2

CHAPTER II
LITERATURE REVIEW
2. 1 Definition
Heterotopic pregnancy is defined as the presence of multiple gestations,
with one being in the uterine cavity and the other outside the uterus, commonly in
the fallopian tube and uncommonly in the cervix or ovary.
3
Spontaneous triplet heterotopic pregnancy has also been reported with two
yolk sacs seen in one tube, and in another case an ectopic pregnancy in each tube
with a single intrauterine gestation. Triplet and quadruplet heterotopic pregnancies
have also been reported, though extremely rare.
3
2. 2 Incidence
Heterotopic pregnancy is very rare in natural conception but traditionally,
the rate of occurrence has been thought to be !3",""" pregnancies or about
"."#$ of all pregnancies, but in the recent literature a rate of !%&"" has been
reported in high'risk groups with the use of assisted reproduction techniques. Tal
et al have proposed that the incidence of heterotopic pregnancy may rise up to in
"" pregnancies where conception is assisted by ovulation induction and in vitro
fertili(ation )*+,-.
,%,.
2. 3 Risk Factors
The increased incidence of multiple pregnancies with ovulation induction
and *+, increases the risk of both ectopic and heterotopic gestation. The
3
hydrostatic forces generated during embryo transfer may also contribute to the
increased risk.
/omen with previous ectopic pregnancy, tubal surgery or previous pelvic
inflammatory disease may be at a higher risk.
3,0
2. C!inica! Presentation
Heterotopic pregnancy may or may not have symptoms. 1bout ."$ are
diagnosed only when the fallopian tube ruptures, at which point emergency
surgery is needed. *f symptoms are present prior to a ruptured tube, the symptoms
are the same as those of ectopic pregnancy.
,3,0
Heterotopic pregnancy can have various presentations and should be
considered more likely )a- after assisted reproduction techniques, )b- with
persistent or rising chorionic gonadotropin levels after dilatation and curettage for
an induced2spontaneous abortion, )c- when the uterine fundus is larger than for
menstrual dates, )d- when more than one corpus luteum is present in a natural
conception, and )e- when vaginal bleeding is absent in the presence of signs and
symptoms of ectopic gestation.
,3,0

3sually, signs of the extrauterine pregnancy predominate. ,our common
presenting signs and symptoms are abdominal pain, adnexal mass, peritoneal
irritation and an enlarged uterus. 1bdominal pain was reported in #3$, and
hypovolemic shock with abdominal tenderness reported in 3$ of heterotopic
pregnancies. *n addition, half of the patients did not complain of vaginal bleeding
in another publication, but it can be the vaginal bleeding does occur4 however, it
4
may be retrograde from the ectopic pregnancy due to the intact endometrium of
the *3 pregnancy.
0,.
1 heterotopic gestation can also present as hematometra and lower quadrant
pain in early pregnancy.
.
5ost commonly, the location of ectopic gestation in a heterotopic pregnancy
is the fallopian tube of which 9597%. The most common site is the ampullary
portion of the tube (80%), followed by the isthmic sement of the tube )"$-,
the fimbria ).$- and the cornual and interstitial regions. However, cervical and
ovarian heterotopic pregnancies have also been reported.
0,&
,igure %. 6ossible location of extrauterine pregnancy
2. " Dia#nosis
Heterotopic pregnancies are usually diagnosed from . to 30 weeks of
gestation. Tal et al reported that 7"$ of the heterotopic pregnancies were
diagnosed between . and # weeks of gestation, %"$ between 8 and " weeks and
5
only "$ after the th week. The early diagnosis of heterotopic pregnancy is
often difficult because the clinical symptoms are lacking.
%,.,7
Heterotopic pregnancies can pose a diagnostic dilemma because an early
transvaginal ultrasound may not diagnose an ex'utero gestation in all cases. 1
diagnosis of a pseudosac should be made with caution, as even in the presence of
a pseudo sac there can be a high false positive diagnosis of an ectopic pregnancy.
Sometimes the presence of a hemorrhagic corpus luteum can confuse and delay
the diagnosis of a heterotopic pregnancy.
3,.,&
The detection rate of heterotopic pregnancy can vary from 0 to #0$ with
transvaginal ultrasound scans. *t is influenced by factors like routine and easy
access to transvaginal ultrasound scans for high risk patients with a history of
previous ectopic pregnancy and those who received fertility treatment.

