides, acute abdominal pain associated with shock should be regarded as suggestive of heterotopic pregnancy. Thus, prompt evaluation and a high index of suspicion are of paramount importance to prevent unwanted sequelae.

Treatment of tubal heterotopic pregnancy with viable intrauterine pregnancy: Analysis of 81 cases from one tertiary care center

OBJECTIVES

The aim of our study was to analyze the treatment and pregnancy outcome of tubal heterotopic pregnancy (HP) patients with a viable intrauterine pregnancy (IUP) in our center.

STUDY DESIGN

This was a retrospective analysis of 81 patients with tubal HP and a viable IUP. Patients were divided into either an expectant treatment group (29 patients) or a surgical treatment group (52 patients, 36 laparoscopy and 16 laparotomy). Data related to the basal clinical characteristic of all patients, rescue treatment and ectopic pregnancy (EP) rupture rate in the expectant treatment group, operation details in the surgical treatment group and pregnancy outcomes were collected and analyzed. Subgroup analyses were also performed.

RESULTS

In the expectant treatment group, the abortion rate, EP rupture rate and rescue treatment rate were 10.34 % (3/29), 21.14 % (7/29) and 34.48 % (10/29), respectively; subgroup analysis revealed that the rescue treatment rate in patients with EP mass enlargement ≥50 % was 71.43 % (5/7), which was significantly higher than that in patients with EP mass enlargement <50 % (15.00 %, 3/20), with P = 0.011. In the surgical treatment group, the abortion rate of all patients was 15.38 % (8/52); the abortion rate was 22.22 % (8/36) in the laparoscopy subgroup, which was significantly higher than that in the laparotomy subgroup (0.00 %, 0/16), with P = 0.038.

CONCLUSIONS

Surgical treatment is a safe treatment option for tubal HP with a viable IUP, and laparoscopic surgery may be a potential risk factor for abortion. A high risk of failure exists for expectant management of tubal HP with a viable IUP, and EP mass enlargement ≥50 % may be a potential predictor of rescue treatment.

Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study

RESEARCH QUESTION

What is the best intervention time and method for patients who are diagnosed with heterotopic caesarean scar pregnancy (HCSP) wishing to preserve intrauterine pregnancy.

DESIGN

Four patients diagnosed with HCSP from January 2014 to May 2019 were enrolled. Because HCSP is rare, data on 27 published cases were extracted to augment the analysis. Clinical characteristics and medical documents related to fetal reduction and subsequent maternal-neonate outcomes were analysed.

RESULTS

The intervention time was significantly earlier in the full-term birth group (6.76 ± 1.05 weeks) compared with pre-term birth group (8.02 ± 1.55 weeks; P = 0.042). The cumulative full-term delivery rate was 91.48% when the intervention was at 6 weeks' gestation and decreased to 42.02% at 8 weeks. The maternal-neonate outcome was similar among the selective fetal reduction and surgical removal groups as was delivery time (34.68 ± 3.12 versus 34.80 ± 6.64 weeks; P = 0.955). In the four cases undergoing selective fetal reduction, the residual mass grew by 1.16-7.07 times compared with the area before reduction. The maximum size of the residual mass was observed at 12-13 weeks and 22-25 weeks.

CONCLUSIONS

Most patients with HCSP who choose to keep intrauterine pregnancy will be able to carry the fetus to term. Selective fetal reduction would be the first intervention of choice and should take place immediately after diagnosis. The residual mass after reduction could continue to grow throughout the whole pregnancy, although this should not be considered as an indication for termination. With good supervision and careful management, the pregnancy could be maintained and carried to term.

The indicator of clinical outcomes for patients with heterotopic pregnancy following in-vitro fertilization with embryo transfer

OBJECTIVE

To explore the early predictors for pregnancy outcomes in patients with heterotopic pregnancy (HP) following in-vitro fertilization with embryo transfer (IVF-ET).

MATERIAL AND METHODS

This retrospective study reviewed 81 patients with HP following IVF-ET in our institution between January 2003 and September 2017. The relationships between clinical outcomes and general characteristics, sonographic features and different management options were analyzed by logistic regression analysis.

