Double Trouble: Primary Heterotopic Pregnancy with Early Rupture

A 34-year-old G1P0 patient presented to the emergency room (ER) at 7-weeks with cramping and vaginal spotting for 12 hours. Her pregnancy was conceived naturally. Serum β-human chorionic gonadotropin (β-hCG) level on arrival was 83 200 IU/L. Transvaginal ultrasonography (TVUS) of the pelvis showed an intrauterine and concomitant right tubal ectopic pregnancy (Figs. 1 and 2). Both embryos of the heterotopic pregnancy showed cardiac activity (Fig. 2). A moderate amount of free fluid was noted (Fig. 1 and Supplemental Video 1), concerning for tubal rupture. The patient underwent an uncomplicated laparoscopic right salpingectomy (Fig. 3A). Serum β-hCG levels on post-operative day (POD) 1 and 5 were 97 100 and 126 946 IU/L, respectively. The patient has an ongoing clinical intrauterine pregnancy at 13 weeks currently (Fig. 3B). Heterotopic pregnancy is defined as the coexistence of an intrauterine pregnancy (IUP) and an ectopic pregnancy (EP), most commonly tubal [1]. Its incidence in natural conceptions is 1 in 30 000 [1,2], though rates are increasing with assisted reproductive technologies and conditions affecting tubal function [2,3]. The diagnosis of a heterotopic pregnancy is challenging because of the presence of an IUP may lower suspicion for a concurrent EP [3,4], and presenting symptoms are often nonspecific [1,3], as in this case. Ultrasonography remains the cornerstone of diagnosis [5,6], and a careful, systematic evaluation of both adnexa is essential even when a normal IUP is already identified [6]. Management depends on maternal stability and gestational viability [3]. Laparoscopy is the standard of care in stable patients and provides excellent maternal and pregnancy outcomes [1,3,4]. Non-surgical options, such as ultrasound-guided injections into the ectopic sac, are highly selective; typically, when the ectopic gestation is accessible, the patient is stable, and surgical risk is high [3,7]. Systemic methotrexate is contraindicated because of the toxicity to the coexisting IUP [3].