/ith an increase in assisted conception the likelihood of detecting

heterotopic pregnancy will increase but missed or delayed diagnosis of
spontaneous heterotopic pregnancy remains a diagnostic dilemma and a challenge
for gynaecologists. *n a case series 9ouis'Sylvestre et al, mentioned 3 cases of
heterotopic pregnancy out of which only one case was a spontaneous heterotopic
pregnancy, & with ovulation induction and & with *+,. The mean gestational age
at the time of the diagnosis was # weeks and .0$ heterotopic pregnancies were
detected by transvaginal ultrasound. 1ll the patients underwent surgical treatment
out of which " had a laparoscopy and 3 had a laparotomy mainly for significant
hemoperitoneum. They found laparoscopy to be useful for the early diagnosis of
heterotopic pregnancy and resulted in good surgical outcomes.
.,&
6
,igure %. Transvaginal ultrasonography demonstrating a small gestational sac
$%& and hematic fluid $E& within the markedly dilated endometrial cavity of the
uterus. Some fluid is present in the cul'de'sac $F&.
,igure %.% Transvaginal ultrasound showing left adnexal mass containing
gestational sac with fetal pole.
7
,igure %.3 Sagittal view of a heterotopic pregnancy at the age of # weeks 3 days:
note the intracervical gestational sac along with an intrauterine sac containing a
viable embryo and a yolk sac.
,igure %.0 3ltrasound image showing the right tubal gestational sac separated
from intrauterine gestational sac
The question however arises in women with spontaneous gestations who
do not necessarily have early ultrasound scans. /omen with previous ectopic
pregnancy, tubal surgery or previous pelvic inflammatory disease may be at a
higher risk and should be scanned at an early gestation to confirm the location of
the pregnancy. 1lso a high index of suspicion is necessary in the low risk
8
symptomatic patient with abdominal or pelvic pain in which ultrasound findings
are consistent with intrauterine gestation sac while free fluid is noted in the pelvis
with or without an adnexal mass.
7,#
The diagnostic role of serum beta h;< levels in heterotopic pregnancy is
debatable. The normal algorithm for the rapid rise in the serum beta h;< in early
pregnancy cannot be used due to the presence of the intrauterine gestation which
could lead to false assurances.
8
2. ' Treat(ent
=nce a heterotopic pregnancy is diagnosed, the next dilemma that arises is
how to manage it without harming the intrauterine pregnancy. 1fter diagnosis, the
ectopic component in case of rupture is always treated surgically and the
intrauterine pregnancy is expected to continue normally. The follow up of
surviving intrauterine pregnancies has been reported to be normal after that with a
rate of successful pregnancy and delivery of 03$.
0,7,#
*n case the ectopic pregnancy was detected early and was unruptured,
treatment options include expectant management with aspiration and installation
of potassium chloride or prostaglandin into the gestational sac.
0,7,#

*f both intrauterine pregnancy and extrauterine pregnancies were not viable
and without rupture, we could treat her with methotre!ate )5T>-. To initiate
5T> therapy, the patient must be hemodynamically stable, with no signs or
symptoms of active bleeding or hemoperitoneum. 5oreover, she must be reliable,
compliant and able to return for regular follow'up. The other factors to be
9
considered are si(e of the gestation, which should not exceed 3.. cm at its greatest
dimension on 3S, absence of cardiac activity, absence of free fluid in 6=? and
beta h;<, which should not be more than .""" m*32ml. 1lso, the patient must
not have any contraindications to medical therapy with 5T>.
8

The laparoscopic approach is technically feasible for both cases without
disrupting the course of an intrauterine pregnancy.
.
,igure %.3 9aparoscopic findings of left tubal ectopic pregnancy in the isthmic
area of the left fallopian tube with hemoperitoneum.