RESULTS

The gestational age at the time of diagnosis was 50.9 ± 12.3 days. Among these cases, 76 were accurately diagnosed by TVS, 1 was misdiagnosed as adnexal torsion by TVS, and 4 were confirmed to have IUPs after the surgical treatment. Hence, the sensitivity of TVS for detecting HP was 93.8% (76/81). However, forty-seven patients (58.0%) had suspected HP when they underwent the initial TVS. Among these patients, live births occurred for 60 patients, 11 of whom delivered preterm. The miscarriage rate was 58.3% (14/24) for patients without IUP cardiac activity at HP diagnosis, and 12.3% (7/57) for patients with IUP cardiac activity; a significant correlation was identified (χ² = 18.651, P < 0.001). Additionally, the abortion rate of patients following fresh non-donor embryo was higher than patients after frozen-thawed embryo (χ² = 10.437, P = 0.001). Further by logistic regression analysis, patients following frozen-thawed embryo and an IUP with cardiac activity at HP diagnosis were identified as two independent factors of pregnancy outcome. (OR = 0.060, 95%CI = 0.008-0.471, P = 0.007; OR = 0.010, 95%CI = 0.001-0.124, P<0.001).

CONCLUSIONS

Patients following frozen-thawed embryo and an IUP with cardiac activity at HP diagnosis could be the independent predictors for a favorable prognosis.

A spontaneous heterotopic pregnancy presenting with acute abdomen treated with natural orifice transluminal endoscopic surgery procedure: Case report

Heterotopic pregnancy occurs 1 in 30000 pregnancies. We present case of an acute abdomen caused by a ruptured ectopic component. Our patient had no known risk factors, which made the diagnosis even more challenging. Intrauterine pregnancy was desired by patient and her husband. A natural orifice transluminal endoscopic surgery (NOTES) procedure was performed, which is a next-generation minimally invasive procedure in this area. After the procedure, our patient was discharged one day after surgery with a viable intrauterine pregnancy.

Two cases of intrauterine pregnancy with tubal stump pregnancy after in vitro fertilization and embryo transfer following ipsilateral salpingectomy: A case report

RATIONALE

The recently increased rate of heterotopic pregnancies (HPs) has been largely attributed to the increased use of assisted reproduction technologies (ARTs). HP is a rare and potentially life-threatening condition. It is unusual in natural conception cycles, occurring in 1:10,000 to 1:50,000 pregnancies. However, with the increased use of ART such as in vitro fertilization and embryo transfer (IVF-ET), the incidence has risen to 0.5-1%.

PATIENT CONCERNS

Case 1 was a 28-year-old woman who presented to our center complaining of a sudden onset of right-side lower abdominal pain with a small amount of vaginal bleeding. She had undergone IVF-ET and received a thawed embryo transfer with two embryos 23 days previously. She had a history of right salpingectomy for an ectopic pregnancy during the downregulation of her ovulatory cycle 1 year ago. Case 2 was a 25-year-old woman who presented to our center complaining of a sudden onset of right-side lower abdominal pain. She had also undergone thawed embryo transfer following IVF-ET with two embryos 35 days previously. She had a history of right salpingectomy for an ectopic pregnancy 1.5 years previously.

DIAGNOSES

Both patients were diagnosed as having a heterotopic pregnancy.

INTERVENTIONS

Patient 1 underwent emergency laparoscopy; patient 2 underwent emergency laparotomy and both were treated medically to prevent abortion of the intrauterine pregnancies.

OUTCOMES

Patient 1 had an incomplete abortion and underwent uterine curettage on the day 10 after the operation. Patient 2 experienced no further complications during pregnancy and a healthy baby girl was born at the 38th gestational week.

LESSONS

Reproductive physicians need to pay more attention to patients who have received more than one embryo at transfer, especially those with a history of salpingectomy.

Live birth after treatment of a spontaneous ovarian heterotopic pregnancy: A case report

Spontaneous heterotopic pregnancies occur in about 1/30000 pregnancies, with the ovarian subtype comprising 2.3% of the total. We report the case of a healthy 32-year-old woman, gravida 4, para 3, who presented to the emergency room with severe abdominal pain. Two weeks earlier, pelvic ultrasound had revealed a 6-week intrauterine pregnancy. She was hemodynamically stable, but had rebound tenderness on the right iliac fossa. Transvaginal ultrasound revealed an evolutive intrauterine pregnancy with a gestational age (GA) of 8 weeks, with a synchronous evolutive adnexal pregnancy of the same GA and some free fluid in the pouch of Douglas. She underwent an urgent laparoscopy which showed an intact gestational sac containing an embryo on the right ovary associated with mild hemoperitoneum. An ovarian wedge resection was performed to preserve ovarian tissue. The intrauterine pregnancy had no complications and the patient delivered vaginally at term. Heterotopic pregnancy is potentially life-threatening. Despite being extremely rare after natural conception, and even more so in the absence of major risk factors, it should be considered in any pregnant woman with abdominal pain. A high index of suspicion is important for a prompt diagnosis, selection of the appropriate surgical treatment and successful obstetric outcomes.

Ultrasound of the First Trimester

Ultrasound is the imaging study of choice for detection and full characterization of early pregnancies based on its accuracy, low cost, safety profile, and abundant availability. This article reviews the goals and utility of first-trimester ultrasound in gestation localization, viability determination, and abnormal pregnancies, including ectopic implantation, retained products, and molar pregnancy.

Spontaneous Heterotopic Pregnancy Associated with Massive Intraperitoneal Haemorrhage and a Normal Heart Rate, Illustrating the Concept of Relative Bradycardia

A 28-year-old, 9 and a half weeks pregnant (spontaneous conception) multigravida presented with abdominal pain and vaginal bleeding. On examination, her abdomen was diffusely tender, particularly in the right iliac fossa, though guarding was absent. Transabdominal and transvaginal ultrasonography demonstrated a viable intrauterine pregnancy and large-volume intraperitoneal haemoperitoneum; the right ovary could not be identified. The patient became hypotensive with decreased responsiveness, yet her heart rate remained normal. She proceeded to surgery where a ruptured right tubal ectopic pregnancy was identified and right salpingectomy was performed. Estimated blood loss was 3900ml. Postoperative recovery was uneventful. Ultrasound 3 days after surgery demonstrated a viable intrauterine pregnancy of gestational age 9 weeks + 1 day. The patient remains well. Her anomaly scan at 20 weeks and 6 days showed normal growth, amniotic fluid, and Dopplers with no obvious structural defects. She is currently 27 weeks pregnant and will be rescanned at 36 weeks.

Heterotopic pregnancy - how easily you can go wrong in diagnosing? A case study

Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms.

Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms.

The risk factors of miscarriage and obstetrical outcomes of intrauterine normal pregnancy following heterotopic pregnancy management

To investigate the clinical characteristics and risk factors for miscarriage of intrauterine normal pregnancy of patients with a heterotopic pregnancy (HP) after treatment.This was a retrospective study of medical records from CHA Bundang Medical Center. Sixty-four patients who were diagnosed with a HP between February 2006 and July 2017 were included in this study. All analyses were performed using SAS software, version 9.4 (SAS Institute, Inc., Cary, NC). P values < .05 were considered statistically significant.Forty-eight patients had tubal ectopic pregnancies (EP), 10 patients had cornual EPs, 1 patient had a cesarean section scar EP, 4 patients had an ovarian EP, and 1 patient had bilateral tubal EP. Among the 64 patients, 14.1% (9/64) miscarried before 10 weeks of gestation after management. Mean gestational age (GA) at treatment was 5.97 ± 0.50 weeks and 6.80 ± 1.04 weeks for miscarriage and nonmiscarriage group, respectively (P = .008). Significant differences were observed between 2 groups in terms of ultrasonographic features at the time HP was diagnosed (P = .040) Logistic regression models indicated that gestational age at treatment showed significant differences between 2 groups (OR: 0.003, 95% CI: 0.001-0.604).Immediate management after diagnosis could expect favorable prognosis of HP. GA at treatment was the only independent risk factor for miscarriage in patients with HP regardless of treatment methods.

Spontaneous ovarian heterotopic pregnancy

Heterotopic pregnancy is a simultaneous intrauterine and ectopic pregnancy. We report a case of a spontaneous ovarian heterotopic pregnancy. A 36-year-old woman, gravida 7 para 4-1-1-5 at 4 weeks gestation (spontaneous conception), presented to the emergency department with vaginal spotting, lower abdominal cramps with human chorionic gonadotropin(hCG) 10 772 mIU/mL (hCG at T0). Abdominal and pelvic examinations were benign. Transvaginal sonogram (TVS) showed an intrauterine gestational sac and yolk sac, no fetal pole visualised. She was discharged home with a diagnosis of threatened abortion. The patient returned to the emergency department 3 weeks later (T1) at 7 weeks gestation with recurrent vaginal bleeding and lower abdominal pain. Her TVS showed an empty uterus with small amount of free fluid in the cul-de-sac. A small 2 cm round mass noted in the adnexa with hCG of 4663 mIU/mL (hCG at T1). Laparoscopy revealed normal fallopian tubes bilaterally and a ruptured right ovarian ectopic pregnancy. Pathology was consistent with ectopic pregnancy. Abnormal hCG patterns should raise suspicion for heterotopic pregnancy.

Effect of method of anesthesia on the reproductive and obstetric outcomes of heterotopic pregnancies

BACKGROUND

Anesthesia is commonly used for surgical termination of the extrauterine component of heterotopic pregnancy. We sought to evaluate the effects of general and regional anesthesia during salpingectomy on reproductive and obstetric outcomes of heterotopic pregnancies.

METHODS

A two-center, retrospective cohort study was conducted, and 49 heterotopic pregnancies were included. Baseline characteristics, reproductive and obstetric outcomes were compared between the general anesthesia and regional anesthesia groups.

RESULTS

Baseline characteristics were comparable for age, weeks of gestation at diagnosis, and duration of anesthesia. No significant difference was found in pregnancy outcome, perinatal outcome or neonatal weight (P >0.05). The rate of miscarriage in the general anesthesia group was 23.5% versus the regional anesthesia group 15.6% (P >0.05).

CONCLUSION

With respect to reproductive and obstetric outcomes, this retrospective study found no difference between general anesthesia and regional anesthesia used for early heterotopic pregnancy.

Study on the incidence and influences on heterotopic pregnancy from embryo transfer of fresh cycles and frozen-thawed cycles

PURPOSE

The purpose of this study was to determine the heterotopic pregnancy rate using fresh versus frozen-thawed embryo transfers and factors associated with heterotopic pregnancy (HP). Management and clinical outcomes after heterotopic pregnancy were also evaluated.

METHODS

In this retrospective cohort study, we included 12,484 women who had clinical pregnancies after in vitro fertilization treatment at our fertility center between 2012 and 2017. Patients received fresh day 3 embryos (F-D3 group), fresh day 5 blastocysts (F-D5 group), frozen-thawed day 3 embryos (T-D3 group), or frozen-thawed day 5 or 6 blastocysts (T-D5/6 groups) transfers. The primary outcome measure was the occurrence of heterotopic pregnancy. Factors associated with heterotopic pregnancy were analyzed using logistic regression.

RESULTS

The heterotopic pregnancy rates were 0.58% in the F-D3, 0.39% in F-D5, 0.56% in T-D3, and 0.33% in T-D5/6 groups, but no differences were found between groups. The risk factors of HP included a history of previous ectopic pregnancy (odds ratio [OR] 5.805, 95% CI 4.578-9.553, P = 0.016) and pelvic inflammation diseases (OR 1.129, 95% CI 1.021-3.178, P = 0.047). Salpingectomy was performed in 62.9% patients either through laparoscopy or through laparotomy. The early abortion rate and late abortion rate were 29.03% and 1.61%, respectively. In total, 66.13% of the patients had a live birth, either a singleton (90.24%) or twins (9.76%).

CONCLUSION

No significant difference in the incidence of heterotopic pregnancy in fresh IVF cycles vs. frozen-thawed cycles could be demonstrated in a large cohort of patients. The risk factors of HP included history of ectopic pregnancy and PID. The clinical outcome after heterotopic pregnancy appears to be favorable.

Advanced abdominal pregnancy in a spontaneous heterotopic pregnancy

Spontaneous heterotopic pregnancy is a potentially life-threatening condition rarely considered when a patient with an intrauterine pregnancy is asymptomatic or presents with complaints such as abdominal pain. An advanced abdominal pregnancy as the form of the ectopic component, outside the context of assisted reproduction, is an even more unusual and perilous diagnosis with very few cases reported in the literature. We report such a case in a 34-year-old multipara, with no known risk factors for ectopic pregnancy. The pregnancy was initially misdiagnosed and managed as a dichorionic gestation, complicated with fetal demise of one of the twins. The correct diagnosis was only made after term delivery of the intrauterine pregnancy. The abdominal pregnancy was subsequently managed via laparotomy with no complications.

Imaging of Female Pelvic Emergencies

Pelvic pain is a common complaint in female patients who present to the emergency department. Although encountered frequently, the path to a definitive diagnosis is not always a straightforward one, and imaging offers a valuable tool to aid in this diagnostic challenge. Radiologists must be familiar with the most common etiologies of female pelvic pain in the emergency setting, their imaging characteristics, and the best way to further evaluate challenging clinical presentations. This allows the radiologist to serve as a valuable asset to the treating physician, aiding in accurate diagnosis, and in guiding the course of treatment, all while ensuring the "Image Wisely" principle. A sonographic approach to female patients presenting to the emergency setting with pelvic pain has been presented in this article and some example entities along with their imaging findings have also been reviewed.